** The bottom line: make sure that venous blood gas reports have ref. intervals and highlight abnormal results. **
Excerpts from the SUI report:
The patient, a 76 year old gentleman, attended the Emergency Department (ED), via 999 ambulance, following an episode of slurred speech and increasing confusion. On arrival he was unconscious with a Glasgow Coma Score of 3/15. The blood glucose recorded by the ambulance crew 40 minutes prior to attendance was 14.6 mmol/L. A venous blood gas analysis was performed shortly after admission which showed a blood glucose of 0.9 mmol/L [the previous post]. However, although the medical staff saw the blood gas results, they failed to notice the blood glucose result. It was nearly two hours later, after the patient had had a CT scan (head) which was normal, that the blood gas results were reviewed again and it was recognised that the patient was hypoglycaemic. The patient was transferred to Critical Care. He had suffered hypoglycaemic brain injury; he died a month later. The pathologist who performed the post mortem exam concluded that he died from a chest infection, secondary to chronic obstructive pulmonary disease (COPD) and metastatic lung cancer (known, progressive). Hypoglycaemic brain injury was reported to have been contributory, but not a direct cause of death.
The patient had been given honey by the GP who attended before calling for an ambulance. It is not clear why the patient's blood glucose level was so low when he arrived in ED. The patient was an insulin-treated diabetic, but there were no reports of recent hypoglycaemic episodes. The patient may have taken an accidental overdose of insulin due to his confusion, however this possibility was explored during discussion with the patient's family but no evidence to suggest this was found. His dietary intake may have been reduced due to the lung cancer disease process which may have led to low blood glucose levels. These are possible causes, however the actual cause for the patient's low blood glucose level could not be determined during the incident investigation. Insulin and C-peptide analyses were not requested.
One of the issues which contributed to the failure to note the venous blood glucose result was the absence of reference intervals on the blood gas analyser venous sample report (but present on arterial blood gas results). Consequently, the profoundly low blood glucose was not highlighted. We have since introduced ref. intervals on venous report formats produced by this and all other blood gas analysers throughout the Trust.
The death was referred to the Coroner whose conclusion was death by natural causes. The Coroner asked that STH highlight (with other Trusts) the importance of ensuring clarity of blood gas result reporting. Specifically, that results should be printed with normal parameters to indicate when results are outside the ref. intervals. Hence this post (belatedly - apologies).
Bws, Godfrey
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Dr GT Gillett, Laboratory Medicine, Northern General Hospital, STH NHS FT, Herries Rd, Sheffield, S5 7AU. Consultant, IMD in Adults, Clinical Chemistry, Sheffield Teaching Hospital NHS Foundation Trust.
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