POTASYUM KLORÜR YANLIŞ UYGULANMASINA BAĞLI ÖLÜM: OLGU SUNUMU

Öz

Potasyum Klorür özellikle çocuklarda akut gastroenterit sonucu ortaya çıkan hipopotasemi tedavisinde intravenöz infüzyon yoluyla kullanılır. Hızlı verilmesi ani ölümlere neden olabileceğinden dikkatli kullanılmalıdır. Sunulan olguda potasyum klorür stajyer hemşire tarafından ateş düşürücü olduğu düşünülerek IV puşe şeklinde uygulanmış olup akut gastroenterit tedavisi gören çocuğun ani ölümüne neden olmuştur. Olgu, yardımcı sağlık personelinin eğitiminin önemini, tedavi amacıyla kullanılan etken maddelerin yanlış kullanımda zararlı sonuçları olabileceğini ve çok da masum olmayabileceklerini, yardımcı sağlık personelinin kusur değerlendirmesinin adli tıbbi açıdan önemini göstermek amacıyla sunulmuştur.

Anahtar Kelimeler

• potasyum
• hiperpotasemi
• intravenöz enjeksiyon
• malpraktis

DEATH DUE TO INADVERTENT ADMINISTRATION OF POTASSIUM CHLORIDE: A CASE REPORT

Öz

Potassium chloride is used for the treatment of hypopotassemia, especially caused from acute gastroenteritis in children, by intravenous route. Owing to the fact that the bolus administration of the drug can cause sudden deaths, it must be used carefully. At the presented case, potassium chloride was applied bolus through intravenous route by the intern nurse considering it as an antipyretic drug and this caused the death of the child treating with acute gastroenteritis. The case is presented to show; importance of allied health personnel’s education, that the active ingredients of the medicines used for treatment can cause harmful results if applied improperly or they may not be so innocent, and importance of allied health personnel’s malpractice evaluation in terms of forensic medicine.

Anahtar Kelimeler

• potassium
• hyperpotassemia
• intravenous injection
• malpractice

Kaynakça

1. Andreoli TE, Evanoff GV, Ketel BL, Shah SV, Walker PD. Böbrek Hastalıkları Ülkü U. Çev. . In: Tuzcu M Çev. Ed . Cecil Essentials of Medi- cine Türkçesi. İstanbul: Yüce Yayınları, 1995:204-5.
2. Tanman F, Neyzi O, Uzel N. Su ele- ktrolit ve asit-baz metabolizması. In: Neyzi O, Ertuğrul T, eds. Pedi- atri-1. İstanbul: Nobel Tıp Kitapevleri, 1993:482-3
3. Battefort F, Dehours E, Vallé B, Hamdaoui A, Bounes V,Ducassé, JL. Suicide attempt by intravenous potassi- um self-poisoning: a case report. Case reports in emergency medicine 2012.
4. Zümrütdal A. Sıvı elektrolit te- davisinde temel prensipler. Anadolu Kardiyol Derg 2013;13:171-7.
5. Goilav B, Trachtman H. Disorders of Potassium Balance. In: Feld LG, Kaskel FJ, eds. In Fluid and Electrolytes in Pe- diatrics. Humana Pres, 2010:67-102.
6. Mushiyakh Y, Dangaria H, Qavi S, Ali N, Pannone J, Tompkins D. Treat- ment and pathogenesis of acute hyper- kalemia. Journal of Community Hos- pital Internal Medicine Perspectives 2012;1 4 .
7. Bosse GM, Platt MA, Anderson SD, Presley MW. Acute oral potas- sium overdose: the role of hemodi- alysis. Journal of Medical Toxicology 2011;7 1 :52-6.
8. Wetherton AR, Corey TS, Buchino JJ, Burrows AM. Fatal intravenous injection of potassium in hospitalized patients. The American Journal of Forensic Medicine And Pathology 2003;24 2 :128-31.

9. Gamsız Bilgin N. Euthanasia: Definition And History of Euthanasia - Ötanazi: Tanım ve Tarihçe. Lokman Hekim Journal of History of Medicine and Folk Medicine 2013;3 2 :25-31.
10. Thierauf A, Musshoff F, Madea B. Post-mortem biochemical investigations of vitreous humor. Forensic science international 2009;192 1 :78-82.
11. Gagajewski A, Murakami MM, Kloss J, Edstorm M, Hillyer M, Peterson GF, Amatuzio J, Apple FS. Measurement of chemical analytes in vitreous humor: stability and precision studies. Journal of forensic sciences 2004;49 2 :371-4.
12. Ahi RS, Garg V. Role of vitreous potassium level in estimating postmortem interval and the factors affecting it. Journal of Clinical and Diagnostic Research 2011;5 1 :13-5.
13. Wetli CV, Davis JH. Fatal hyperkalemia from accidental overdose of potassium chloride. JAMA: The Journal of the American Medical Association 1978;240 13 :1339.
14. Dibbi HM, Al-Abrashy HF, Hussain WA, Fatani MI, Karima TM. Causes and outcome of medication errors in hospitalized patients. Saudi medical journal 2006;27 10 :1489-92.
15. Esmail R, Cummings C, Dersch D, Duchscherer G, Glowa J, Liggett, G. Using Healthcare Failure Mode and Effect Analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate. Healthc Q 2005;8:73-80.
16. Hawkins C. Hazard of potassium chloride solution. British Medical Journal 1987;294 6563 :54.
17. Tobias JD, Yadav G, Gupta SK, Jain G. Medication errors: a matter of serious concern. Anaesthesia, Pain & Intensive Care 2013;17 2 :111-3.
18. http://www.resmigazete.gov.tr/main. aspx?home=http://www.resmigazete. gov.tr/eskiler/2010/03/20100308. htm&main=http://www.resmigazete.gov. tr/eskiler/2010/03/20100308.htm Erişim tarihi: 12 Ocak 2012.
19. Koohestani H, Baghcheghi N. Barriers to the reporting of medication administration errors among nursing students. Aust J Adv Nurs 2009;27 1 :66-74.
20. Wolf ZR, Hicks R, Serembus JF. Characteristics of medication errors made by students during the administration phase: a descriptive study. Journal of Professional Nursing 2006;22 1 :39-51.