Unintended purge during the start-up process of a syringe pump: report of a case presented with vascular collapse.

The case of a 50 year-old woman who developed a sudden decrease in arterial pressure while she was being prepared for surgery for a fractured lumbar spine in the prone position, is reported. She was receiving propofol, remifentanil, and sodium nitroprusside via three syringe pumps through an intravenous cannula at the dorsum of her left hand. The cause of the vascular collapse was the purge of the syringe pumps during the self-check process.