Inadvertent Intravenous Administration of Milk in Postoperative Intensive Care Unit: Sequelae and Management

Abstract

Tubing misconnections is an unfortunate and rare occurrence in intensive care units, but the complication is grossly underreported as it is often attributed to human error rather than device failure. This potential underreporting of a complication causes concern because it can be prevented by making an appropriate device design and increase awareness among health care workers. In this case report, we have discussed an enteral feed misconnection to an intravenous cannula has led to respiratory distress and acute kidney injury in a patient admitted to the postoperative intensive care unit. We propose a standard operating protocol for management in such a scenario and the role of ventilation-perfusion (V/Q) scan as an alternative to conventional computed tomography pulmonary angiogram (CTPA) in acute kidney injury patients.

Wrong-route drug administration errors: A review of the literature

“…Historically, management of wrong-route drug errors has included supportive care and is based largely on case reports. [6,12,17] Early recognition of this complication should be followed by immediate cessation of the infusion and removal of the line. Patients presenting with acute deterioration may require resuscitation with intubation, ventilation, intravenous fluids and inotropic support.…”

“…Disseminated intravascular coagulation (DIC), anaphylactic or hypersensitivity reactions to foreign antigens and phlebitis related to high osmolality solutions have also been reported. [1,2,[10][11][12] Characteristics of the incorrectly administered infusate, such as the composition (enteral feed v. medication), size of particulate matter, volume administered and rate of administration are hypothesised to predict the resulting clinical severity. [10,13] Finally, oral drugs administered intravenously may have greater drug bioavailability with potential for toxicity.…”