Document Detail

Inadvertent intravenous administration of an elemental enteral nutrition formula.
MedLine Citation:
PMID:  8251684     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: To report a case of intravenous infusion of an elemental enteral nutrition formula. CASE SUMMARY: A 65-year-old woman with a high-output jejunostomy required fluid and electrolyte replacement via a central line and enteral nutrition support via a gastrostomy tube. She inadvertently received 160 mL of half-strength elemental enteral nutrition formula (Vivonex TEN) via her central venous catheter. After four hours of the infusion, the patient felt ill and was found to by hypotensive and pyrexic. Over the next 24 hours she developed severe back pain and diffuse muscle tenderness. Her creatine kinase concentration was mildly elevated and there were no electrocardiographic changes. There was no rise in serum amylase concentration. Her renal function deteriorated markedly over the following three hours but responded to hydration and diuretic therapy. Liver enzymes, slightly elevated prior to this event, remained unchanged. Blood cultures were negative, but prophylactic therapy with vancomycin and ceftazidime was instituted. The patient recovered and was discharged eight days later. DISCUSSION: Previous reports of inadvertent intravenous administration of enteral feedings have described such complications as osmolarity, microembolism, hypersensitivity, and septicemia. This patient's nonfatal outcome may have been related to the infusion of the enteral formula via the central rather than the peripheral route, the infusion of an elemental rather than a whole protein formula, and the use of sterile water to reconstitute the formula. CONCLUSIONS: Particular care should be taken when a patient has more than one catheter implanted on the chest or abdomen (e.g., central venous or peritoneal dialysis catheter). It is important that inservice training is provided and written protocols are available for the safe infusion of enteral formulas.
M Malone; S Aftahi; L Howard
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  The Annals of pharmacotherapy     Volume:  27     ISSN:  1060-0280     ISO Abbreviation:  Ann Pharmacother     Publication Date:  1993 Oct 
Date Detail:
Created Date:  1994-01-07     Completed Date:  1994-01-07     Revised Date:  2004-11-17    
Medline Journal Info:
Nlm Unique ID:  9203131     Medline TA:  Ann Pharmacother     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  1187-9     Citation Subset:  IM    
Albany College of Pharmacy, NY 12208.
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MeSH Terms
Catheterization, Central Venous / adverse effects
Enteral Nutrition / adverse effects*
Fluid Therapy
Infusions, Intravenous / adverse effects*
Medication Errors*

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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