Abstrait

Accidental intravenous administration of enteral formula through a central line in an infant.

Sulafa Sindi, Morouj Kandil, Mohammed Ghazi

Medication error is common in hospitalized patients. However, milk ingestion through an intravenous line is a rare entity that has fatal medical sequel if managed late or misdiagnosed.

A rare case report of an 11 month old infant who received a 5 ml of intravenous formula milk through central line with subsequent complications of sepsis and acute respiratory distress syndrome within few minutes of ingestion. Moreover, complications of acute renal failure along with hepatic insufficiency and coagulation disorders could happen.

These errors are possible due to compatible connections between intravascular catheter and enteral feeding catheter.

Confusion between lines connected to the patient could occur, either due to system or human errors. Healthcare system has a major role in elaborating the use of each line connected to the patient whether to the patient’s family or entitled caregiver to decrease the potential morbidity or mortality of children.