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A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.
This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication.
US Department of Health and Human Services. September 26, 2023. 2:00-3:00 PM (eastern).
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Centor RM, Dhaliwal G. Annals On Call. July 2023.
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Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.
CAHPS Research Meetings. Agency for Healthcare Research and Quality, Rockville, MD. October 19, 2023; 11:00 AM—4:00 PM (eastern).
Jt Comm J Qual Patient Saf. 2023;49(9):435-450.