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Death due to intravenous application of enteral feed
G Fechner1, A Du Chesne, C Ortmann
1Institute of Legal Medicine, Münster, Germany.
International Journal of Legal Medicine
|February 25, 2003
Insights
Accidental intravenous injection of pureed carrots caused immediate death in an infant. Carrot particles were found obstructing pulmonary and systemic blood vessels, highlighting a critical medication error risk.
Area of Science:
- Pediatric Medicine
- Medical Toxicology
- Pathology
Background:
- Infants require careful administration of intravenous (IV) fluids and enteral nutrition via nasogastric (NG) tubes.
- Accurate medication and feeding protocols are crucial to prevent adverse events in neonates and infants.
Observation:
- A 6-month-old infant received both IV infusions and enteral feeds through an NG tube.
- During treatment, enteral feed containing pureed carrots mixed with water was inadvertently administered intravenously.
Findings:
- The infant experienced immediate death following the accidental IV injection of carrot material.
- Post-mortem examination revealed carrot particles within the pulmonary vasculature and disseminated throughout systemic organs.
Implications:
- This case underscores the severe consequences of medication and administration errors in pediatric care.
- Strict protocols and double-checking procedures are essential to prevent catastrophic events during infant feeding and medication administration.
Abstract:
A 6-month-old male infant was treated with intravenous infusions and enteral feed via a naso-gastric tube. Accidentally, enteral feed containing pureed carrots diluted with water was injected intravenously and the child died immediately. Carrot material could be found in the pulmonary blood vessels and in various organs of the systemic circulation.