THE ACCIDENTAL introduction into the heart of plastic tubing being used for intravenous fluid administration is an uncommon but by no means unique occurrence. Indeed, at least 14 cases have now been recorded in the literature. In eight of these cases the plastic catheter was introduced into a surgically exposed vein under direct vision. In six other cases, catheter placement involving the threading of plastic tubing through a large-bore needle introduced by direct venipuncture was employed. Recently the use of commercially available intravenous catheter sets has become quite popular due to the ease of introduction and the obviation of exposing a vein. With the use of this set, the needle, through which the tubing is introduced, is withdrawn toward the end of the tubing closest to the infusion bottle and left in place. The sharp edges of the needle are therefore in a position to sever the polyethylene catheter lying