Accidental hypoglycaemia caused by an arterial flush drug error

Thirugnanam, M.; French, J.

doi:10.1111/anae.12671

Cited by 3 publications

(4 citation statements)

References 4 publications

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“…There are several reports related to the risk of errors during blood collection [14,16] and the effect of blood sample contamination with glucose-containing solutions on the interpretation of chemistry parameters. [17] Conventional coagulation tests could also show spurious results because of iatrogenic acute hyperglycemia caused by hemodilution with a glucose-containing solution.…”

Section: Discussionmentioning

confidence: 99%

The effect of hyperglycemia on blood coagulation

Shin

Lee

et al. 2016

Medicine

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We performed a study to investigate whether contamination of hemostasis samples with a glucose-containing solution might generate spurious results in rotational thromboelastometry (ROTEM) tests.Venous blood was taken from 12 healthy volunteers and divided into 4 specimen bottles, which were contaminated with different concentrations (0%, 5%, 10%, and 20%) of glucose solution.Significant lengthening of INTEMCT was observed in the 10% and 20% groups compared with baseline values (7.7% and 9%, P = 0.041 and P = 0.037, respectively). INTEMCFT increased by 20.1% in the 20% group (P = 0.005). INTEMα-angle and INTEMMCF decreased by 3.9% and 2.7%, respectively, in the 20% group (P = 0.010 and P = 0.049, respectively). EXTEMCFT was prolonged significantly, by 10.2%, 15.5%, and 25.6%, in the 5%, 10%, and 20% groups, respectively (P = 0.004, P < 0.001, and P < 0.001, respectively). EXTEMα-angle decreased significantly by 1.9%, 3.2%, and 4.0% in the 5%, 10%, and 20% groups, respectively (P = 0.014, P = 0.001, and P = 0.005, respectively). EXTEMMCF decreased by 3.4% in the 20% group (P = 0.023). FIBTEMMCF decreased by 9.2% and 17.5% in the 10% and 20% groups, respectively (P = 0.019 and P = 0.021, respectively). A significant correlation was observed between standard glucose solution contamination in the specimens and percentage variation of EXTEMCFT, EXTEMMCF, and FIBTEMMCF.To obtain accurate data from the ROTEM test regarding the hemostatic status of patients, specimens with suspected or known contamination should not be analyzed.

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Section: Discussionmentioning

confidence: 99%

The effect of hyperglycemia on blood coagulation

Shin

Lee

et al. 2016

Medicine

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“…9 Despite the numerous recommendations, implementation of the guidance varies and cases of hypoglycaemia and neuroglycopaenia continue to occur due to inadvertent treatment of falsely elevated ABG blood glucose readings. [14][15][16][17][18] Indeed, a previous unpublished analysis of the English National Health Service National Learning and Reporting System (NHS NRLS) database conducted at our institution revealed 299 reported incidents of the error between 2005 and 2015, equating to an average of one reported error every two weeks. The real number of unreported errors is likely to be considerably more than this, with one postal study showing that 30% of the 241 adult ICUs across the United Kingdom have reported errors associated with incorrect flush fluid use in arterial lines, with 5% dextrose being the most frequently cited incorrect fluid.…”

Section: Introductionmentioning

confidence: 94%

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique*

Patel

Skorupska

Hodges

et al. 2020

Journal of the Intensive Care Society

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Background Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Methods Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. Results (1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Conclusion Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

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“…Among the various types of potential errors that may occur during blood collection from vascular devices, blood sample contamination with glucose solutions has been described as an important cause of spurious hyperglycaemia [2,3], which may occasionally lead to serious harm due to unwarranted prescription of insulin and consequent iatrogenic hypoglycaemia [4,5].…”

Section: Introductionmentioning

confidence: 99%

“…The collection of blood through vascular access devices is commonplace in clinical practice, especially in intensive care units, emergency rooms, oncology or paediatric departments, as well as in patients requiring continuous therapy or fluid infusions . Among the various types of potential errors that may occur during blood collection from vascular devices, blood sample contamination with glucose solutions has been described as an important cause of spurious hyperglycaemia , which may occasionally lead to serious harm due to unwarranted prescription of insulin and consequent iatrogenic hypoglycaemia . Contamination with a glucose‐containing solution was also found to have a profound impact on the measured values of other clinical chemistry parameters .…”

Section: Introductionmentioning

confidence: 99%

The effect of hyperglycaemia on haemostasis testing – a volunteer study

et al. 2014

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SummaryWe investigated whether the contamination of samples with glucose subsequently tested for haemostasis affected the results, including prothrombin time, activated partial thromboplastin time and fibrinogen concentration. Venous blood was collected from 12 healthy subjects and divided into four aliquots, which were subjected to different degrees of contamination with standard glucose solution (0%, 5%, 10%, 20%). With increasing glucose contamination, prothrombin time increased from mean (SD) 11.0 (0.7) s to 11.2 (0.7) s, 11.5 (0.7) s and 12.2 (0.8) s, all p < 0.001. Activated partial thromboplastin time decreased from 32.3 (0.9) s to 30.9 (0.8) s, 30.8 (0.8) s, and 29.7 (0.7) s, all p < 0.001. Fibrinogen concentration decreased from 3.8 (0.7) g.l À1 to 3.7 (0.6) g.l À1

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Accidental hypoglycaemia caused by an arterial flush drug error

Cited by 3 publications

References 4 publications

The effect of hyperglycemia on blood coagulation

The effect of hyperglycemia on blood coagulation

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique*

The effect of hyperglycaemia on haemostasis testing – a volunteer study

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