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30 July 2012
MHRA Drug Safety Update - Glucose solutions: false blood glucose readings when used to flush arterial lines, leading to incorrect insulin administration and potentially fatal hypoglycaemia
There have been reports of glucose-containing solutions being inadvertently used to flush arterial lines of patients in intensive care units. As a result blood samples drawn from the lines gave falsely high plasma glucose readings resulting in inappropriate insulin administration. These actions lead to several cases of hypoglycaemia, some of which were fatal.
Clinicians are reminded that solutions containing glucose should not be used to flush arterial lines, unless there is no suitable alternative. Saline infusions are recommended as the flush solution for arterial lines, to minimise the risk of contamination and adverse effects.
If samples are drawn from arterial lines for estimation of biochemistry, a minimum volume of three times the dead space of the cannula system should be discarded first to avoid contamination.
For more information see the MHRA website.