Warning! Enteral Feeding Tube Declogging System Uses a Luer Lock Syringe

A nurse reported concerns with CLOG ZAPPER, an enteral feeding tube declogging system (made by Avanos) used to clear blockages from enteral feeding formulations. According to the instructions for use (IFU), the kit includes a 10 mL syringe with an enzyme-containing powder that must be mixed with 10 mL of water. The IFU instructs users to connect the syringe to the blue luer lock applicator and gently instill 2 to 5 mL of the solution into the feeding tube. The CLOG ZAPPER solution should remain in the tubing for 30 to 60 minutes to clear the feeding tube, and then the user should flush with 6 mL of water.

According to the reporting organization, in 2025, Avanos changed the presentation of the syringe containing the CLOG ZAPPER powder from an oral slip tip (Figure 1) to a luer lock connection (Figure 2), but the nurse was not aware of the change. The nurse reported that the tip of the current (luer lock) syringe provided in the CLOG ZAPPER kit did not fit securely to the clear connector that comes attached to the applicator. This resulted in a significant amount of the enzyme powder solution spilling over the edges of the applicator (instead of going into the feeding tube). 

Figure 1. Avanos previously dispensed an oral slip tip syringe with the CLOG ZAPPER kit, such as the ones shown.

Figure 2. The new CLOG ZAPPER syringe provided in the kit has a luer tip instead of a slip tip (red arrow). The practitioner must remove the clear connector from the blue applicator (blue arrow) and attach the luer lock syringe containing the enzyme solution.

In order to get the new luer lock syringe to connect to the blue luer lock applicator, the practitioner must remove the clear connector, which was designed to connect to an oral slip tip syringe. When connecting the luer lock syringe with the clear connector, the pieces did not fit securely, causing the solution to leak. Avanos includes an addendum inside the CLOG ZAPPER kit, instructing users to remove the clear connector from the applicator (Figure 3). However, practitioners may be unaware of this change or forget to remove the connector. Besides the risk of leaking, the more serious concern is that the luer lock syringe format could lead to misconnections; practitioners could connect the luer lock syringe containing the non-sterile enzyme solution directly to a patient's intravenous (IV) tubing.

Figure 3. An addendum to the CLOG ZAPPER IFU instructs users to remove the clear connector from the applicator, but this step was missed by the nurse who reported this event.

ISMP has previously warned about the risk of tubing misconnections and wrong route administration errors when non-parenteral medications are dispensed in luer lock syringes. The CLOG ZAPPER syringe displays “I.V.” in a circle with a line through it (Figure 2), intending to warn practitioners that this should not be administered IV. However, practitioners may easily overlook this warning, and the luer lock design allows for this inappropriate connection. The IFU also instructs users to “Keep APPLICATOR and SYRINGE together with patient if procedure must be repeated.” Storing the syringe in a patient’s room creates a significant risk in the hospital setting.

The hospital reported that Avanos indicated that the luer lock connector was an intentional modification design change to their product and that they were not planning to change the connector type. We have reached out to Avanos to recommend changing to an ENFit (enteral/oral) syringe and applicator connector to prevent inadvertent IV administration. If your organization uses this product, immediately inform staff of this risk. Ensure practitioners understand the risk of misconnection when using a luer lock syringe for a non-parenteral medication and emphasize why they should never store this syringe at the bedside. Educate practitioners about the addendum and the need to remove the clear connector from the blue applicator before use to prevent leakage. 

Citation:
Institute for Safe Medication Practices (ISMP). Warning! Enteral Feeding Tube Declogging System Uses a Luer Lock Syringe. ISMP Medication Safety Alert! Acute Care. 2026;31(7):1-3.