胰岛素笔注射部位不当导致脓毒症1例报道

A case of sepsis caused by improper injection of insulin

目的:探讨胰岛素笔使用不当可能造成的用药差错。方法:临床药师通过药学查房、药学问诊获悉:1例老年男性患者因自行在左侧鼻孔下疖肿周围注射胰岛素,造成上唇部皮肤软组织感染的肺炎克雷伯杆菌入血,继发脓毒症、血行播散性肺脓肿及脑梗死(感染性栓塞)。临床药师结合胰岛素制剂的高危属性、糖尿病病人易发感染的病原学特点、病人的疾病状态分析本例用药差错发生的原因。结果:患者于中日友好医院呼吸与危重症医学科经过抗感染、补液、呼吸支持、胸腔积液引流、抗凝、降血糖、降血压及营养支持,治疗15 d后,该患者的感染症状得到有效控制,转回当地医院继续完成抗感染疗程。结论:该例罕见的用药错误提示临床药师要注视胰岛素注射部位的宣教,减少由此产生的医疗资源的浪费,和巨大的经济损失。

Objective： To discuss the improper use of insulin pen causing the medication error. Methods： Through pharmacy rounds and pharmacy consultation, the clinical pharmacists were informed that an elderly male patient who was admitted to the Department of MICU of China-Japan Friendship Hospital injected insulin around the left nostril by himself, causing Klebsiella pneumoniae infection in skin and soft tissues of the upper lip, secondary sepsis, pulmonary abscess and cerebral infarction（infectious embolism）. The clinical pharmacists summarized the high-risk properties of insulin preparations, the pathogenic characteristics of diabetic patients, and the patient＇s disease status, and analyzed the reasons for medication errors in this case. Results： After the anti-infection treatment, fluid replacement, respiratory support. drainage of pleural effusion, anticoagulation, decreasing blood glucose, lowering blood pressure and nutritional support for 15 days, the infection symptoms were effectively controlled, and the patient was discharged to the local hospital to complete anti-infection treatment. Conclusion： This case of rare medication error prompted clinical pharmacists to watch the education of insulin injection site in order to reduce the waste of medical resources and huge economic losses.