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Oral and nasal enteral tube placement errors and complications in a pediatric intensive care unit
Amy M Creel1, Margaret K Winkler
1Department of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA.
Insights
Enteral tube misplacement in pediatric intensive care units (PICUs) is a serious risk, potentially leading to respiratory complications. Traditional placement checks are insufficient, necessitating exploration of new techniques to ensure patient safety.
Area of Science:
- Pediatric critical care medicine
- Medical device safety
- Patient outcomes research
Background:
- Enteral tube feeding is common in pediatric intensive care units (PICUs).
- Accurate tube placement is crucial for effective nutrition and to prevent complications.
- Existing placement verification methods may not be sufficient in critically ill children.
Observation:
- A case series identified five instances of oral/nasal enteral tube misplacement into the respiratory tract within a single PICU.
- Four of these misplacements occurred even with endotracheal tubes in place.
- Patients experienced significant respiratory deterioration, including pneumothorax, pulmonary hemorrhage, and increased oxygen needs.
Findings:
- Critically ill pediatric patients may have unique anatomical or physiological factors increasing the risk of enteral tube misplacement.
- Misplacement into the respiratory tract can lead to severe adverse events, including potential mortality.
- Standard methods for confirming enteral tube placement failed to prevent respiratory tract intubation in these cases.
Implications:
- PICUs should re-evaluate current enteral tube placement protocols.
- Development and implementation of novel, more reliable placement verification techniques are urgently needed.
- Enhanced vigilance and training are essential to mitigate the risks associated with enteral tube use in pediatric critical care.
Objective:
To report five cases of errors in the placement of oral/nasal enteral tubes in a pediatric intensive care unit, and to review literature on placement techniques and complication rates.
Design:
Case series and review of the literature.
Setting:
A 19-bed pediatric intensive care unit in a tertiary care pediatric hospital.
Patients:
A 14-yr-old male with respiratory distress following a near drowning, a 10-yr-old male with recurrent acute lymphocytic leukemia and Pneumocystis carinii pneumonia, a 16-yr-old female with complex congenital heart disease and respiratory failure, a 16-yr-old male with status asthmaticus, and a 2-yr-old male with congenital heart disease.
Interventions:
None.
Main Results:
Five cases of enteral tube placement errors occurred in our combined medical-surgical pediatric critical care unit within the past year. All five resulted in placement of the feeding tube in the respiratory tract, four occurred despite the presence of cuffed endotracheal tubes. Three of the five patients had subsequent worsening of their respiratory status. One developed a pneumothorax, one developed pulmonary hemorrhage, and one developed an increased oxygen requirement.
Conclusions:
Patients in the pediatric intensive care unit may have characteristics that place them at an increased risk for misplacement of oral or nasal enteral tubes into the respiratory tract. Placement of enteral tubes into the respiratory tract may cause serious morbidity and possibly mortality. Checking the placement of enteral tubes with traditional methods does not prevent misplacement in the respiratory tree, and new techniques should be considered.
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