Inadvertent intravenous polyethylene glycol 4000 infusion in a child

To the Editor:

Polyethylene glycol-(PEG)based laxatives are the most prescribed osmotic oral laxatives and proven to be safe in children with chronic constipation.¹ However, little is known about the improper administration of the drug by infusion. We report a case of unintentional intravenous PEG 4000 infusion without any local or systemic toxic effects.

A 5-year-old girl with Worster-Drought syndrome was admitted to our hospital with an aspiration pneumonia, for which she received amoxicillin/clavulanic acid and oxygen. By accident, four gram of electrolyte-free PEG 4000 (Forlax^® junior) dissolved in 50 mL tap water intended for enteral administration, was given intravenously in 2 minutes via the infusion pump.

Within several minutes she developed moderate tachypnea and the heart rate increased from 130 to 160 per minute with warm distal extremities, normal capillary refill and age-appropriate systolic and diastolic blood pressure. The mental status was unchanged. However, she developed wide open eyes with dilated pupils. An intravenous bolus of 500 mL sodium chloride 0.9% was given to dilute the drug in the bloodstream and to reduce the risk of vaso-occlusive effects. Hyperhydration (2000 mL/m2/day) was performed for two days as a preventive measure of potential agent-induced nephropathy. Urinary production in the subsequent 72 hours was normal. Amoxicillin/clavulanic acid was continued to reduce the risk of a bacteriaemia by the injected unsterile solution.

Repeated laboratory analyses showed normal values for complete blood count, liver enzymes, renal function tests, serum electrolytes and blood gas analysis in the first 72 hours after the incident. The girl showed no hemodynamic, neurological or metabolic sequelae during follow-up. She was discharged from the hospital 7 days later without any evidence of complications.

Potential side-effects associated with parenteral infusion of PEG may be attributed to several factors: osmolality of the solution, metabolism and clearance, intravascular coagulation/ microembolization, bacteriaemia due to the administration of a non-sterile product, and hypersensitivity to the various components.

PEG 4000 is a large molecule and will not be exchanged through cell membranes. The risk after intravenous injection would therefore be the vaso-occlusive effect. Because of the high molecular weight of PEG 4000, there was no expected advantage for dialyzation. The pH of the solution is approximately 7, which is within the ranges for acidity for preparations for intravenous use. The solution appeared to be hypo-osmotic (70 mosmol/kg), which theoretically could lead to hemolysis after intravenous administration. None of these side effects took place.

This observation is in accordance with the only other case report of a substantially equal intravenous drug administration error of PEG described in the literature. In this case a 4-year-old girl inadvertently received 391 mL of intravenous PEG 3350 with additional electrolytes without any complaints.²

We provide a possible approach for management in a case of an unintentional intravenous administration of PEG as described in this 5-year-old girl without any evidence of complications.