Be aware of critical drugs in emergency departments: An extreme iatrogenic insulin overdose via subcutaneous and intramuscular routes

Öz

Introduction: Insulin is a highly used parenteral medication in emergency departments. Although most severe insulin overdoses occur as suicide attempts, medication errors can be the reason. We aimed to highlight the potential medication errors in emergency departments due to the poor control of critical drugs like insulin and the similarities between the brand names of drugs, as we experienced during this case. Case Report: We present a 75-year-old diabetic woman with an extreme insulin overdose. A total of 3000 UI of insulin was administered by subcutaneous and intramuscular routes. She developed typical and atypical episodes of hypoglycemia requiring intravenous dextrose, a high-calorie diet, and glucagon administration. Almost all of the classic side effects of glucagon occurred during her intensive care unit follow-up. She recovered without any sequela or recurrence of hypoglycemia at the end of 5 days of admission. Conclusion: Insulin overdose can be a life-threatening condition by causing hypoglycemia. Albeit rare, insulin overdose can occur as a medication error in hospitals. To prevent such incidents for emergency departments, the medication errors should be objectively laid out, and proactive strategies should be integrated without adversely affecting acute care.

Anahtar Kelimeler

• insulin
• overdose
• misadministration
• critical drugs
• emergency department
• medication error

Öz

Giriş: İnsülin acil servislerde sıklıkla kullanılan parenteral bir ilaçtır. Çoğu şiddetli insülin doz aşımı intihar girişimi olarak ortaya çıksa da, nedeni ilaç hataları da olabilir. Bu vakada tecrübe ettiğimiz gibi, acil servislerde insülin gibi kritik ilaçların yetersiz kontrolü ve ilaçların marka isimleri arasındaki benzerlikler nedeniyle ortaya çıkabilecek olası ilaç hatalarını vurgulamayı amaçladık. Olgu Sunumu: Aşırı insülin doz aşımı olan 75 yaşında diyabetik bir kadın sunmaktayız. Hastanın subkütan ve kas içi yollarla toplam 3000 UI insülin alımı oldu. Hastada intravenöz dekstroz, yüksek kalorili diyet ve glukagon uygulaması gerektiren, tipik ve atipik hipoglisemi atakları gelişti. Glukagonun klasik yan etkilerinin neredeyse tamamı yoğun bakım ünitesi takibi sırasında ortaya çıktı. Hasta hastaneye yatışından sonraki 5. günün sonunda herhangi bir sekel veya hipoglisemi nüksü olmadan taburcu oldu. Sonuç: İnsülin doz aşımı, hipoglisemiye neden olarak yaşamı tehdit eden bir durum olabilir. Nadir de olsa insülin doz aşımı hastanelerde ilaç hatası olarak ortaya çıkabilir. Acil servislerde bu tür olayları önlemek için, ilaçla ilgili hatalar objektif bir şekilde ortaya konulmalı ve akut bakımı olumsuz yönde etkilemeden proaktif stratejiler entegre edilmelidir.

Anahtar Kelimeler

• insulin
• doz aşımı
• yanlış uygulama
• kritik ilaçlar
• acil servis
• ilaç hataları

Kaynakça

1. McDowell SE, Ferner HS, Ferner RE. The pathophysiology of medication errors: how and where they arise. Br J Clin Pharmacol 2009; 67 :605-13.
2. Tan X, Gu D, Lin X, Fang H, Asakawa T. Investigation of the characteristics of medication errors and adverse drug reactions using pharmacovigilance data in China. Saudi Pharm J 2020; 28: 1190-6.
3. Pham JC, Story JL, Hicks RW, Shore AD, Morlock LL, Cheung DS, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med 2011; 40: 485-92.
4. Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, Schiff G. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf 2017; 16: 1103-9.
5. Faber J, Azzugnuni M, Di Romana S, Vanhaeverbeek M. Fatal confusion between ‘Losec’ and ‘Lasix’. Lancet 1991; 337: 1286-7.
6. Cohen MR. Medication errors: error No. 20. Know the patient’s diagnosis before you administer the drugs. Nursing 1978; 8 :74.
7. Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med 2014; 6: 45-55.
8. Thewjitcharoen Y, Lekpittaya N, Himathongkam T. Attempted suicide by massive insulin injection:a case report and review of the literature. J Med Assoc Thai 2008; 91: 1920-4.

9. Johansen NJ, Christensen MB. A Systematic Review on Insulin Overdose Cases: Clinical Course, Complications and Treatment Options. Basic Clin Pharmacol Toxicol 2018; 122: 650-9.
10. Hawton K, Clements A, Simkin S, Malmberg M. Doctors who kill themselves: A study of methods used for suicide. Q J Med 2000; 93: 351-7.
11. Sato Y, Mizuno Y, Suganuma K, Shiroto K, Ikeda T, Yamashita K, et al. Pharmacokinetics of insulin disappearance after massive overdosing. Endocr J 2018; 65: 1147-53.
12. Monroe PS, Heck WD, Lavsa SM. Changes to medication-use processes after overdose of U-500 regular insulin. Am J Health Syst Pharm 2012; 69: 2089-93.