Preventing accidental IV infusion of breast milk in neonates
From the June 15, 2006 issue
This week we heard from the mother of a hospitalized infant named Zoey who accidentally received breast milk intravenously (IV) instead of through a nasogastric (NG) tube. The baby was born with duodenal atresia-complete absence of the duodenal lumen-so surgery was necessary at birth. The procedure was successful, after which a NG tube was inserted in order to provide nutrition with regular feedings of 30 mL of fortified breast milk administered over 2 hours. At the time of the event, an IV syringe pump for medications was located on the left side of the baby's incubator and an identical pump used to deliver breast milk via the NG tube was on the right. The pumps used identical IV administration tubing. Although it's not clear how the tubing used for breast milk was connected to the NG tube, a nurse mistakenly connected a syringe containing breast milk to the wrong line. About 10 mL of milk was infused IV before the problem was recognized. The baby developed respiratory distress and also had seizures. She was treated supportively and, fortunately, she recovered and does not seem to have any lasting adverse effects. How-ever, infusion of non-sterile, particulate fluid such as enteral feedings or breast milk can be fatal, as it carries the risk of sepsis, diffuse intravascular coagulation (DIC), or emboli to major organs, which can lead to organ damage and pulmonary embolism.
Review of the literature reveals cases of inadvertent IV administration of breast milk reported as early as 1972.(1) As this case demonstrates, inadvertent IV administration of breast milk is still happening today despite recognition of the problem more than 3 decades ago. Ryan et al(2) recently reported a similar case and noted that neonatal health professionals communicated eight previously unknown events to the authors after they posted a question about accidental milk infusion to an online, e-mail discussion group.
All hospital staff-particularly in neonatal units-need to take the risk of misconnections seriously and proactively eliminate all chances of IV infusion or direct injection of non-sterile, particulate fluids meant for enteral administration. An April 2006 Joint Commission Sentinel Event Alert on tubing misconnections (www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_36.htm) provided a number of excellent recommendations for preventing such tragedies, including: 1) tracing the tubing to the point of origin before making any connections or reconnections, 2) rechecking connections and tracing all patient tubes and catheters to their sources upon transfer to a new setting, and 3) labeling tubes and administration sets. However, as emphasized in many of our prior newsletters as well as in the April Sentinel Event Alert, the best chance of eliminating the risk of injecting enteral solutions intravenously is to use an oral syringe which is incompatible with IV tubing.
Enteral pumps for adults cannot deliver feedings in the small amounts necessary for premature infants.3 Thus, as in the aforementioned event, staff in neonatal and pediatric intensive care units sometimes employ off-label use of parenteral syringe pumps to administer breast milk enterally, although infusion rates may vary slightly from the programmed rate.(3,4) (Some pump manufacturers are in the process of adjusting IV syringe pumps to accommodate oral syringes.) In these cases, syringes with standard Luer connections should be avoided and NG tubes should connect only to oral syringes via syringe extension sets. Viasys Healthcare (www.viasyshealthcare.com) and Neo Devices (www.neodevices.com) offer such systems, with non-Luer feeding tubes and extension sets. For example, the CORFLO Enteral Feeding System from Viasys has an administration set, for use with a syringe pump, that can only be connected to a syringe tip on an oral syringe (see photo in the PDF version of the newsletter). Unlike typical IV sets with a male Luer at the distal end, the connector at the distal end of the set is female and will only connect to a proprietary male connector on the system's feeding tube, thus preventing possible connection with an IV line. There are no IV ports on the NG tube or the administration set. The feeding tube has a side port that only allows connection of an oral syringe. Both the administration set and feeding tube also have an orange stripe along their lengths to distinguish them from IV lines. Unless makeshift fittings are created, feedings and oral medications cannot be administered via an IV line when using this tubing and an oral syringe. Children's Medical Ventures (http://enteralextensionsets.respironics.com/) also offers non-Luer extension sets for enteral feedings, but the company does not provide feeding tubes.
Although IV administration of breast milk may not happen often, the risk of patient harm is high when it occurs. Its remedy is within reach of all providers: use an anti-IV NG tube and administration set, and an oral syringe. We also recommend labeling the pumps as "Medication" or "Breast Milk" as well as labeling the breast milk syringes. If your organization hasn't addressed this issue, put it on your safety agenda now! Zoey's mom wanted us to advocate for immediate action before another child is injured from this potentially fatal but preventable error.
References: 1) Wallace JR, Payne RW, Mack AJ. Inadvertent IV infusion of milk. Lancet 1972:1264-6.
2) Ryan CA, Mohammed I, Murphy B. Normal neurological and developmental outcome after an accidental IV infusion of expressed breast milk in a neonate. Pediatrics 2006;117(1):236-8. 3) Page L. Diligence, technology prevent IV and feeding tube mix-ups: finding the wrong fit. Materials Management in Health Care April 2006:24-28. 4) Copeland D, Appel J. Implementation of an enteral nutrition and medication administration system utilizing oral syringes in the NICU. Neonatal Network January/February 2006;25(1):21-24.