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Safety Bulletin.pdf

ISMPCSB2008-01DDAVP.pdf
Preview of Safety Bulletin
🔗 Source: ismp-canada.org
📊 Size: 136 KB
👤 Author: Rob
⬇️ Downloads: 113

Summary

ISMP Canada reports a case of a young adult who died after undergoing neurosurgery and receiving desmopressin for central diabetes insipidus. The patient experienced water intoxication and hyponatremia due to improper fluid management. Contributing factors included continued IV administration of hypotonic fluid and desmopressin after serum sodium normalization, and an acute shift in serum sodium. ISMP Canada recommends developing standardized order sets, monitoring parameters, and guidelines for desmopressin therapy, as well as careful management of fluid and electrolyte balance to prevent similar incidents.

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Description

ISMP Canada reports a case of a young adult who died after undergoing neurosurgery and receiving desmopressin for central diabetes insipidus.

Technical Information

  • File Format: PDF
  • File Size: 136 KB
  • Pages: 4
  • Language: EN
  • Author: Rob
  • Total Downloads: 113
  • Last Updated: 2 weeks ago

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