Infusion error deaths


Intravenous news: report “ISMP recently learned about the tragic deaths of two 6-year-old children stemming from severe postoperative hyponatremia. The fatal events occurred at two different hospitals. In at least one of these cases, it is clear that the rapid administration of plain D5W (dextrose 5% in water) postoperatively resulted in acute hyponatremia secondary to free water retention (also called water intoxication, which is described below). Postoperative children are at high risk for developing hyponatremia, and many fatalities from this disorder have been reported in the literature. When the serum sodium concentration rapidly falls below 120 mEq/L over 24 to 48 hours as in the two events described below the bodys compensatory mechanism is often overwhelmed and severe cerebral edema ensues, resulting in brainstem herniation, mechanical compression of vital midbrain structures, and death.”

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