A 3-day-old infant weighing 1.3 kg was prescribed total parenteral nutrition containing 1 unit of regular insulin per each 327-mL bag. A pharmacy technician mistakenly added 1 mL of regular insulin (100 units) rather than 1 mL of a pharmacy-prepared dilution of 1 unit/mL regular insulin. The mistake was caught 2 hours later when the infant’s blood glucose measured 3 mg/dL. Rapid treatment with dextrose boluses ensued, and the blood glucose returned to normal within 12 hours.
Fonte: Medscape CME