Abstract
BackgroundAccidental intravenous administration of an enteral feeding can be fatal or cause complications such as sepsis, acute respiratory and circulatory failure, acute renal failure, hepatic insufficiency, coagulation disorders and severe permanent neurological sequelae. These “wrong route” errors are possible due to compatible connections between enteral feeding systems and intravascular infusion catheters.Case presentationWe report a six-week-old male infant who received a 5 ml intravenous infusion of breast milk. Within five minutes of administration the child developed tachycardia and tachypnea, accompanied by a sudden decrease in oxygen saturation on pulse oximetry to 69%. The infant received supplemental oxygen via nasal cannula and was transferred to the pediatric intensive care unit. Broad-spectrum antibiotics were administered for 48 hours. Vital signs returned to normal within a few hours. Neurological follow-up through 3 years did not reveal any neurodevelopmental abnormalities.ConclusionDevelopment of specific enteral feeding connections, which are incompatible with intravascular catheter connections, is needed urgently to prevent a misconnection with potential morbidity or mortality of children.
Highlights
Accidental intravenous administration of an enteral feeding can be fatal or cause complications such as sepsis, acute respiratory and circulatory failure, acute renal failure, hepatic insufficiency, coagulation disorders and severe permanent neurological sequelae
Development of specific enteral feeding connections, which are incompatible with intravascular catheter connections, is needed urgently to prevent a misconnection with potential morbidity or mortality of children
We report a six-week-old male infant who received 5 ml of breast milk intravenously and recovered completely
Summary
Designed non interconnecting tubing should be used to prevent consequences that can arise from misconnected enteral feeding tubing. Medical staff and associated caregivers should be instructed in the use of enteral feeding tubing to prevent route errors. Authors’ contributions All authors have participated in case report design, interpretation, and writing of the report. MD collected the data of the case report, review of literature, and drafted the first version of the manuscript. BB collected the data of the case report. GK primarily participated in case report design and helped to draft the manuscript. Author details 1Department of Pediatric Hematology and Oncology, University Children’s Hospital Tübingen, Hoppe-Seyler-Str.1, 72076. Author details 1Department of Pediatric Hematology and Oncology, University Children’s Hospital Tübingen, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany. 2Department of Pediatric Cardiology and Pediatric Intensive Care, University Children’s Hospital Tübingen, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany. 3Department of Pediatric Cardiology, University Children’s Hospital Giessen, Feulegenstr12, 35390 Giessen, Germany
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