Dear vascular access professionals,
I am working with my organization to address recommendations of the FDA and their warnings/recommendations in August and October of 2009 concerning fatal and disastrous mishaps with glucometers and insulin drips.
The alerts specifically address the inability of GDH-PQQ based glucometers to differentiate non-glucose sugars from glucose. These glucometers then report great overestimations of actual blood sugar. FDA reports 13 deaths since 2003 based on this phenomenon. To illustrate the level of overestimation, in one case the patient was killed and another suffered irreversible neurological damage because their actual lab assay glucoses were 8-19, but their glucometers reported values of 200-300. They received repeated doses of insulin while hypoglycemic because their providers thought they were hyperglycemic.
Then there are other factors that over and under estimate glucose, such as hematocrit, blood pressure, vaspressors, injury to the limb, shock, acetaminophen, altitude, temperature and so on.
What steps have your organizations taken to protect vulnerable patients from severe iatrogenic hypoglycemia?
Art Hansen, RN, BSN