Infant deaths associated with medical tubing entanglement
The US Food and Drug Administration (FDA) issued a warning earlier this month about a strangulation risk when pediatric patients receiving enteral feedings get tangled in their enteral feeding delivery sets. The feeding set tubing can become wrapped around a child’s neck and cause strangulation and death. FDA received reports of two toddlers who died after being strangled by the enteral tubing. ECRI and the Institute for Safe Medication Practices (ISMP) Patient Safety Organization (PSO) has also received reports of children getting tangled in enteral feeding delivery sets.
Although not mentioned in the FDA warning, similar events have occurred with intravenous (IV) tubing. In our June 2, 2005 newsletter, we wrote about a case report published in Lancet that described a tragic event in which a 10-month-old child, hospitalized with leukemia, was found by nursing staff, pulseless, cyanotic, and apneic, with clavicular IV tubing tightly wrapped twice around the child’s neck. Sadly, all resuscitation attempts failed. Similar cases in the US and Canada have been reported. Strangulation risks can also be associated with oxygen tubing, electrical cords, and monitor leads. The risk might increase when a child connected to medical tubing is moving around, such as rolling over, sitting up, or crawling, and when not being watched closely.
Direct supervision, use of accessories to stabilize flexible lines (IV stabilizers; plastic sleeve), video surveillance systems, and assessment of the need for continuous, rather than intermittent IV infusions (e.g., saline or heparin locked IV sites), have also been recommended. A tool is available to help assess the risk of strangulation in children (policy & procedure).
Access this Free Resource
You must be logged in to view and download this document.