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Tuchmann-Durand C, Thevenet E, Moulin F, Lesage F, Bouchereau J, Oualha M, Khraiche D, Brassier A, Wicker C, Gobin-Limballe S, Arnoux JB, Lacaille F, Wicart C, Coat B, Schlattler J, Cisternino S, Renolleau S, Secretan PH, De Lonlay P. Administration of gamma-hydroxybutyrate instead of beta-hydroxybutyrate to a liver transplant recipient suffering from propionic acidemia and cardiomyopathy: A case report on a medication prescribing error. JIMD Rep 2020; 51:25-29. [PMID: 32071836 PMCID: PMC7012734 DOI: 10.1002/jmd2.12090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022] Open
Abstract
Beta‐hydroxybutyrate (BHB) is a synthetic ketone body used as an adjuvant energy substrate in the treatment of patients with metabolic cardiomyopathy. A medication prescribing error led to the administration of the general anesthetic sodium gamma‐hydroxybutyrate (GHB) instead of sodium BHB in a liver transplant recipient with propionic acidemia and cardiomyopathy, causing acute coma. A 15‐year‐old boy suffering from neonatal propionic acidemia underwent liver transplantation (LT) for metabolic decompensation and cardiomyopathy (treated with cardiotropic drugs and BHB) diagnosed a year previously. The patient had been rapidly extubated after LT, and was recovering well. Eight days after LT, the patient suddenly became comatose. No metabolic, immunological, hypertensive, or infectious complications were apparent. The brain magnetic resonance imaging and electroencephalography results were normal. The coma was soon attributed to a medication prescribing error: administration of GHB instead of BHB on day 8 post‐LT. The patient recovered fully within a few hours of GHB withdrawal. The computerized prescription system had automatically suggested the referenced anesthetic GHB (administered intravenously) instead of the non‐referenced ketone body BHB, triggering coma in our patient. A computerized prescription system generated a medication prescribing error for a rare disease, in which the general anesthetic GHB was mistaken for the nonreferenced energy substrate BHB.
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Affiliation(s)
- Caroline Tuchmann-Durand
- Imagine Institut des Maladies Génétiques, Paris, France and Biotherapy Department Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Eloise Thevenet
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Florence Moulin
- Intensive Care Unit Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris and Paris Descartes University Paris France
| | - Fabrice Lesage
- Intensive Care Unit Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris and Paris Descartes University Paris France
| | - Juliette Bouchereau
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Mehdi Oualha
- Intensive Care Unit Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris and Paris Descartes University Paris France
| | - Diala Khraiche
- Cardiology Care Unit Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Anaïs Brassier
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Camille Wicker
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Stéphanie Gobin-Limballe
- Molecular Genetic Department Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Jean-Baptiste Arnoux
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Florence Lacaille
- Paediatric Hepatology Unit, Reference Center for Rare Pediatric Liver Diseases, Department of Gastroenterology-Hepatology-Nutrition Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, APHP, Filière Filfoie, ERN Transplantchild Paris France
| | - Clotilde Wicart
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Bruno Coat
- Pharmacy's Department Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Joel Schlattler
- Pharmacy's Department Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Salvatore Cisternino
- Pharmacy's Department Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Sylvain Renolleau
- Intensive Care Unit Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris and Paris Descartes University Paris France
| | - Philippe-Henri Secretan
- Pharmacy's Department Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France
| | - Pascale De Lonlay
- Reference Center for Inherited Metabolic Diseases Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris Paris France.,Imagine Institut des Maladies Génétiques Filière G2M, MetabERN, INEM 1151, Paris Descartes University Paris France
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