A death resulting from inadvertent intravenous infusion of enteral feed

Abstract

A female patient suffering from the after-effects of an intracerebral hemorrhage, inadvertently received approximately 50 ml of enteral feed containing high molecular weight dextrin intravenously and died 6 h later despite intensive emergency resuscitation attempts. The total quantity of enteral feed received was calculated from the amounts of dextrin measured in the blood. This is the first report describing how the total quantity of enteral feed administered intravenously was determined using biochemical analysis.

Death due to intravenous application of enteral feed

“…One fatal case was reported by Takeshita et al 2002 and in two fatal cases the cause of death was septicaemia (Donovan 1979;Casewell and Philpott-Howard 1983). The ingredients of enteral feed differ between products from different manufacturers.…”

Complications of Peripheral Venous Access Devices: Prevention, Detection, and Recovery Strategies

“…Although some patients recover from misconnections, these events can result in permanent injury (eg, permanent neurological deficits, organ failure) or death or both. [10][11][12][13][14][15]39,41 The underlying cause of many misconnections is device overcompatibility. The ability to connect components of infusion systems (eg, PICC hubs, intravenous tubing) to sequential compression devices, enteral feeding sets, and blood pressure cuff tubing (among other devices) is an intrinsic risk.…”

“…Table 1 provides basic definitions and signs and symptoms of these complications. [11][12][13][14][15] Signs and symptoms vary widely, may be subtle or catastrophic, and onset varies widely, from insidious to abrupt Local pain, swelling, tenderness, and local and/or streaking erythema Venous cording (rigidity and firmness) may be palpable in severe cases 3 Sudden dyspnea, cough, wheezing, chest and/or shoulder pain, agitation, sense of impending doom, tachypnea, tachycardia, hypotension, and/or neurological findings consistent with cerebrovascular accident 16 A harsh systolic murmur may be present…”

Tubing Misconnections

“…51,52 In the majority of the cases, the misconnection is described as being accidental in nature. 43,[47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62]76,77 In one case the written order for the feeding is described as "hard to understand" and therefore a contributing factor. 8 Staff fatigue is cited in one case described in the JC Sentinel Event Alert.…”