Description of Event or Problem · 1
A PATIENT WITH HISTORY OF BENIGN ESSENTIAL HYPERTENSION, CHRONIC PANCREATITIS, AND CHRONIC RENAL FAILURE (TREATED WITH PERITONEAL DIALYSIS SOLUTION EXTRANEAL - A LABELED INTERFERENT FOR THE TEST STRIPS) WAS ADMITTED TO THE FACILITY ON 11/15/05 AT 6:30PM. AT ADMISSION, PATIENT'S BLOOD GLUCOSE WAS 6.75 MMOL/L. CAPILLARY BLOOD GLUCOSE MONITORING, USING THE SUSPECT DEVICE, WAS STARTED IN 2005, AT 9PM, AND REVEALED A VALUE OF 12.7 MMOL/L. CONSEQUENTLY, INSULIN THERAPY WAS STARTED AS FOLLOWS: ACTRAPID (SUBCUTANEOUSLY, 8 IU) ON THE FOLLOWING DAY (4 HOURS) AND 6-12 IU EVERY 4 HRS, FOLLOWED BY UMULINE BY INTRAVENOUS SYRINGE INFUSION ELECTRIC PUMPS (IVSE) THE NEXT DAY (2 HRS) WITH POSOLOGY ADAPTED TO CAPILLARY GLUCOSE VALUES THAT VARIED FROM 13.9 - 7.8 MMOL/L. OVERALL, THE PATIENT RECEIVED 8 IU OF INSULIN ONE DAY AFTER THE ORIGINAL DATE AT 4AM, 66 IU BETWEEN THAT DAY AND THE FOLLOWING DAY, 93 IU BETWEEN THE NEXT TWO DAYS, AND 25.5 IU ONE DAY AFTER THE ORIGINAL DATE. DUE TO HAEMODYNAMIC INSTABILITY ONE DAY LATER, AN ULTRASOUND EXAMINATION WAS PERFORMED AND SHOWED AN ANEURYSM OF THE ASCENDING AORTA. THE SUSPECTED DIAGNOSIS OF HYPOGLYCEMIA MASKED BY INTERFERENCE BETWEEN CAPILLARY GLUCOSE STRIPS (UTILIZING GDH CHEMISTRY) AND DIALYSIS SOLUTION WAS ESTABLISHED. IN RESPONSE TO THE EVENT, THE PATIENT IMMEDIATELY RECEIVED AN INJECTION OF 30% GLUCOSE SOLUTION AND INSULIN WAS WITHDRAWN. UMULINE WAS RESUMED A FEW HOURS LATER, WITH MONITORING OF CAPILLARY GLUCOSE WITH GOD CHEMISTRY STRIP, BEFORE BEING DEFINITIVELY WITHDRAWN ON THE NEXT DAY AT 12AM. RETROSPECTIVELY, THE SERUM GLUCOSE WAS FOUND TO BE AT 2.2 MMOL/L ON TWO DAYS BEFORE AT 7AM AND AT 2.9 MMOL/L ON THE FOLLOWING DAY AT7AM (CAPILLARY GLUCOSE VALUE ON TWO DAYS AFTER THE ORIGINAL DATE, WAS 8.8 MMOL/L AT 6AM AND 7.8 MMOL/L AT 8AM AND 7.8 MMOL/L THE SAME DAY AT 7AM). THE PATIENT DID NOT RECOVER CONSCIOUSNESS AND DIED TWO DAYS LATER, 24 HOURS AFTER THE DIAGNOSIS.