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新生儿意外静脉输注牛奶:一例管理策略与预防方案的病例报告

Accidental Intravenous Administration of Milk in a Newborn: A Case Report on Management Strategies and Prevention Protocols.

作者信息

Baydoun Sultana, Awaida Issa, Naufal Naufal

机构信息

Department of Neonatology, Lebanese University Faculty of Medicine, Beirut, LBN.

Department of Pediatrics, Lebanese University Faculty of Medicine, Beirut, LBN.

出版信息

Cureus. 2024 Nov 10;16(11):e73371. doi: 10.7759/cureus.73371. eCollection 2024 Nov.

Abstract

In the following article, we present a case report detailing a medical error wherein a post-term baby boy, admitted to our neonatal intensive care unit due to respiratory distress and hypoglycemia, inadvertently received enteral formula via umbilical venous catheter over approximately one hour. Our report encompasses the hospital course, management strategies, and the resultant outcome. Immediately following the incident, the infant exhibited symptoms of respiratory distress, mottled skin, hypotension, and thrombocytopenia. Prompt intervention entailed administering supportive care, closely monitoring vital signs, particularly blood pressure, with the administration of vasopressors, and initiating broad-spectrum antibiotic therapy. Fortunately, the infant responded well to treatment and exhibited no discernible long-term adverse effects. Subsequent to the incident, thorough investigations were conducted to ascertain its root cause. Furthermore, measures were implemented to enhance medical staff education regarding such occurrences and to develop preventive protocols.

摘要

在以下文章中,我们呈现一份病例报告,详细描述了一起医疗差错。一名过期产男婴因呼吸窘迫和低血糖入住我们的新生儿重症监护病房,在大约一小时内通过脐静脉导管意外接受了肠内配方奶。我们的报告涵盖了住院过程、管理策略及最终结果。事件发生后,婴儿立即出现呼吸窘迫、皮肤斑纹、低血压和血小板减少的症状。及时的干预措施包括给予支持性护理、密切监测生命体征,尤其是血压,并给予血管升压药,同时启动广谱抗生素治疗。幸运的是,婴儿对治疗反应良好,未出现明显的长期不良影响。事件发生后,进行了全面调查以确定其根本原因。此外,还采取了措施加强医务人员对此类事件的教育,并制定预防方案。

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