Intentional ingestion of hand sanitizer in an adult psychiatric unit

Intentional ingestion of ethanol- or isopropanol-based hand sanitizer has been reported in the literature in a variety of settings within the health care system. Specifically in psychiatric units, case reports have only described ingestion of ethanol-based products. This report describes a case of intentional ingestion of isopropanol-based hand sanitizer by a patient while hospitalized on a psychiatric unit. The patient developed acute respiratory failure, acute kidney injury, and metabolic encephalopathy and was treated for 3 days in the intensive care unit before returning to the psychiatric unit. This case highlights the process of identifying suspected ingestion while hospitalized. In any patient who has a sudden change in level of consciousness, clinicians should consider the potential for ingestion of ethanol- or isopropanol-based hand sanitizer. Facilities should be aware of how accessible hand sanitizer is, particularly in areas with patients who have a history of substance dependence.