A 51-year-old man inadvertently ingested 20 to 30 ml of hexachlorophene the night before an aortic bifurcation graft. He died at the close of the procedure with uncorrectable hypotension and bradycardia. The calf and thigh muscles were rigidly contracted. Several other fatalities following hexachlorophene ingestion have been reported. No common pattern has been observed although most of the patients went into coma without localizing signs. Every precaution should be taken to prevent the accidental self-administration of these frequently used preoperative skin preparations.