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A 60-year-old man, unconscious as a result of a cardiopulmonary arrest with resuscitation, was receiving enteral alimentation, through a Silastic nasogastric (NG) tube. The 24-hour supply of 3,000 ml of nutrient (Vivonex) was being divided into three bottles daily, each administered over eight hours by infusion pump. Powdered nutrient was dissolved in sterile water for irrigation contained in liter bottles with screw caps. The screw cap was modified to accept an I.V. solution administration set with a pump chamber and the Luer-Lok tip of the set connected directly to the NG tube. The solution set and screw cap were to be changed every 24 hours.
On the second day, the person placing the fresh set and cap on the first bottle that day connected the line to a central venous catheter instead of to the NG tube. The patient received approximately 400 ml of solution before the error was recognized.
Although the patient experienced seizures, it could not be determined with certainty whether these were due to inadvertent I.V. infusion or to the patient's previous cerebral anoxia. The patient was placed on prophylactic antibiotic therapy. He experienced no fevers after the incident. Since the patient was also already on a ventilator, respiratory difficulty, if it occurred, was not readily recognizable.
Obviously, the person who connected the solution to the I.V. catheter did not think about what he or she was doing. The container was not an I.V. bottle; it had a special screw cap. The solution was not a clear liquid. The individual should have been aware of what type of therapy the patient was receiving and of the difference between enteral and parenteral alimentation (some are confused by the term "hyperalimentation" and do not differentiate).
There are other considerations. A pharmacist prepared the final solutions and labeled the bottles with labels normally used for I.V. therapy. If enteral alimentation is to be used, off-color labels should be utilized. They should prominently warn that the solution is "for enteral use-not for injection." These labels would help greatly to prevent errors in administration.
Tubing used with enteral alimentation should have connections that cannot fit I.V. catheters. Some companies manufacture infusion pump sets for use specifically with enteral alimentation. The tubing will not accommodate an I.V. catheter. Other companies should make such sets available from some manufacturers of en-teral alimentation products, but these are not easily used with infusion pumps.
Lastly, if enteral and parenteral alimentation are being used in your institution, make sure that hospital personne recieve the educational support necessary to understand and utilize this type of therapy properly.