COVID-19 and Stress: A Young Male Presenting with Central Cyanosis, Dark Urine, Oliguria, Jaundice and Anemia due to Methemoglobinemia as a result of Suicidal Naphthalene Mothball Poisoning Recovered with Exchange Transfusion

A young man presented with abdominal pain and vomiting after eating Naphthalene Mothball. He had dyspnea, central cyanosis (SaO2 on air was 67% on air), marked pallor, deep jaundice and dehydration. His urine color was black; and, his plasma in clotted blood sample was brownish. He was treated as methemoglobinemia due to suicidal Naphthalene Mothball poisoning with fluid and electrolyte replacement, ascorbic acid, N-acetylcystine and exchange transfusion twice with four units of whole blood. Dramatic improvement in central cyanosis immediately following exchange transfusion. Psychiatric consultation and counselling were done; he admitted the main reason for committing suicide was socioeconomic stress due to COVID-19.

Starvation ketoacidosis and refeeding syndrome

Starvation ketoacidosis (SKA) is a rarer cause of ketoacidosis. Most patients will only have a mild acidosis, but if exacerbated by stress can result in a severe acidosis. We describe a 66-year-old man admitted with reduced consciousness and found to have a severe metabolic acidosis with raised anion gap. His body mass index (BMI) was noted to be within the healthy range at 23 kg/m2; however, it was last documented 1 year previously at 28 kg/m2 with no clear timeframe of weight loss. While his acidosis improved with intravenous fluids, he subsequently developed severe electrolyte imbalance consistent with refeeding during his admission. Awareness of SKA as a cause for high anion gap metabolic acidosis is important and knowledge of management including intravenous fluids, thiamine, dietetic input and electrolyte replacement is vital.

Idiopathic Adult Onset Fanconi’s Syndrome in a Patient Treated with Oxaliplatin

Proximal tubular injury is known complication of chemotherapy such as carboplatin. However, there are far more other causes of injury and in many situations, the etiology is difficult to elucidate. Here we describe a case of a patient who presented with a urine analysis consistent of Fanconi’s syndrome with signs and symptoms of the disorder prior to chemotherapy but requiring admission for aggressive electrolyte replacement soon after the chemotherapy was completed. We further discuss causes of Fanconi’s syndrome and the importance of evaluation of the proximal convoluted tubule prior to administration of chemotherapy.

Euglycemic Diabetic Ketoacidosis in a Patient With Gestational Diabetes Mellitus and COVID-19 Infection

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening medical emergency requiring urgent treatment. Euglycemic DKA may occur in patients with both type 1 and type 2 Diabetes Mellitus (DM), as well as pregnancy. The absence of marked hyperglycemia can result in delayed diagnosis and treatment, resulting in potential adverse outcomes. Diabetes is a major comorbidity associated with severe hospital course and high fatality rate among patients with COVID-19 infection. We report our experience in a patient with gestational diabetes mellitus who developed euglycemic DKA and COVID-19 infection in her third trimester of pregnancy. Clinical Case: A 30-year-old lady at 29weeks gestation presented with two-day history of vomiting, diarrhea and abdominal pain. She reported good fetal movements. She had been diagnosed with Gestational Diabetes Mellitus (GDM) at 20 weeks gestational age, receiving treatment with multiple daily injections of insulin. 5 days earlier, she had tested positive for COVID-19 infection. She was asymptomatic; testing was performed as she had been in contact with a confirmed case. On examination she was afebrile and vitally stable, but dehydrated. Her initial laboratory investigations showed ketonemia with normal glucose level and normal anion gap. She was treated as a case of starvation ketosis and dehydration, with intravenous fluids and electrolyte replacement. However, 3 days later, the patient complained of worsening nausea and vomiting with dry cough and she developed hypotension. Chest X-ray showed bilateral mid and lower zone pulmonary infiltrates. She was treated as COVID-19 pneumonia, received 2 units of COVID-19 convalescent plasma and broad-spectrum intravenous antibiotics. Repeated investigations showed worsening ketosis with high anion gap metabolic acidosis, consistent with a diagnosis of euglycemic DKA. Insulin infusion was initiated, isotonic saline with electrolyte replacement was also continued. She symptomatically improved over the next two days, with resolution of ketonemia and acidosis. The patient was discharged and she was well at her outpatient follow up visit. She underwent emergency Cesarean Section at 37 weeks gestational age, due to non-reassuring electronic fetal monitoring. She delivered a healthy female infant weighing 2445grams. Conclusion: Pregnancy is a high-risk period for DKA particularly when associated with other stressors that were identified in our patient – GDM, restricted calorie intake and COVID-19 infection. Diabetes is a risk factor for developing severe forms of COVID-19 and on the other hand, COVID-19 infection is associated with poor glycemic control and higher risk of hyperglycemic emergencies including ketoacidosis in diabetic patients. Prompt recognition of euglycemic DKA is critical in pregnancy, as this condition is associated with high fetal mortality rates.

Safety of a Nurse-Driven Standardized Potassium Replacement Protocol in Critically Ill Patients With Renal Insufficiency

Background In critically ill patients, maintaining appropriate serum potassium concentrations requires careful supplementation to correct hypokalemia but avoid hyperkalemia. At the study institution, an institution-based, nurse-driven standardized electrolyte replacement protocol is used in critically ill patients with a serum creatinine concentration of 2 mg/dL or less. If the serum creatinine concentration is greater than 2 mg/dL, electrolyte replacement requires a physician order. Objective To determine if standardized potassium supplementation is safe in critically ill patients with renal insufficiency not requiring renal replacement therapy. Methods This study was an institutional review board–approved, single-center, retrospective evaluation of critically ill patients receiving intravenous potassium replacement per protocol. Patients were grouped according to serum creatinine concentration (≤ 2 mg/dL or > 2 mg/dL) at the time of replacement. The primary outcome was the incidence of hyperkalemia (potassium concentration ≥ 5 mEq/L) following potassium replacement. Secondary outcomes were the incidence of hyperkalemia, change in serum potassium concentration, and need for hyperkalemia treatment. Outcomes were analyzed using χ2 and t tests. Results Of 814 patients screened, 145 were included (99 with serum creatinine ≤ 2 mg/dL and 46 with serum creatinine > 2 mg/dL). The incidence of hyperkalemia was not different between groups (P = .57). Five patients experienced hyperkalemia; none received hyperkalemia treatment. Change in serum potassium was similar for patients in the 2 groups (P = .33). Conclusions A standardized, nurse-driven electrolyte replacement protocol can be used safely in critically ill patients with renal insufficiency not requiring renal replacement therapy.

Patient with Bartter syndrome in whom chronic potassium depletion was considered one of the causes of hyponatremia

A 53-year-old man was admitted to our hospital because of general fatigue and disorientation. He had been diagnosed with Bartter syndrome in his teens and had been taking potassium preparations since then. However, his serum potassium concentration (K+s) remained persistently low. Ten days before admission, he developed fever. He was diagnosed as having bronchitis and was treated with antibiotics. Although his fever subsided, general fatigue worsened. Laboratory examination showed hyponatraemia (127 mEq/L), while K+s was 2.3 mEq/L. C reactive protein was negative. On admission, laboratory examination revealed deterioration of hyponatraemia (125 mEq/L). Although his serum sodium concentration (Na+s) was refractory to electrolyte replacement, the level increased towards normal after spironolactone administration, following normalisation of K+s, suggesting that hyponatraemia was caused by K+ depletion. Physicians should be aware of the importance of the effects of exchangeable K+ (K+e) on Na+s.

Oseltamivir-Associated Bradycardia in Critically Ill Patients

Background: Oseltamivir is frequently administered to critically ill patients with presumed influenza. It may modulate Na+, K+, and Ca2+ channels to produce bradycardia. Objective: To evaluate the association between oseltamivir and bradycardia in critically ill patients and assess parameters associated with bradycardia. Methods: This was a retrospective audit of 203 critically ill adults with presumed influenza receiving at least 2 doses of oseltamivir. The primary outcome was the occurrence of bradycardia, defined as a heart rate (HR) ≤59 beats per minute (BPM) while receiving oseltamivir or a decrease of ≥20 BPM compared with the lowest HR before initiating oseltamivir. Results: A total of 88 (43.4%) patients manifested bradycardia, 59 with HR ≤59 BPM, 19 with HR decrease of ≥20 BPM, and 10 with both. The time from first dose to bradycardia was 51.4 ± 43 hours. In all, 48 (54.6%) patients received therapies for bradycardia, including increased inotropic/vasopressor dose, electrolyte replacement, electrocardiogram, discontinuation of other medications, cardiology consult, discontinuation of oseltamivir, and pacer placement. There were no significant differences between groups with bradycardia versus without in terms of demographics, laboratory values, hospital characteristics, or oseltamivir dosing. Multivariate logistic regression showed that bradycardia was associated with baseline HR, age, past medical history of neurological issues, and positive influenza status. Between hours 6 through 126, significant differences existed between groups in actual and lowest HR. Conclusion and Relevance: Oseltamivir was associated with clinically relevant bradycardia in critically ill patients. Clinicians should closely monitor HR in critically ill patients receiving oseltamivir.

Over-the-counter antacids linked to severe hypokalaemia in the context of threatened preterm labour

A healthy multiparous woman presented at 35 weeks and 4 days’ gestation with threatened preterm labour on multiple occasions. An incidental finding of severe hypokalaemia (2.4 mmol/L) was detected on routine blood tests. The cause of this hypokalaemia was not initially obvious. It was eventually linked to overuse of over-the-counter antacids for pregnancy-associated heartburn. The patient was managed with parenteral and then oral electrolyte replacement which corrected a pH of 7.55, bicarbonate of 36.7 mEq/L and a base excess 13.1. In this case report we consider whether hypokalaemia could be linked to uterine irritability and threatened preterm labour, whether antacids were being abused in the context of an eating disorder and the importance of taking a full drug history.

Prediction of electrolyte refresh time for Mg-Air battery

In order to understand when to replace the electrolyte of the Mg-Air battery, the effect of the surface area of Metal anode according to the consumption. For each capacity of the Mg-Air battery pack on the electrolyte concentration was calculated, the timing of electrolyte replacement was predicted.