Vomiting, electrolyte disturbance, and medications; the perfect storm for acquired long QT syndrome and cardiac arrest: a case report

Background Acquired long QT syndrome is an important and preventable cause of cardiac arrest. Certain medications and electrolyte disturbance are common contributors, and often coexist. In this case, we report five contributors to cardiac arrest. Case presentation This case is of a 51-year-old Caucasian female patient who presented with vomiting associated with hypokalemia and hypomagnesemia. She subsequently received ondansetron and metoclopramide, on the background of chronic treatment with fluoxetine. She then suffered an in-hospital monitored cardiac arrest, with features of long QT and torsades de pointes retrospectively noted on her prearrest electrocardiogram. She was diagnosed with acquired long QT syndrome, and her QT interval later normalized after removal of offending causes. Conclusions This case highlights the importance of proper consideration prior to prescribing QT prolonging medications, especially in patients who have other risk factors for prolonged QT, such as electrolyte disturbances and pretreatment with QT prolonging medications.

Serious acid-base disorder or life-threatening arrhythmia in patients with ABO-incompatible liver transplantation who received therapeutic plasma exchange : A report of two cases

Background: Excessive citrate load during therapeutic plasma exchange (TPE) can cause metabolic alkalosis with compensatory hypercarbia and electrolyte disturbances. If TPE is required immediately before ABO-incompatible (ABOi) liver transplant (LT) surgery, metabolic derangement and severe electrolyte disturbance could worsen during LT anesthesia.Case: We report two ABOi LT cases who received TPE on the day of surgery because isoagglutinin titers did not be dropped below 1:8. One case had a surprisingly high metabolic alkalosis with a pH of 7.73 immediately after tracheal intubation because of hyperventilation during mask bagging. The other experienced sudden ventricular tachycardia and blood pressure drop after surgical incision accompanied with severe hypokalemia of 1.8 mmol/L despite supplementation with potassium.Conclusions: Special attention should be paid to patients who just completed TPE the operative day morning as they are vulnerable to severe acid-base disturbances and life-threatening ventricular arrhythmias in ABOi LT.

CLINICO-ETIOLOGICAL PROFILE OF HYPONATREMIA AMONG ADMITTED PATIENTS AT DR. RADHA KRISHNAN GOVT. MEDICAL COLLEGE AND HOSPITAL HAMIRPUR HIMACHAL PRADESH

Hyponatremia is a common electrolyte disturbance encountered in hospitals. It is dened as serum concentration <135 meq/l. Various comorbidities predispose to the development of hyponatremia. Patient has symptoms of both hyponatremia as well as comorbidities. This contributes to increased morbidity and mortality .However early recognition and treatment makes prognosis better. Aim: To study clinical features of patients admitted with hyponatremia and investigate them to nd out various aetiologies. Methods And Material: Study was conducted at newly opened medical college at Hamirpur in Himachal Pradesh with limited facilities. A total of 50 patients with symptoms and documented hyponatremia were enrolled in study. Detailed history, clinical examination and laboratory investigations were done. Data thus collected was analysed. Results: Total number of patients was 50. Females were more as compared to males. Mean age of presentation was 67 years and lethargy ,nausea and vomiting were the most common symptoms. Diabetes mellitus and hypertension were the most common comorbidities. Among drugs diuretics were the most commonly used causing hyponatremia. Out of 50 patients 45 patients recovered and ve patients have to be referred because of comorbidities. Conclusions: Hyponatremia is a common problem and clinicians need to be aware of it mainly in the elderly patients. A systemic approach and simple diagnostic algorithm can signicantly improve the outcome in these patients. Treatment of hyponatremia is governed by levels of hyponatremia not by its etiology along with comorbid conditions.

Endoscopic Endonasal Resection of Symptomatic Rathke Cleft Cysts: Total Resection or Partial Resection

Objective: Rathke cleft cysts (RCC) are benign sellar lesions, and endoscopic endonasal surgery (EES) for symptomatic RCC is becoming increasingly popular, but total resection or partial resection (TR or PR) of the cyst wall is still inconclusive. The aim of this study was to review the complications and clinical prognoses associated with total and partial resection of the cyst wall by EES.Methods: We retrospectively analyzed a series of 72 patients with symptomatic RCC treated by EES from -January 2011 to June 2019 at Shenzhen University First Affiliated Hospital. For these 72 cases, 30 were treated with TR and 42 were treated with PR. Intra- and post-operative complications and clinical prognosis were investigated.Results: All 72 patients underwent a pure EES. In the TR group, 10 patients (33.3%) had intraoperative cerebrospinal fluid leakage (CSF leak), three patients (10%) had postoperative CSF leak, eight patients (26.7%) had postoperative diabetes insipidus (DI), eight patients (26.7%) had postoperative electrolyte disturbance, and 12 patients (40%) had temporary hypopituitarism postoperatively. While in the PR group, three patients (7.1%) had intraoperative CSF leak, two patients (4.8%) had postoperative DI, three patients (7.1%) had postoperative electrolyte disturbance, four patients (9.5%) had temporary hypopituitarism postoperatively, and no cases experienced postoperative CSF leak. The intra- and post-operative complications were significantly higher in TR group then PR group (P IntraoperativeCSFleak = 0.004, P Post−operativeCSFleak =0.036, P TransientDI = 0.008, P Temporaryhypopituitarism = 0.002, P Permanenthypopituitarism = 0.036, P Electrolytedisturbance = 0.023). No significant differences in post-operative improvement and recurrence.Conclusions: EES is a safe and effective approach for the treatment of symptomatic RCC. Complete sucking out the cyst contents and partial resection of the cyst wall may be sufficient for treatment, and total resection of the cyst wall is associated with a higher incidence of complications.

Climate change and nephrology

Climate change should be of special concern for the nephrologist, as the kidney has a critical role in protecting the host from dehydration, but it is also a favorite target of heat stress and dehydration. Here we discuss how rising temperatures and extreme heat events may affect the kidney. The most severe presentation of heat stress is heat stroke, which can result in severe electrolyte disturbance and both acute and chronic kidney disease (CKD). However, lesser levels of heat stress also have multiple effects, including exacerbating kidney disease and precipitating cardiovascular events in subjects with established kidney disease. Heat stress can also increase the risk for kidney stones, cause multiple electrolyte abnormalities and induce both acute and chronic kidney disease. Recently there have been multiple epidemics of CKD of uncertain etiology in various regions of the world, including Mesoamerica, Sri Lanka, India and Thailand. There is increasing evidence that climate change and heat stress may play a contributory role in these conditions, although other causes, including toxins, could also be involved. As climate change worsens, the nephrologist should prepare for an increase in diseases associated with heat stress and dehydration.

833 CLINICAL PATHWAY DEVELOPMENT AND IMPLEMENTATION FOR THE MANAGEMENT OF CHYLE LEAK FOLLOWING OESOPHAGECTOMY: THE OXFORD EXPERIENCE

Thoracic chyle leakage is a major and frequently encountered complication following oesophagectomy. The incidence of chyle leakage depends on the definition used and been reported to be as high as 20% among patients undergoing oesophagectomy. The sequalae can be severe and include hypovolemia, electrolyte disturbance, malnutrition, immune suppression, and increased mortality, thereby making prompt diagnosis and optimum management essential. Nevertheless, controversy remains surrounding the nature and timing of interventions. Methods Retrospective audit was performed of 227 consecutive patients undergoing oesophagectomy between October 2014 and April 2018 at the Oxford Oesophagogastric Centre. Following pathway implementation, data are being prospectively collected along with surveys of the experience and satisfaction of stakeholders. Results Chyle leak was treated in 29 (12.8%) post-operative patients. Females were over twice as likely to be treated for chyle leak (OR 2.31, P = 0.042), while age and length of operation showed no association. Chyle leak was associated with a failure to complete the ERAS pathway (P = 0.005), an increased length of stay (P = 0.0001) with the median length of stay being 4 days greater among the chyle leak group, and increased rates of readmission (P = 0.032). Conclusion Our data highlight the significant morbidity associated with thoracic chyle leakage. Upon review of best available evidence, a clinical pathway was developed for the early diagnosis and standardised management of chyle leak (Figure 1). The goal of the pathway is that patients achieve predetermined outcome within a specified time frame. Here we present our development and experience of the Oxford Oesophagogastric Chyle Leak Pathway and describe the particular challenges and interim outcomes of its implementation.

Rhabdomyolysis Following Administration of Comirnaty®

Introduction: Vaccination against COVID-19 is essential to control the pandemic. The vaccines developed so far have good safety profiles but full knowledge of adverse effects will only be acquired with time and through case reports. Case Description: We present the case of a man admitted with rhabdomyolysis 3 days after receiving his first dose of the Pfizer coronavirus vaccine Comirnaty® Other traumatic, infectious, endocrine, electrolyte disturbance and autoimmune causes of rhabdomyolysis were excluded. The temporal relationship between vaccine administration and disease onset indicated possible causality. The patient had a favourable evolution after receiving fluids and completely recovered. To our knowledge, there have been only 69 reports of rhabdomyolysis following Comirnaty® administration in Europe, as stated by the European Medicines Agency, and this is the first case report in Portugal. Discussion: When a patient presents with rhabdomyolysis without an obvious traumatic or exertional cause, other aetiologies need to be excluded. Drug use is one of the most common causes of rhabdomyolysis in adults. Conclusion: We present a case compatible with an adverse effect of Comirnaty® in order to raise awareness of this condition in vaccinated patients.

Contemporary approach to understand and manage COVID-19-related arrhythmia

Arrhythmia, one of the most common complications of COVID-19, was reported in nearly one-third of diagnosed COVID-19 patients, with higher prevalence rate among ICU admitted patients. The underlying etiology for arrhythmia in these cases are mostly multifactorial as those patients may suffer from one or more of the following predisposing mechanisms; catecholamine surge, hypoxia, myocarditis, cytokine storm, QTc prolongation, electrolyte disturbance, and pro-arrhythmic drugs usage. Obviously, the risk for arrhythmia and the associated lethal outcome would rise dramatically among patients with preexisting cardiac disease such as myocardial ischemia, heart failure, cardiomyopathy, and hereditary arrhythmias. Considering all of these variables, the management strategy of COVID-19 patients should expand from managing a viral infection and related host immune response to include the prevention of predictable causes for arrhythmia. This may necessitate the need to investigate the role of some drugs that modulate the pathway of arrhythmia generation. Of these drugs, we discuss the potential role of adrenergic antagonists, trimetazidine, ranolazine, and the debatable angiotensin converting enzyme inhibitors drugs. We also recommend monitoring the level of: unbound free fatty acids, serum electrolytes, troponin, and QTc (even in the absence of apparent pro-arrhythmic drug use) as these may be the only indicators for patients at risk for arrhythmic complications.

Osmotic demyelination syndrome following slow correction of hyponatraemia

Hyponatraemia is the most common electrolyte disturbance observed in hospital inpatients. We report a 90-year-old woman admitted generally unwell following a fall with marked confusion. Examination revealed a tender suprapubic region, and investigations observed elevated inflammatory markers and bacteriuria. Admission investigations demonstrated a serum sodium of 110 mmol/L with associated serum osmolality 236 mmol/kg and urine osmolality 346 mmol/kg. She was treated for hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone (SIADH) and urosepsis. However, her serum sodium failed to normalise despite fluid restriction, necessitating treatment with demeclocycline and hypertonic saline. Despite slow reversal of hyponatraemia over 1 month, the patient developed generalised seizures with pontine and thalamic changes on MRI consistent with osmotic demyelination syndrome (ODS). This case highlights the risk of ODS, a rare but devastating consequence of hyponatraemia treatment, despite cautious sodium correction.