Root causes of intraoperative hypoglycemia: A case series

Eric S. Schwenk, Boris Mraovic, Ryan P. Maxwell, Gina S. Kim, Jesse M. Ehrenfeld, Richard H. Epstein

Research output: Contribution to journalArticlepeer-review

10 Scopus citations

Abstract

Study Objective: To describe the root causes of intraoperative hypoglycemic events. Design: Retrospective analysis. Setting: Large academic teaching hospital. Measurements: Data from 80,379 ASA physical status 1, 2, 3, 4, and 5 surgical patients were reviewed. Blood glucose values, insulin, oral hypoglycemic medication doses, and doses of glucose or other medications for hypoglycemia treatment were recorded. Main Results: Hypoglycemia in many patients had multiple etiologies, with many cases (8 of 17) involving preventable errors. The most common root causes of hypoglycemia were ineffective communication, circulatory shock, failure to monitor, and excessive insulin administration. Conclusion: Intraoperative hypoglycemia was rare, but often preventable. Better communication among providers and between providers and patients may reduce the number of intraoperative hypoglycemic events. Many transient episodes of hypoglycemia did not result in any apparent complications, rendering their clinical importance uncertain. Critically ill patients in circulatory shock represent a group that may require close glucose monitoring.

Original languageEnglish (US)
Pages (from-to)625-630
Number of pages6
JournalJournal of Clinical Anesthesia
Volume24
Issue number8
DOIs
StatePublished - Dec 2012
Externally publishedYes

Keywords

  • Diabetes
  • Glucose monitoring
  • Human error
  • Hypoglycemia, intraoperative
  • Insulin
  • Shock

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

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