Improvised drug delivery: A cause
From the April 22, 2004 issue
Problem: Have you ever used IV tubing and/or an IV
pump to administer an oral solution or liquid nutrition to
patients via a gastric or nasogastric tube? Before you say
"no," don't overlook the potential for purposefully
using this method of delivering enteral solutions. For example,
GoLYTELY bowel prep has been administered via nasogastric
tube to older children and adults due to vomiting or intolerance
to the large volume necessary for effectiveness. For some
patients, an enteral infusion pump is not capable of delivering
the solution at the desired infusion rate (e.g., 600-1,000
mL over an hour). Thus, we have heard about many instances
in which an IV pump has been used to administer GoLYTELY.
This is often accomplished by placing GoLYTELY in a plastic
enteral container and jury-rigging the solution administration
sets. For example, an IV pump set is cut just below its drip
chamber, and the end of the enteral solution apparatus (with
attached feeding tube connector) is then jammed into the cut
IV tubing and secured with tape to prevent leakage. The solution
is then administered via a nasogastric tube using an IV pump.
Of course, this form of improvised drug delivery could result
in accidentally connecting the IV tubing to an IV access site.
In fact, cases of accidental IV administration of GoLYTELY,
or a similar high molecular weight polyethylene glycol solution,
have been reported in the literature.(1, 2) Many years ago,
nine patients received polyethylene glycol 300 intravenously;
seven developed renal tubular necrosis but recovered, and
two patients died as a result of polyethylene glycol toxicity.
More recently, a 4-year-old child received GoLYTELY intravenously.
1 The child had presented to the ED after ingesting a large
number of 6-mercaptopurine tablets. After treatment with activated
charcoal, the child was started on GoLYTELY, which was to
be administered using IV tubing attached to a nasogastric
tube. After 1 hour, a nurse discovered that the solution was
actually being administered through an IV access line; 391
mL had already infused. Luckily, the child showed no evidence
of acidosis or renal failure, and glycol levels were undetectable.
He was discharged several days later without further complication.
With opaque IV medications in use today, healthcare professionals
can no longer rely on visual appearance to determine the suitability
of administering solutions IV. Thus, it's not surprising that
enteral feedings have also been administered via IV infusion
Ready-to-hang, closed enteral nutrition containers are easily
spiked with an IV infusion set, allowing the formula to flow
freely or to be delivered via an IV infusion pump. In our
March 20, 2003 newsletter, we reported several instances in
which this occurred. In one case, the nurse couldn't find
an enteral feeding set, so she improvised and used IV tubing
and an IV pump until another nurse recognized that this was
an error waiting to happen. In another case, the patient received
the enteral feeding IV for 2 hours, but luckily suffered no
Safe Practice Recommendation: Of course, the most
obvious solution is to prohibit the use of IV tubing and IV
pumps to administer enteral solutions. However, simply having
such a policy in place is not sufficient; nor can violation
of such a policy be considered the root cause if an error
occurs. As implied above, healthcare providers use these devices
to overcome obstacles to enteral administration. Thus, it
might be helpful to hold focus groups with nurses to dig deeper
into both the obvious and subtle incentives for using IV tubing
and IV pumps for enteral administration. The reasons are often
rooted in system-based problems for which safer solutions
can be found.
For example, if enteral solutions like GoLYTELY must be administered
quickly in large volumes, you might be able to use an adapter
to connect two enteral feeding pumps, each delivering half
the desired volume simultaneously. Also, some enteral pumps
are capable of delivering higher volumes per hour (e.g., 500
mL per hour with the Ross Embrace pump), and some nasogastric
tubes have a dual port to facilitate connection to two enteral
pumps simultaneously. Bold labels that state "WARNING!
For enteral use only" should also appear on the containers
of all enteral products that could possibly be connected to
IV tubing. It's equally important to investigate other potential
uses of IV tubing and IV infusion pumps for enteral administration.
For example, neonates have sometimes been fed breast milk
or formula via a nasogastric tube using an IV pump to permit
very slow delivery.
(1) Guzman DD, Teoh D, & Velez LI: Accidental
intravenous infusion of Golytely(R) in a 4-year-old female
(abstract). J Toxicol Clin Toxicol 2002; 40(2):361-362.
(2) Tuckler V, Cramm K, & Martinez J:
Accidental large intravenous infusion of Golytely (abstract).
J Toxicol Clin Toxicol 2002; 40(5):687.