Conclusion Gentian violet is an efficacious for use in oral candidiasis; however, overuse on the tongue and oral mucosa is toxic, a fact not widely appreciated. The use of GV should probably be limited to cases resistant to properly administered nystatin treatment. Because of the extensive staining of the child’s mouth, a parent may not be aware of the formation of membranes and ulcers. Until more is known about this condition, a 0.5% or 1 % solution of GV should be used and limited to three days of one to two swabbings
drug
per
Department of Ambulatory Pediatrics Phoenix Children’s Phoenix, Arizona
Hospital
REFERENCES
2.
10.
PJ. Therapy of oral thrush: a comparative evaluation of gentian violet, Mycostatin, and amphotericin B. Monogr Ther. 1957;2:16-24.
Avery ME,
11.
LR, eds. Pediatric MediBaltimore, MD: Williams &
First
cine. 1st ed.
Wilkins; 1989. Schwartz MW, Charney EB, Curry TA, Ludwig S, eds. Pediatric Primary Care. A
Approach. 1 st ed. Chicago, IL: Year Book Medical PublishProblem Oriented
ers ;
1987.
12.
Hockelman RA, ed. Primary Pediatric Care. 1st ed. St. Louis, MO: CV Mosby
13.
Rulolph AM, Hoffman SIE, eds. Pediatrics. 18th ed. Los Altos, CA: AppletonCentury-Crofts; 1987. Derschewitz RA, ed. Ambulatory Pediatric Care. 1st ed. Philadelphia, PA: JB Lippincott Co; 1988.
Co; 1987.
14.
15.
day. 3,15 Janice P. Piatt, M.D. Paul S. Bergeson, M.D.
1.
atric Therapy. 12th ed. Philadelphia, PA: WB Saunders Co; 1986.
Slotkowski EL. Mucosal irritation following use of gentian violet. Am J Dis Child. 1966;112:250-252.
Accidental Intravenous Administration of Semi-Elemental Formula in an Infant
Kozinn
Slotkowski EL. Formation of mucous membrane lesions secondary to
prolonged use of one percent aqueous gentian violet. J Pediatr. 1957;57:652-654. 3. John RW. Necrosis of oral mucosa after local application of crystal violet. BMJ
1968;1:157-158. 4.
Horsfield P, Logan FA, Newey JA. Oral irritation with gentian violet. BMJ 1976;2:528. Letter.
5.
Behrman EB, Vaughn VC, eds. Nelson Textbook of Pediatrics. 13th ed. Philadelphia, PA: WB Saunders Co; 1987.
Continuous enteral nutrition (CEN) has some advantages in pediatrics when compared with total parenteral nutrition, namely, its greater feasibility and more physiologic approach to infant nutrition. The two types of nutrition are not substitutes for each other. Rather, they are complementary and can even be interassociated, thus allowing an earlier reintroduction of enteral nutrition and a decrease in the secondary effects of total parenteral
1 nutrition.
6.
Like other techniques, CEN needs special care and attention, as well as some training; to guarantee the results. Con-
8.
tinuous-perfusion systems capable of supplying exactly programmed enteral food may be similar to those used for intravenous infusion and used for the same patient. Catheters are easy to differentiate by checking their location in
Avery ME, Tausch HW, eds. Schaffer’s Diseases of the Newborn. 5th ed. Philadelphia, PA: WB Saunders Co; 1984. 7. Fanaroff AF, Martin RJ, eds. NeonatalPerinatat Medicine, Diseases of the Fetus and Infant. 4th ed. St. Louis, MO: CV Mosby Co; 1987. Eichenwald HF, Stroeder S, eds. Current in Pediatrics. 1 st ed. PhiladelPA: BC Decker Inc; 1989.
Therapy phia, 9.
Gellis SS,
Kagan BM,
eds. Current Pedi-
the child, but if
the connections between infusion syringe and catheter are wide apart and the contents appear alike
(lipid solution and milk), there may be mistakes and problems. We have recently had the apportunity to see one of these rare complications in an infant who inadvertently received, through a scalp vein, 10 mL of semi-ele mental formula, which was being delivered through continuous enteral administration. Case
Report
An 11-month-old girl, whose history included congenital malformation of the biliary ducts and secondary cirrhosis and who had been surgically treated, was admitted because of repeated episodes of cholangitis. A computed tomography scan revealed an intra-
hepatic biliary cyst. Surgical drainage was performed. Postsurgical recovery was satisfactory. She needed metronidazole, ceftriaxone, and total parenteral nutrition (TPN) . After several days, she began receiving CEN in the form of a semielemental formula, with increasing volumes and concentrations. Administration of antibiotics and CEN was achieved through catheters and infusion syringe pumps that had similar characteristics. On the 10th day after surgery, when the infant was on CEN, a nurse inadvertently connected the feeding syringe pump to the Y connector of the IV perfusion system. After several minutes, the infant suddenly began to cry and vomited. The initial physical examination revealed the incorrect connection. As the administration system was set at 80 mL/hr, we calculated she had received a total infusion of 15 mL of the formula in the bloodstream through the vein. We observed tachycardia (190 beats/min) . The blood pressure was
95/50 mmHg. Her peripheral pulses normal, with good capillary refill. We also observed a mild perioral cyanosis associated with neither inwere
Downloaded from cpj.sagepub.com at UNIV OF PITTSBURGH on June 19, 2015
757
creased
respiratory frequency (35 nor abnormal pulmo-
breaths/min)
nary auscultation. Rectal temperature was 37.5°C. We did not identify signs of phlebitis of the vein. The parents were informed, and the infant was taken to the pediatric intensive care unit to be monitored. We initiated treatment with oxygen by mask and an intravenous bolus of
methylprednisolone (1.5 mg/kg). Tobramycin (5 mg/kg/day) was added to the antibiotics mentioned before. Enteral nutrition was stopped. We considered the possible
complications: anaphylactic shock, septicemia, intravascular hemolysis, and fatty and/or gaseous embolism. Her blood cell count; sodium, potassium, glucose, urea, and creatinine levels; prothrombin time; fibrinogen level; and split fibrin products were assessed. Arterial pH, P02, PC02, and sodium bicarbonate levels were determined, and urinalysis was done. Blood and milk formula were cultured for bacteria. Two hours later, the cyanosis disappeared, temperature reached 38.7°C, and diarrhea began. Stools were sparse, liquid mucous, without blood and at a rate of eight per day. This picture disappeared progressively within 48 hours. Diuresis was always normal (2 mL/kg/hr). After the first 48 hours, the infant was clinically well. Results of all tests performed were normal, with the exception of a mild anemia secondary to her baseline disease. Bacterial cultures from blood and milk formula were
negative. Discussion that more freutilization of CEN and the quent occasional need to use catheters and pumps similar to the parenteral ones may have caused this complication and may cause it to be more common than one might We
758
can assume
suppose in view of the
scarcity of
reports about it.2,3 In our case, the initial management had to be based upon the known complications of parenteral nutrition, while keeping in mind, among other factors, the different problems arising from the use of lipids and proteins through such a procedure (i.e., fatty or gaseous em-
bolism,
anaphylactic reaction, septicemia, phlebitis, and intravascular hemolysis) . Our child, at least clinically, did not show any of these complications. The volume of transfused was small in absolute terms, but if we take into account the patient’s weight, the relative volume is similar to that in the case reported by Wallace et al,4 in which the complications were fatty embolism and hypersensitivity reaction. In two other published cases, also of adults, erroneous infusions were done with more complete enteral nutrients. In one case, death occurred,2 while the other presented as septic shock caused by Streptococcus viridans.2 Another error associated with perfusion connection was the administration of total parenteral nutrition through an epidural catheter,’ in which no milk
symptoms were
seen.
Phlebitis and intravascular hemolysis can be caused by higher osmolarity of the infusion used. It is possible the initial symptoms (crying, irritability) might be attributable to phlebitis. However, anatomic alteration in the perfused vein was not seen, nor was the osmolarity of the formula we were administering to the child, 204 to 237 mOsm/L, higher than the plasma osmolarity. The lipid composition of this semi-elemental formula is similar to that used in total parenteral nutrition with medium-chain triglycerides and linolenic acid; though the size of the particles is not known, the child
Downloaded from cpj.sagepub.com at UNIV OF PITTSBURGH on June 19, 2015
did not show signs of fatty embolism. In the same reported case, disseminated intravascular co-
agulation was noticed, but we did find signs ofthis.4,s Tachycardia, digestive symptoms (diarrhea, vomiting), even fever and cyanosis, could be interpreted as produced by protein hypersensitivity or by bacterial antigens. 1,4 Bacte-
not
rial cultures of the formula, catheter, and blood were negative. In conclusion, attention must be given to this potential complication, and especially to the prevention of these accidents, by adopting different connections for enteral feeding and parenteral solutions or making it easy to recognize both catheters by means of different colors or other types of signals. 2,6 Maria José
Lopez Garcia, M.D.
Professor of Pediatrics
Ignacio Sorribes Monrabal, M.D. Resident Physician Rafael Fernandez-Delgado Cerda, M.D. Professor of Pediatrics
Department of Pediatrics University Clinic Hospital Valencia, Spain
REFERENCES 1.
2.
Serna AV, Morales MT, Casquero J, Carbonell JD. Nutricion enteral a débito continuo: utilizacion en el
Pediatrika. paciente pediatrico. 1982;8:674-681. Stellato TA, Danziger LH, Nearman HS, Creger RJ. Inadvertent intravenous administration of enteral diet. JPEN.
1984;4:453-455. 3.
4.
5.
Patel PC, Sharif AMY, Farnando PUE. Accidental infusion of total parenteral nutrition solution through an epidural
catheter. Anaesthesia. 1984;39:383-384. Wallace JR, Payne RW, Mack AJ. Inadvertent intravenous infusion of milk. Lancet. 1972;1:1264-1266. Solomon RB. Intravenous milk infusion Lancet.
6.
1972;2:187. Letter. SJ, Rokowsky WJ.
Gurmarnik
Color-
coded intravenous lines. Crit Care Med.
1983 ; 11 :765.
Letter.
drug
per
Department of Ambulatory Pediatrics Phoenix Children’s Phoenix, Arizona
Hospital
REFERENCES
2.
10.
PJ. Therapy of oral thrush: a comparative evaluation of gentian violet, Mycostatin, and amphotericin B. Monogr Ther. 1957;2:16-24.
Avery ME,
11.
LR, eds. Pediatric MediBaltimore, MD: Williams &
First
cine. 1st ed.
Wilkins; 1989. Schwartz MW, Charney EB, Curry TA, Ludwig S, eds. Pediatric Primary Care. A
Approach. 1 st ed. Chicago, IL: Year Book Medical PublishProblem Oriented
ers ;
1987.
12.
Hockelman RA, ed. Primary Pediatric Care. 1st ed. St. Louis, MO: CV Mosby
13.
Rulolph AM, Hoffman SIE, eds. Pediatrics. 18th ed. Los Altos, CA: AppletonCentury-Crofts; 1987. Derschewitz RA, ed. Ambulatory Pediatric Care. 1st ed. Philadelphia, PA: JB Lippincott Co; 1988.
Co; 1987.
14.
15.
day. 3,15 Janice P. Piatt, M.D. Paul S. Bergeson, M.D.
1.
atric Therapy. 12th ed. Philadelphia, PA: WB Saunders Co; 1986.
Slotkowski EL. Mucosal irritation following use of gentian violet. Am J Dis Child. 1966;112:250-252.
Accidental Intravenous Administration of Semi-Elemental Formula in an Infant
Kozinn
Slotkowski EL. Formation of mucous membrane lesions secondary to
prolonged use of one percent aqueous gentian violet. J Pediatr. 1957;57:652-654. 3. John RW. Necrosis of oral mucosa after local application of crystal violet. BMJ
1968;1:157-158. 4.
Horsfield P, Logan FA, Newey JA. Oral irritation with gentian violet. BMJ 1976;2:528. Letter.
5.
Behrman EB, Vaughn VC, eds. Nelson Textbook of Pediatrics. 13th ed. Philadelphia, PA: WB Saunders Co; 1987.
Continuous enteral nutrition (CEN) has some advantages in pediatrics when compared with total parenteral nutrition, namely, its greater feasibility and more physiologic approach to infant nutrition. The two types of nutrition are not substitutes for each other. Rather, they are complementary and can even be interassociated, thus allowing an earlier reintroduction of enteral nutrition and a decrease in the secondary effects of total parenteral
1 nutrition.
6.
Like other techniques, CEN needs special care and attention, as well as some training; to guarantee the results. Con-
8.
tinuous-perfusion systems capable of supplying exactly programmed enteral food may be similar to those used for intravenous infusion and used for the same patient. Catheters are easy to differentiate by checking their location in
Avery ME, Tausch HW, eds. Schaffer’s Diseases of the Newborn. 5th ed. Philadelphia, PA: WB Saunders Co; 1984. 7. Fanaroff AF, Martin RJ, eds. NeonatalPerinatat Medicine, Diseases of the Fetus and Infant. 4th ed. St. Louis, MO: CV Mosby Co; 1987. Eichenwald HF, Stroeder S, eds. Current in Pediatrics. 1 st ed. PhiladelPA: BC Decker Inc; 1989.
Therapy phia, 9.
Gellis SS,
Kagan BM,
eds. Current Pedi-
the child, but if
the connections between infusion syringe and catheter are wide apart and the contents appear alike
(lipid solution and milk), there may be mistakes and problems. We have recently had the apportunity to see one of these rare complications in an infant who inadvertently received, through a scalp vein, 10 mL of semi-ele mental formula, which was being delivered through continuous enteral administration. Case
Report
An 11-month-old girl, whose history included congenital malformation of the biliary ducts and secondary cirrhosis and who had been surgically treated, was admitted because of repeated episodes of cholangitis. A computed tomography scan revealed an intra-
hepatic biliary cyst. Surgical drainage was performed. Postsurgical recovery was satisfactory. She needed metronidazole, ceftriaxone, and total parenteral nutrition (TPN) . After several days, she began receiving CEN in the form of a semielemental formula, with increasing volumes and concentrations. Administration of antibiotics and CEN was achieved through catheters and infusion syringe pumps that had similar characteristics. On the 10th day after surgery, when the infant was on CEN, a nurse inadvertently connected the feeding syringe pump to the Y connector of the IV perfusion system. After several minutes, the infant suddenly began to cry and vomited. The initial physical examination revealed the incorrect connection. As the administration system was set at 80 mL/hr, we calculated she had received a total infusion of 15 mL of the formula in the bloodstream through the vein. We observed tachycardia (190 beats/min) . The blood pressure was
95/50 mmHg. Her peripheral pulses normal, with good capillary refill. We also observed a mild perioral cyanosis associated with neither inwere
Downloaded from cpj.sagepub.com at UNIV OF PITTSBURGH on June 19, 2015
757
creased
respiratory frequency (35 nor abnormal pulmo-
breaths/min)
nary auscultation. Rectal temperature was 37.5°C. We did not identify signs of phlebitis of the vein. The parents were informed, and the infant was taken to the pediatric intensive care unit to be monitored. We initiated treatment with oxygen by mask and an intravenous bolus of
methylprednisolone (1.5 mg/kg). Tobramycin (5 mg/kg/day) was added to the antibiotics mentioned before. Enteral nutrition was stopped. We considered the possible
complications: anaphylactic shock, septicemia, intravascular hemolysis, and fatty and/or gaseous embolism. Her blood cell count; sodium, potassium, glucose, urea, and creatinine levels; prothrombin time; fibrinogen level; and split fibrin products were assessed. Arterial pH, P02, PC02, and sodium bicarbonate levels were determined, and urinalysis was done. Blood and milk formula were cultured for bacteria. Two hours later, the cyanosis disappeared, temperature reached 38.7°C, and diarrhea began. Stools were sparse, liquid mucous, without blood and at a rate of eight per day. This picture disappeared progressively within 48 hours. Diuresis was always normal (2 mL/kg/hr). After the first 48 hours, the infant was clinically well. Results of all tests performed were normal, with the exception of a mild anemia secondary to her baseline disease. Bacterial cultures from blood and milk formula were
negative. Discussion that more freutilization of CEN and the quent occasional need to use catheters and pumps similar to the parenteral ones may have caused this complication and may cause it to be more common than one might We
758
can assume
suppose in view of the
scarcity of
reports about it.2,3 In our case, the initial management had to be based upon the known complications of parenteral nutrition, while keeping in mind, among other factors, the different problems arising from the use of lipids and proteins through such a procedure (i.e., fatty or gaseous em-
bolism,
anaphylactic reaction, septicemia, phlebitis, and intravascular hemolysis) . Our child, at least clinically, did not show any of these complications. The volume of transfused was small in absolute terms, but if we take into account the patient’s weight, the relative volume is similar to that in the case reported by Wallace et al,4 in which the complications were fatty embolism and hypersensitivity reaction. In two other published cases, also of adults, erroneous infusions were done with more complete enteral nutrients. In one case, death occurred,2 while the other presented as septic shock caused by Streptococcus viridans.2 Another error associated with perfusion connection was the administration of total parenteral nutrition through an epidural catheter,’ in which no milk
symptoms were
seen.
Phlebitis and intravascular hemolysis can be caused by higher osmolarity of the infusion used. It is possible the initial symptoms (crying, irritability) might be attributable to phlebitis. However, anatomic alteration in the perfused vein was not seen, nor was the osmolarity of the formula we were administering to the child, 204 to 237 mOsm/L, higher than the plasma osmolarity. The lipid composition of this semi-elemental formula is similar to that used in total parenteral nutrition with medium-chain triglycerides and linolenic acid; though the size of the particles is not known, the child
Downloaded from cpj.sagepub.com at UNIV OF PITTSBURGH on June 19, 2015
did not show signs of fatty embolism. In the same reported case, disseminated intravascular co-
agulation was noticed, but we did find signs ofthis.4,s Tachycardia, digestive symptoms (diarrhea, vomiting), even fever and cyanosis, could be interpreted as produced by protein hypersensitivity or by bacterial antigens. 1,4 Bacte-
not
rial cultures of the formula, catheter, and blood were negative. In conclusion, attention must be given to this potential complication, and especially to the prevention of these accidents, by adopting different connections for enteral feeding and parenteral solutions or making it easy to recognize both catheters by means of different colors or other types of signals. 2,6 Maria José
Lopez Garcia, M.D.
Professor of Pediatrics
Ignacio Sorribes Monrabal, M.D. Resident Physician Rafael Fernandez-Delgado Cerda, M.D. Professor of Pediatrics
Department of Pediatrics University Clinic Hospital Valencia, Spain
REFERENCES 1.
2.
Serna AV, Morales MT, Casquero J, Carbonell JD. Nutricion enteral a débito continuo: utilizacion en el
Pediatrika. paciente pediatrico. 1982;8:674-681. Stellato TA, Danziger LH, Nearman HS, Creger RJ. Inadvertent intravenous administration of enteral diet. JPEN.
1984;4:453-455. 3.
4.
5.
Patel PC, Sharif AMY, Farnando PUE. Accidental infusion of total parenteral nutrition solution through an epidural
catheter. Anaesthesia. 1984;39:383-384. Wallace JR, Payne RW, Mack AJ. Inadvertent intravenous infusion of milk. Lancet. 1972;1:1264-1266. Solomon RB. Intravenous milk infusion Lancet.
6.
1972;2:187. Letter. SJ, Rokowsky WJ.
Gurmarnik
Color-
coded intravenous lines. Crit Care Med.
1983 ; 11 :765.
Letter.
