Maximum serum K+ concentration within 1 hour with enteral replacement in severe hypokalemia.

Introduction: Introduction: we report two cases with severe hypokalemia. Patients and methods: a 68-year-old woman was admitted with lower limb swelling and urinary symptoms; on the fourth day serum K+ concentration (s[K+]) was 2.3 mmol/L. A 64-year-old woman was admitted with pain in the lumbosacral spine, she was diagnosed with multiple myeloma. After receiving specific therapy she showed s[K+] at 2.4 mmol/L. A KCl solution containing 26.8 mEq of K+ was administered enterally, which increased s[K+] by 0.7 mmol/L within 1 h. Results and conclusion: these cases reveal that peak s[K+] may be achieved within 1 hour after KCl intake in severe hypokalemia, which is probably faster than IV administration.

Introducción: Introducción: se presentan dos casos clínicos con hipopotasemia severa. Pacientes y métodos: mujer de 68 años que ingresó por edema en miembros inferiores y síntomas urinarios; al cuarto día, el nivel sérico de K+ ([K+]s) era de 2,3 mmol/L. Una mujer de 64 años ingresó por dolor en la columna lumbosacra y fue diagnosticada de mieloma múltiple; luego de recibir terapia específica, presentó una [K+]s de 2.4 mmol/L. Se administró por vía enteral una solución de KCl que contenía 26,8 mEq de K+, aumentando la [K+]s en 0,7 mmol/L en 1 h. Resultados y conclusión: estos casos revelan que la [K+]s máxima se alcanzaría 1 hora después de la ingestión de KCl en la hipopotasemia grave, probablemente en menos tiempo que por vía intravenosa.

Exogenously applied nutrients can improve the chickpea productivity under water stress conditions by modulating the antioxidant enzyme system / Nutrientes aplicados exogenamente melhoram a produtividade do grão-de bico em condições de estresse hídrico, modulando o sistema de enzimas antioxidantes

Water stress is one of the major factor restricting the growth and development of chickpea plants by inducing various morphological and physiological changes. Therefore, the present research activity was designed to improve the chickpea productivity under water stress conditions by modulating antioxidant enzyme system. Experimental treatments comprised of two chickpea genotypes i.e. Bhakhar 2011 (drought tolerant) and DUSHT (drought sensitive), two water stress levels i.e. water stress at flowering stage and water stress at flowering + pod formation + grain filling stage including well watered (control) and three exogenous application of nutrients i.e. KCl 200 ppm, MgCl2, 50 ppm and CaCl2, 10 mM including distilled water (control). Results indicated that water stress at various growth stages adversely affects the growth, yield and quality attributes of both chickpea cultivars. Exogenous application of nutrients improved the growth, yield and antioxidant enzyme activities of both chickpea genotypes even under water stress conditions. However, superior results were obtained with foliar spray of potassium chloride on Bhakhar 2011 under well-watered conditions. Similarly, foliar spray of potassium chloride on chickpea cultivar Bhakhar 2011 cultivated under stress at flowering + pod formation + grain filling stage produced significantly higher contents of superoxide dismutase, peroxidase and catalase. These results suggests that the application of potassium chloride mitigates the adverse effects of water stress and enhanced tolerance in chickpea mainly due to higher antioxidant enzymes activity, demonstrating the protective measures of plant cells in stress conditions.

O estresse hídrico é um dos principais fatores que restringem o crescimento e o desenvolvimento das plantas de grão-de-bico, induzindo várias alterações morfológicas e fisiológicas. Portanto, a presente atividade de pesquisa foi projetada para melhorar a produtividade do grão-de-bico em condições de estresse hídrico, por meio da modulação do sistema de enzimas antioxidantes. Tratamentos experimentais compostos de dois genótipos de grão-de-bico, ou seja, Bhakhar 2011 (tolerante à seca) e DUSHT (sensível à seca), dois níveis de estresse hídrico, ou seja, estresse hídrico na fase de floração e estresse hídrico na floração + formação de vagens + estágio de enchimento de grãos incluindo bem irrigado (controle) e três aplicações exógenas de nutrientes, ou seja, KCl 200 ppm, MgCl2 50 ppm e CaCl2 10 mM, incluindo água destilada (controle). Os resultados indicaram que o estresse hídrico em vários estágios de crescimento afeta negativamente os atributos de crescimento, rendimento e qualidade de ambas as cultivares de grão-de-bico. A aplicação exógena de nutrientes melhorou o crescimento, o rendimento e as atividades das enzimas antioxidantes de ambos os genótipos de grão-de-bico, mesmo em condições de estresse hídrico. No entanto, resultados superiores foram obtidos com pulverização foliar de cloreto de potássio em Bhakhar 2011, em condições bem irrigadas. Da mesma forma, a pulverização foliar de cloreto de potássio na cultivar de grão-de-bico Bhakhar 2011 cultivada sob estresse na fase de floração + formação de vagens + enchimento de grãos produziu teores significativamente maiores de superóxido dismutase, peroxidase e catalase. Esses resultados sugerem que a aplicação de cloreto de potássio atenua os efeitos adversos do estresse hídrico e aumenta a tolerância no grão-de-bico, principalmente em razão de mais atividade de enzimas antioxidantes, demonstrando as medidas protetoras das células vegetais em condições de estresse.

Del Nido versus HTK cardioplegia for myocardial protection during adult complex valve surgery: a retrospective study.

BACKGROUND: Histidine-tryptophan-ketoglutarate (HTK) and del Nido (DN) cardioplegia are intracellular-type and extracellular-type solution respectively, both can provide a long period of myocardial protection with single-dose infusion, but studies comparing the two are rare for adult cardiac surgery. This study aims to evaluate whether DN is suitable for cardioplegia in complex and high-risk valve surgery with long-term cardiac ischemia when compared with HTK. METHODS: The perioperative records of adult patients infused with DN/HTK as a cardioplegic solution who underwent complex valve surgery with an expected myocardial ischaemic duration longer than 90 min between Oct 2018 and Oct 2019 were analysed retrospectively. RESULTS: Of the 160 patients who received DN/HTK and underwent complex valve surgery, we propensity matched 73 pairs. Both groups achieved satisfactory cardiac arrest effects, and no significant difference was found in their cTnI and CK-MB levels within 12 to 72 h postoperatively. The DN group had a higher rate of return to spontaneous rhythm (0.88 v 0.52, P < 0.001), a lower frequency of postoperative severe arrythmias (12% v 26%, P = 0.036), a higher postoperative stroke volume (65 v 59 ml, P = 0.011) and a higher cardiac output (6.0 v 4.9 L/min, P = 0.007) as evaluated by echocardiography, fewer transfusions and shorter ICU stays (both P < 0.05). The two groups had similar inotrope usage and similar incidences of low cardiac output, morbidities and mortality. Subgroup analysis showed that when the aortic clamping time was greater than 120 min, the advantages of DN were weakened. CONCLUSIONS: DN can be safely applied to complex valve surgery, and it has a similar myocardial protection effect as HTK. Further prospective studies are required to verify these retrospective findings. Trial registration retrospectively registered.

The effects of 0.9% saline versus Plasma-Lyte 148 on renal function as assessed by creatinine concentration in patients undergoing major surgery: A single-centre double-blinded cluster crossover trial.

OBJECTIVES: Saline and Plasma-Lyte have different physiochemical contents; consequently, they may differently affect patients' renal function. We compared the effects of fluid therapy with 0.9% saline and with Plasma-Lyte 148 on renal function as assessed by creatinine concentration among patients undergoing major surgery. METHODS: We conducted a prospective, double-blinded cluster crossover trial comparing the effects of the two fluids on major surgery patients. The primary aim was to establish the pilot feasibility, safety and preliminary efficacy evidence base for a large interventional trial to establish whether saline or Plasma-Lyte is the preferred crystalloid fluid for managing major surgery patients. The primary efficacy outcome was the proportion of patients with changes in renal function as assessed by creatinine concentration during their index hospital admission. We used changes in creatinine to define acute kidney injury (AKI) according to the RIFLE criteria. RESULTS: The study was feasible with 100% patient and clinician acceptance. There were no deviations from the trial protocol. After screening, we allocated 602 patients to saline and 458 to Plasma-Lyte. The median (IQR) volume of intraoperative fluid received was 2000 mL (1000:2000) in both groups. Forty-nine saline patients (8.1%) and 49 Plasma-Lyte patients (10.7%) developed a postoperative AKI (adjusted incidence rate ratio [aIRR]: 1.34; 95% CI: 0.93-1.95; p = 0.120). No differences were observed in the development of postoperative complications (aIRR: 0.98; 95% CI: 0.89-1.08) or the severity of the worst complication (aIRR: 1.00; 95% CI: 0.78-1.30). The median (IQR) length of hospital stay was six days (3:11) for the saline group and five days (3:10) for the Plasma-Lyte group (aIRR: 0.85; 95% CI: 0.73-0.98). There were no serious adverse events relating to the trial fluids, nor were there fluid crossover or contamination events. CONCLUSIONS: The study design was feasible to support a future follow-up larger clinical trial. Patients treated with saline did not demonstrate an increased incidence of postoperative AKI (defined as changes in creatinine) compared to those treated with Plasma-Lyte. Our findings imply that clinicians can reasonably use either solution intraoperatively for adult patients undergoing major surgery. TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; ACTRN12613001042730; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364988.

Effect of 0.9% NaCl compared to plasma-lyte on biomarkers of kidney injury, sodium excretion and tubular transport proteins in patients undergoing primary uncemented hip replacement - a randomized trial.

BACKGROUND: Isotonic saline (IS) is widely used to secure perioperative cardiovascular stability. However, the high amount of chloride in IS can induce hyperchloremic acidosis. Therefore, IS is suspected to increase the risk of acute kidney injury (AKI). Biomarkers may have potential as indicators. METHODS: In a double-blinded, placebo-controlled study, 38 patients undergoing primary uncemented hip replacement were randomized to IS or PlasmaLyte (PL). Infusion was given during surgery as 15 ml/kg the first hour and 5 ml/kg the following two hours. Urinary samples were collected upon admission and the day after surgery. As surgery was initiated, urine was collected over the course of 4 h. Hereafter, another urine collection proceeded until the morning. Urine was analyzed for markers of AKI neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). Arterious and venous blood samples for measurements of pH and plasma electrolytes including chloride (p-Cl) were collected as surgery was initiated, at the end of surgery and the following morning. RESULTS: IS induced an increase in p-Cl (111 ± 2 mmol/L after IS and 108 ± 3 after PL, p = 0.004) and a decrease in pH (7.39 ± 0.02 after IS and 7.43 ± 0.03 after PL, p = 0.001). Urinary NGAL excretion increased in both groups (ΔNGAL: 5.5 [4.1; 11.7] µg/mmol creatinine p = 0.004 after IS vs. 5.5 [2.1;9.4] µg/mmol creatinine after PL, p < 0.001). No difference was found between the groups (p = 0.839). Similarly, urinary KIM-1 excretion increased in both groups (ΔKIM-1: IS 115.8 [74.1; 156.2] ng/mmol creatinine, p < 0.001 vs. PL 152.4 [120.1; 307.9] ng/mmol creatinine, p < 0.001). No difference between the groups (p = 0.064). FENa increased (1.08 ± 0.52% after IS and 1.66 ± 1.15% after PL, p = 0.032). ENaC excretion was different within groups (p = 0.019). CONCLUSION: A significantly higher plasma chloride and a lower pH was present in the group receiving isotonic saline. However, u-NGAL and u-KIM-1 increased significantly in both groups after surgery despite absence of changes in creatinine. These results indicate that surgery induced subclinical kidney injury. Also, the IS group had a delayed sodium excretion as compared to the PL group which may indicate that IS affects renal sodium excretion differently from PL. TRIAL REGISTRATION: ClinicalTrials.gov Identifier:  NCT02528448 , 19/08/2015.

The myocardial protective effect of monosodium phosphate cardioplegia in cardiopulmonary bypass in infants with an atrial septal defect.

This study aimed to investigate the myocardial protective effect of liquid sodium phosphocreatine cardiac arrest in extracorporeal circulation surgery treating infants with atrial septal defects.Eighty-four infants with atrial septal defects who required extracorporeal circulation surgery treatment at our hospital from January 2016 to June 2018 were divided into an observation group and a control group through a digitally randomized method, with 42 cases in each group. The control group adopted the conventional modified St Thomas II high potassium cold liquid crystal cardiac arrest, while the observation group adopted the liquid sodium phosphocreatine cardiac arrest.The myocardial enzyme indexes of the 2 groups 3, 6, 12, and 24 hours postoperatively were higher than before establishing the cardiopulmonary bypass and the enzyme indexes of the control group at the same time were higher than that of the observation group; adenosine triphosphate, adenosine diphosphate, and other energy levels and the postoperative recovery rate energy levels of the observation group were higher than those in the control group, the difference was statistically significant (P < .05).Liquid sodium phosphocreatine cardiac arrest used in extracorporeal circulation surgery treating infants with atrial septal defects can reduce myocardial ischemia-reperfusion injury, maintain energy supply during ischemia, strengthen the St Thomas II effect, and aid postoperative cardiac function recovery of high potassium cold liquid crystal cardiac arrest used in infants with atrial septal defects and treated with extracorporeal circulation surgery.

Transitioning to Del Nido cardioplegia for all-comers: the next switching gear?

BACKGROUND: Exclusive use of Del Nido cardioplegia administration in all adult patients undergoing cardiac surgery has been studied for operative, postoperative and myocardial protection outcomes. METHODS: From November 2016 to October 2017, Del Nido cardioplegia was used in 131 consecutive patients (DN group). Using a propensity score, DN group was compared to 251 patients having received intermittent cold blood cardioplegia (CB group). RESULTS: Preoperative characteristics were similar in DN and CB groups. Operative outcomes were statistically different (p < 0.0001): cardiopulmonary bypass (CPB) time (DN 105.9 ± 46.5, CB 131.2 ± 38.8); aortic cross-clamp time (DN 80.8 ± 35.5, CB 102.2 ± 31.3); operative time (DN 203.1 ± 65.0, CB 241.5 ± 54.7); total cardioplegia volume (DN 1328 ± 879, CB 3773 ± 1226); and peak glycemia on CPB (DN 8.2 ± 2.3, CB 9.0 ± 1.8). No statistical differences were noted in intensive care unit stay, hospital stay and hospital death. Myocardial protection outcomes were similar: discharge left ventricular ejection fraction (DN 52 ± 11, CB 51 ± 10); Troponin levels at the end of the surgery (DN 871 ± 1623, CB 1958 ± 854), day 1 (DN 853 ± 1139, CB 993 ± 8234) and day 4 (DN 442 ± 540, CB 463 ± 317). CONCLUSION: Del Nido cardioplegia use in all adult cardiac surgeries is associated with improved surgical efficiency. The design of larger trials including adults combined cardiac procedures and emergencies is needed.

Heterotopic pregnancy: Simultaneous viable and nonviable pregnancies.

Heterotopic pregnancy occurs when a patient has simultaneous intrauterine and ectopic pregnancies. Rates of heterotopic pregnancy have been rising with increased availability and access to in vitro fertilization and other advanced fertility technologies. Symptoms of heterotopic pregnancy are nonspecific, such as vague abdominal pain, so transvaginal ultrasound is a crucial part of the diagnostic process. Laparoscopy is the most commonly performed treatment of the ectopic pregnancy; other options include localized injections of methotrexate and/or potassium chloride. Following definitive termination of the ectopic pregnancy, many patients will successfully deliver the intrauterine pregnancy at term. Early identification of heterotopic pregnancy can reduce maternal morbidity and mortality.

Single-dose cardioplegia protects myocardium as well as traditional repetitive dosing: A noninferiority randomized study.

OBJECTIVE: The present prospective noninferiority randomized trial was designed to demonstrate the safety and efficacy of a single dose of Custodiol histidine-tryptophan-ketoglutarate compared with repetitive cold-blood cardioplegia. METHODS: From October 2012 to May 2014, 110 patients were randomly assigned to 1 of 2 groups: Group 1 (55 patients) received repetitive cold-blood cardioplegia, and group 2 (55 patients) received single-dose Custodiol histidine-tryptophan-ketoglutarate. Isolated aortic valve replacement, isolated mitral valve replacement, and multivalve procedures represented the most frequent operations, with 39 cases (71%) in group 1 and 49 cases (89%) in group 2. There was no difference in cardiopulmonary bypass time (102 ± 26 minutes vs 99 ± 19 minutes, P = .70) or aortic crossclamp time (77 ± 19 minutes vs 74 ± 17 minutes, P = .33). All patients underwent preoperative electrocardiogram and determination of creatine kinase-MB, troponin I, left ventricular ejection fraction, and regional wall motion. Postoperative cardiac biomarkers were checked at 7, 24, and 48 hours, and an echocardiogram was obtained to check for left ventricular function abnormalities. RESULTS: There was no difference in cardiac biomarkers release between the 2 groups at baseline and 7, 24, and 48 hours postoperatively (creatine kinase, P = .18, troponin P = .23). Left ventricular function was similar between groups preoperatively and at 24 hours after surgery. No death or myocardial infarction was observed in either group. There were no differences in intensive care unit length of stay, incidence of atrial fibrillation, use of inotropes or vasopressors support, time of intubation, or creatinine levels. CONCLUSIONS: A single dose of Custodiol histidine-tryptophan-ketoglutarate cardioplegia is not inferior to repeated cold-blood cardioplegia during elective cardiac surgery.

Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit.

OBJECTIVE: Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. DESIGN: A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. PATIENTS: Pediatric patients with congenital or acquired cardiac disease. SETTING: Twenty-four-bed cardiothoracic intensive care unit in a tertiary children's hospital. INTERVENTIONS: Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. RESULTS: There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001). CONCLUSION: The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.

Horseshoe Kidney Protection with Histidine-Tryptophan-Ketoglutarate Solution during Surgical Abdominal Aortic Aneurysm Repair.

CASE REPORT: We report an unusual case of a 65-year-old male patient with horseshoe kidney, who underwent a successful open repair for an abdominal aortic aneurysm (AAA). The accessory renal arteries were perfused with histidine-tryptophan-ketoglutarate (HTK) solution (Custodiol®; Dr. Franz-Kohler Chemie GmbH, Bensheim, Germany) during the vascular reconstruction. There were no creatinine and estimated glomerular filtration rate (eGFR) modifications in the postoperative time. In the literature, only two cases of Custodiol solution for kidney protection during aortic surgery are reported. To the best of our knowledge, this is the first case of Custodiol perfusion for horseshoe kidney protection. DISCUSSION: The concomitant presence of horseshoe kidney and an AAA requires a specific preoperative planning. This is necessary to define the appropriate surgical procedure and strategy. The onset of acute kidney injury is an aspect that must always be taken into consideration during aortic surgery, even more in the case we are reporting. Indeed, despite the complexity of the kidney anatomy, the use of Custodiol solution allowed a proper maintenance of the perioperative renal function, as shown by the postoperative levels of creatinine and eGFR. CONCLUSIONS: Preoperative planning and organ preservation are crucial in AAA open repair, especially in the presence of congenital anomalies such as horseshoe kidney.

Bolus potassium in frustrated ventricular fibrillation storm.

BACKGROUND: Ventricular fibrillation (VF) is a well-known ominous complication of ischemic heart disease. While firmly structured algorithms have been developed for its management, yet its mortality rate remains high. CASE PRESENTATION: This is a case report of a 46-year-old gentleman who was a victim of recurrent cardiac arrest in the ward while awaiting coronary artery bypass grafting (CABG) surgery. Emergency CABG was performed, intraoperatively he experienced recurrent VF which was reverted by direct current cardioversion-Defibrillation. He was sent to the Cardiac Surgery Intensive Care Unit (CSICU) with an open chest on extracorporeal membrane oxygenation (ECMO) support and an intra-aortic balloon pump. Postoperatively in CSICU he still experienced malignant ventricular arrhythmia with dropping of ejection fraction to less than 10%. The last few episodes of VF were lengthy, lasting more than an hour (while on ECMO support) with the failure of various antiarrhythmic medications to abort them. Eventually, a decision was made to give him 20 mmol boluses of potassium chloride (KCl) intravenously aiming at introducing a state of asystole, but the rhythm changed to sinus rhythm. CONCLUSIONS: This report highlighted the fact that optimum management of VF is still lacking and necessitates more studies. The appropriate effective dose of potassium replacement during VF might need to be reconsidered in patients with persistent VF.

Electronic prescription: frequency and severity of medication errors

SUMMARY OBJECTIVE: To assess the frequency and severity of prescriptions errors with potentially dangerous drugs (heparin and potassium chloride for injection concentrate) before and after the introduction of a computerized provider order entry (CPOE) system. METHODS: This is a retrospective study that compared errors in manual/pre-typed prescriptions in 2007 (Stage 1) with CPOE prescriptions in 2014 (Stage 2) (Total = 1,028 prescriptions), in two high-complexity hospitals of Belo Horizonte, Brasil. RESULTS: An increase of 25% in the frequency of errors in Hospital 1 was observed after the intervention (p<0.001). In contrast, a decreased error frequency of 85% was observed in Hospital 2 (p<0.001). Regarding potassium chloride, the error rate remained unchanged in Hospital 1 (p>0.05). In Hospital 2, a significant decrease was recorded in Stage 2 (p<0.001). A reduced error severity with heparin (p<0.001) was noted, while potassium chloride-related prescription severity remain unchanged (p> 0.05). CONCLUSIONS: The frequency and severity of medication errors after the introduction of CPOE was affected differently in the two hospitals, which shows a need for thorough observation when the prescription system is modified. Control of new potential errors introduced and their causes for the adoption of measures to prevent these events must be in place during and after the implementation of this technology.

RESUMO OBJETIVO: Avaliar a frequência e a gravidade de erros em prescrições envolvendo medicamentos potencialmente perigosos (heparina e cloreto de potássio concentrado injetável) antes e após a introdução de um sistema de prescrição eletrônica. MÉTODOS: Trata-se de estudo retrospectivo que comparou erros em prescrições manuais e pré-digitadas de 2007 (Fase 1) com prescrições eletrônicas de 2014 (Fase 2) (total = 1.028 prescrições), em dois hospitais de alta complexidade de Belo Horizonte. RESULTADOS: Foi observado no hospital 1 aumento de 25% dos erros depois da intervenção (p<0,001), e no hospital 2 foi verificada redução de 85% (p<0,001). Para o cloreto de potássio, a frequência de erros permaneceu a mesma no hospital 1 (p>0,05), independentemente da fase e, no hospital 2, ocorreu redução significativa na fase 2 (p<0,001). Foi identificada redução da gravidade dos erros com a heparina (p<0,001), mas não houve alteração na gravidade dos erros com cloreto de potássio (p>0,05). CONCLUSÕES: A frequência e a gravidade dos erros de medicação após a introdução de prescrição eletrônica foram impactadas de forma diferente nos dois hospitais, demonstrando necessidade de observação criteriosa quando o sistema de prescrição é modificado. Durante e após a implantação dessa tecnologia, deve existir controle dos novos erros potenciais introduzidos e suas causas para a adoção de medidas de prevenção desses eventos.

Coexistence of myasthenia gravis with hypokalemic periodic paralysis: a rare presentation.

Bilateral symmetrical weakness of acute onset is not very uncommon and the differential varies widely from life-threatening neurological illnesses to metabolic and electrolyte derangements. We report the case of a young female with severe muscle weakness, respiratory distress and hypokalemia who required immediate intubation on arrival to emergency department. During hospital course, even after normalisation of serum potassium and some improvement in limb weakness, patient failed multiple attempts of extubation because of type II respiratory failure. Subsequently, acetyl cholinesterase antibodies were checked which came out positive, and diagnosis of myasthenia gravis and hypokalemic periodic paralysis was made. She was successfully extubated after intravenous pulse steroids, pyridostigmine and plasmapheresis. Patient was finally discharged home on oral steroids, pyridostigmine and azathioprine. In a patient presenting with hypokalemic weakness, the suspicion of a second disorder should be very high if weakness fails to resolve following correction of hypokalemia.

Potassium supplementation mitigates corticosteroid-induced neuropsychiatric effects in pediatric oncology patients.

Corticosteroids play an essential role in the treatment of pediatric malignancies, but have many untoward side effects including behavioral and mood disturbances which can be quite burdensome to families. Potassium chloride has been used anecdotally to decrease these neuropsychiatric effects but this experience has not been studied systematically. We therefore retrospectively reviewed our experience utilizing KCl supplementation to reduce corticosteroid-induced neuropsychiatric effects among children with acute lymphoblastic leukemia. Thirteen of 16 patients (81%) had a objective benefit with KCl at a median dose of 0.5 mEq/kg/day, with no reported adverse effects. Further prospective study is required to confirm these data.

Can an amino acid-based oral rehydration solution be effective in managing immune therapy-induced diarrhea?

Immune checkpoint inhibitor (ICPi) therapy has transformed the way we treat cancer. However, its immune related adverse events (irAEs) can be debilitating and life threatening. Immune therapy-induced diarrhea (ITID) is one of the most commonly encountered irAEs and can lead to expensive and prolonged hospitalizations. The current standard of care for grade 3 or 4 ITID involves ICPi discontinuation, the initiation of steroids, and infliximab for refractory disease. This treatment regimen reverses the desired anti-tumor effect of ICPis, can lead to side effects, and is cost-ineffective. We report the first case of the successful treatment of grade 3 ITID with steroids and an amino acid-based oral rehydration solution (AA-ORS), enterade. Research suggests that AA-ORS may be used to reduce diarrhea and adequately hydrate patients, in contrast to glucose-based oral rehydration solutions, which have been implicated as a contributing factor to diarrhea in cancer patients. We hypothesize that an AA-ORS may mitigate ITID via safer and more economically viable means than the current standard of care, but more controlled trials are needed to test this hypothesis.

Desenvolvimento de produto cárneo de ovino com reduzido teor de sódio / Development of meat product of sheep with reduced sodium content

O uso de partes pouco comerciais da carne ovina na elaboração de produtos cárneos processados tem se mostrado bastante promissor, bem como práticas que reduzam o teor de sódio presente nos alimentos. O presente trabalho objetivou formular linguiça de ovino com reduzido teor de sódio, substituindo o cloreto de sódio pelo cloreto de potássio e avaliando as características físico-químicas e sensoriais do produto. Os resultados obtidos foram semelhantes quanto à composição centesimal das duas formulações elaboradas. Contudo, o teste sensorial apontou um Índice de Aceitabilidade de 86% para a fórmula contendo sódio, enquanto o mesmo índice foi de 39% para aquela contendo potássio. Aliada à baixa intenção de compra da segunda formulação, constatou-se que o corte do sódio da formulação ainda enfrenta resistência quanto à aceitação dos atributos.