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December 1989

Safety Hazard With Intravenous Pumps

Author Affiliations

Children's Hospital National Medical Center 111 Michigan Ave NW Washington, DC 20010

Am J Dis Child. 1989;143(12):1390-1391. doi:10.1001/archpedi.1989.02150240012002

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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

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