Intensive Care Med

DOI 10.1007/s00134-008-1362-7 CO RRESPONDENCE

Stefan Korsatko gas analysis (Cobas B221, Roche
Martin Ellmerer Diagnostics, glucose oxidase method)
Lukas Schaupp showed a glucose value of 183 mg/dl.
Julia K. Mader Peritoneal dialysate was exchanged
Karl-Heinz Smolle but due to further deterioration of his
Beate Tiran condition he was admitted to the ICU
Johannes Plank in the afternoon. At the ICU a capil-
lary glucose value of 496 mg/dl was
attained at 19:00 using a bedside
Hypoglycaemic coma due glucose meter [Accu-ChekGo,
Roche Diagnostics using GDH-PQQ
to falsely high point-of-care (glucose dehydrogenase pyrroloqui-
glucose measurements nolinequinone test method)]. Despite
in an ICU-patient with peritoneal aggressive insulin administration
dialysis: a critical incidence (*70 IU over 8 h) no accordant
decline of glucose was observed
report (Fig. 1a). At 2:30 in the morning, the
patient developed tachyarrhythmia,
Accepted: 21 November 2008
but this seemed not to disturb his
Springer-Verlag 2008 sleep. The nurse in charge suspected
hypokalemia following high-dose
insulin infusion to be causal for the
formation of arrhythmias, she per-
formed an analysis for electrolytes
(Cobas B221, Roche Diagnostics). In
fact hypokalemia was present
(3.2 mmol/l), but more surprisingly a
routinely included blood glucose
measurement revealed a value of
38 mg/dl, which was in major dis-
agreement to the capillary
measurement performed just before
(393 mg/dl). At that time the patient
was not asleep, but in a hypoglycae-
mic coma and regained consciousness
promptly after glucose
administration.
On the next day blood samples of
the patient were analysed for glucose
with commonly used glucose-meters
(Fig. 1b). The falsely high glucose
values measured with certain devices

Sir:
Hypoglycaemia is a frequent com-
plication in the establishment of tight
glycaemic control by means of
intensified insulin therapy [1].
Patients in intensive care are often
not capable to communicate the
presence of hypoglycaemia-associ-
ated adverse events and, thus, the
reliability and accuracy of glucose
measurements are especially impor-
tant in this environment [2].
Therefore, every attempt should be
taken to ensure that point-of-care
glucose testing is reliable and tech-
nically unavoidable limitations of
devices in certain patient groups are
well communicated between industry
and ICU personnel.
In this context, we report a critical Fig. 1 a Point of care blood glucose measurements (Accu-Chek Go, filled circle vs.
incidence due to falsely high point- Cobas B221, filled square) and insulin infusion rate profile of a septic peritoneal dialysis
patient admitted to intensive care. b Results of glucose-meter test performed with
of-care glucose measurements in a commonly used glucose measurement devices (? glucose oxidase method, ?? glucose
68-year-old man with a history of dehydrogenase-flavin adenine dinucleotide method, ??? GDH-PQQ method) in the same
diabetes and continuous ambulatory patient on the next morning. Two different blood samples have been tested twice with each
peritoneal dialysis, who was hospi- device (diamond = sample 1, asterisk = sample 2; data are mean values). Cobas B221,
talised for sepsis. In the morning of diamond = 122 mg/dl, asterisk = 146 mg/dl; OneTouch Ultra, diamond = 112 mg/dl,
asterisk = 134 mg/dl; Contour TS, diamond = 114 mg/dl, asterisk = 149 mg/dl. Accu-
the first day the patient was increas- Chek Go, diamond = 441 mg/dl, asterisk = 481 mg/dl; Accu-Chek Inform, dia-
ingly disorientated and dyspnoeic on mond = 476 mg/dl, asterisk = 521 mg/dl; Glucocard X-Meter, diamond = 438 mg/dl,
the ward. Results of an arterial blood asterisk = 447 mg/dl; Freestyle Mini, diamond = 495 mg/dl, asterisk = 500 mg/dl
can be explained by interference of
the test-strips with icodextrine, a
glucose polymer, which is used as
peritoneal dialysate and which is hy-
drolysed in the systemic circulation to
maltose metabolites. These metabo-
lites may affect the enzymatic GDH-
PQQ test method and result in falsely
high glucose readings.
In a safety alert statement [3],
published in 2005, the FDA recom-
mends that if patients are receiving
substances containing maltose (e.g.
intravenous human immunoglobulin),
icodextrin (e.g. peritoneal dialysis
solution), galactose (e.g. certain con-
trast agents), or xylose (e.g. oral D-
xylose), clinicians must use only
those systems whose tests strips con-
tain glucose oxidase, glucose
dehydrogenase-nicotinamide adenine
dinucleotide, or glucose dehydroge-
nase-flavin adenine dinucleotide.
However, reports about severe inci-
dences [4, 5] are continuing.
Therefore, in case of suddenly much
higher glucose values and inexplica-
ble insulin resistance, a validated
alternative method has to be available 5. Nienhuis WA, Bruijns RH, Vastenburg
in each institution to verify that the G, Wouters RS (2006) Hypoglycaemic
coma due to falsely elevated glucose
glucose measurement is correct. values in a patient with diabetes mellitus
and peritoneal dialysis. Ned Tijdschr
Geneeskd 150:15741576
References
S. Korsatko
M. Ellmerer
L. Schaupp

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K.-H. Smolle
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