Article Text

Learning from errors
Severe unrecognised hypoglycaemia presenting as pseudonormoglycaemia and unexplained coma in two patients with renal failure
  1. Ori Galante,
  2. Avital Abriel,
  3. Lone S Avnun,
  4. Boris Rugachov,
  5. Yaniv Almog
  1. Soroka University Medical Center, POB 151, Beer-Sheva, 84101, Israel
  1. almogya{at}bgu.ac.il

Summary

We describe the occurrence of pseudonormoglycaemia and the consequences of severe prolonged hypoglycaemia observed in two patients with renal failure requiring renal replacement therapy. There was a persistent discrepancy, in both cases, between glucose levels measured by the hospital laboratory and those measured by the bedside glucometer, resulting in a significantly false high glucose measurement (pseudonormoglycaemia). This inaccurate glucose determination led to a delayed diagnosis of their truly severe and prolonged hypoglycaemia ultimately leading to prolonged coma and death. Icodextrin, a polysaccharide commonly used in continuous ambulatory peritoneal dialysis solutes, and maltose-containing solutions such as immunoglobulins for intravenous administration, can cause a dangerous overestimation of glucose levels determined by capillary blood glucose analysers utilising glucose dehydrogenase. A high level of awareness is required in order to avoid incidents related to misinterpretation of glucose levels.

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Footnotes

  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication

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