RT Journal
A1 SCHWARTZ MD, GORELICK M
T1 SAfety hazard with intravenous pumps
JF American Journal of Diseases of Children
JO American Journal of Diseases of Children
YR 1989
FD December 1
VO 143
IS 12
SP 1390
OP 1391
DO 10.1001/archpedi.1989.02150240012002
UL http://dx.doi.org/10.1001/archpedi.1989.02150240012002
AB Sir.—The following patient reports document a safety hazard associated with the IMED (model 960) volumetric infusion pump (IMED Corp, San Diego, Calif).Patient Reports.—Patient 1.—A 3-year-old black girl presented with chronic secretory diarrhea. She had been receiving total parental nutrition since the first year of life. During recent hospitalization for suspected central line sepsis, the patient played with the settings on the IMED volumetric infusion pump (model 960), changing the rate to 632 mL/h, thereby self-administering a 120-mL bolus of the 25% dextrose, with 2.5 g of protein per deciliter of the total parenteral nutrition solution. The patient was discovered in an obtunded state, with blood pressure elevated to 146/94 mm/Hg. Findings of an initial laboratory examination were consistent with a hyperosmolar, hyperglycemic, nonketotic state: glucose, 65.5 mmol/L; serum osmolarity, 375 mOsm/L; calcium, 2.74 mmol/L; magnesium, 1.15 mmol/L; phosphorus, 2.29 mmol/L; potassium, 5.7 mmol/L; and serum