[Intraoperative management of potentially fatal arrhythmias after anesthesia induced by severe hypokalemia: A case report].

Severe hypokalemia is defined as the concentration of serum potassium lower than 2.5 mmol/L, which may lead to serious arrhythmias and cause mortality. We report an unusual case of potentially fatal ventricular arrhythmias induced by severe hypokalemia in a patient undergoing laparoscopic partial nephrectomy in Peking University Third Hospital due to irregular use of indapamide before operation. Indapamide is a sulfonamide diuretic with vasodilative and calcium antagonistic effects, which enhances sodium delivery to the renal distal tubules resulting in a dose-related increase in urinary potassium excretion and decreases serum potassium concentrations. The electrolyte disorder caused by the diuretic is more likely to occur in the elderly patients, especially those with malnutrition or long-term fasting. Hence, the serum potassium concentration of the patients under indapamide therapy, especially elderly patients, should be monitored carefully. Meanwhile, the potassium concentration measured by arterial blood gas analysis is different from that measured by venous blood or laboratory test. According to the previous research, the concentration of potassium in venous blood was slightly higher than that in arterial blood, and the difference value was 0.1-0.5 mmol/L. This error should be taken into account when rapid intravenous potassium supplementation or reduction of blood potassium level was carried out clinically. In the correction of severe hypokalemia, the standard approach often did not work well for treating severe hypokalemia. The tailored rapid potassium supplementation strategy shortened the time of hypokalemia and was a safe and better treatment option to remedy life-threatening arrhythmias caused by severe hypokalemia with a high success rate. Through the anesthesia management of this case, we conclude that for the elderly patients who take indapamide or other potassium excretion diuretics, the electrolyte concentration and the general volume state of the patients should be comprehensively measured and fully evaluated before operation. It may be necessary for us to reexamine the serum electrolyte concentration before anesthesia induction on the morning of surgery in patients with the history of hypokalemia. For severe hypokalemia detected after anesthesia, central venous cannulation access for individualized rapid potassium supplementation is an effective approach to reverse the life-threatening arrhythmias caused by severe hypokalemia and ensure the safety of the patients.

Intraoperative management of potentially fatal arrhythmias after anesthesia induced by severe hypokalemia: A case report / 北京大学学报(医学版)

Severe hypokalemia is defined as the concentration of serum potassium lower than 2.5 mmol/L, which may lead to serious arrhythmias and cause mortality. We report an unusual case of potentially fatal ventricular arrhythmias induced by severe hypokalemia in a patient undergoing laparoscopic partial nephrectomy in Peking University Third Hospital due to irregular use of indapamide before operation. Indapamide is a sulfonamide diuretic with vasodilative and calcium antagonistic effects, which enhances sodium delivery to the renal distal tubules resulting in a dose-related increase in urinary potassium excretion and decreases serum potassium concentrations. The electrolyte disorder caused by the diuretic is more likely to occur in the elderly patients, especially those with malnutrition or long-term fasting. Hence, the serum potassium concentration of the patients under indapamide therapy, especially elderly patients, should be monitored carefully. Meanwhile, the potassium concentration measured by arterial blood gas analysis is different from that measured by venous blood or laboratory test. According to the previous research, the concentration of potassium in venous blood was slightly higher than that in arterial blood, and the difference value was 0.1-0.5 mmol/L. This error should be taken into account when rapid intravenous potassium supplementation or reduction of blood potassium level was carried out clinically. In the correction of severe hypokalemia, the standard approach often did not work well for treating severe hypokalemia. The tailored rapid potassium supplementation strategy shortened the time of hypokalemia and was a safe and better treatment option to remedy life-threatening arrhythmias caused by severe hypokalemia with a high success rate. Through the anesthesia management of this case, we conclude that for the elderly patients who take indapamide or other potassium excretion diuretics, the electrolyte concentration and the general volume state of the patients should be comprehensively measured and fully evaluated before operation. It may be necessary for us to reexamine the serum electrolyte concentration before anesthesia induction on the morning of surgery in patients with the history of hypokalemia. For severe hypokalemia detected after anesthesia, central venous cannulation access for individualized rapid potassium supplementation is an effective approach to reverse the life-threatening arrhythmias caused by severe hypokalemia and ensure the safety of the patients.

Hydrogel Carbohydrate-Electrolyte Beverage Does Not Improve Glucose Availability, Substrate Oxidation, Gastrointestinal Symptoms or Exercise Performance, Compared With a Concentration and Nutrient-Matched Placebo.

The impact of a carbohydrate-electrolyte solution with sodium alginate and pectin for hydrogel formation (CES-HGel), was compared to a standard CES with otherwise matched ingredients (CES-Std), for blood glucose, substrate oxidation, gastrointestinal symptoms (GIS; nausea, belching, bloating, pain, regurgitation, flatulence, urge to defecate, and diarrhea), and exercise performance. Nine trained male endurance runners completed 3 hr of steady-state running (SS) at 60% V˙O2max, consuming 90 g/hr of carbohydrate from CES-HGel or CES-Std (53 g/hr maltodextrin, 37 g/hr fructose, 16% w/v solution) in a randomized crossover design, followed by an incremental time to exhaustion (TTE) test. Blood glucose and substrate oxidation were measured every 30 min during SS and oxidation throughout TTE. Breath hydrogen (H2) was measured every 30 min during exercise and every 15 min for 2 hr postexercise. GIS were recorded every 15 min throughout SS, immediately after and every 15-min post-TTE. No differences in blood glucose (incremental area under the curve [mean ± SD]: CES-HGel 1,100 ± 96 mmol·L-1·150 min-1 and CES-Std 1,076 ± 58 mmol·L-1·150 min-1; p = .266) were observed during SS. There were no differences in substrate oxidation during SS (carbohydrate: p = .650; fat: p = .765) or TTE (carbohydrate: p = .466; fat: p = .633) and no effect of trial on GIS incidence (100% in both trials) or severity (summative rating score: CES-HGel 29.1 ± 32.6 and CES-Std 34.8 ± 34.8; p = .262). Breath hydrogen was not different between trials (p = .347), nor was TTE performance (CES-HGel 722 ± 182 s and CES-Std: 756 ± 187 s; p = .08). In conclusion, sodium alginate and pectin added to a CES consumed during endurance running does not alter the blood glucose responses, carbohydrate malabsorption, substrate oxidation, GIS, or TTE beyond those of a CES with otherwise matched ingredients.

No Benefit of Ingestion of a Ketone Monoester Supplement on 10-km Running Performance.

PURPOSE: Preexercise ingestion of exogenous ketones alters the metabolic response to exercise, but effects on exercise performance have been equivocal. METHODS: On two occasions in a double-blind, randomized crossover design, eight endurance-trained runners performed 1 h of submaximal exercise at approximately 65% V˙O2max immediately followed by a 10-km self-paced time trial (TT) on a motorized treadmill. An 8% carbohydrate-electrolyte solution was consumed before and during exercise, either alone (CHO + PLA), or with 573 mg·kg of a ketone monoester supplement (CHO + KME). Expired air, HR, and RPE were monitored during submaximal exercise. Serial venous blood samples were assayed for plasma glucose, lactate, and ß-hydroxybutyrate concentrations. RESULTS: CHO + KME produced plasma ß-hydroxybutyrate concentrations of approximately 1.0 to 1.3 mM during exercise (P < 0.001), but plasma glucose and lactate concentrations were similar during exercise in both trials. V˙O2, running economy, respiratory exchange ratio, HR, and RPE were also similar between trials. Performance in the 10-km TT was not different (P = 0.483) between CHO + KME (mean, 2402 s; 95% confidence interval, 2204-2600 s) and CHO + PLA (mean, 2422 s; 95% confidence interval, 2217-2628 s). Cognitive performance, measured by reaction time and a multitasking test, did not differ between trials. CONCLUSIONS: Compared with carbohydrate alone, coingestion of KME by endurance-trained athletes elevated plasma ß-hydroxybutyrate concentrations, but did not improve 10-km running TT or cognitive performance.

Retrospective evaluation of the effect of intravenous fluid administration on development of postoperative reflux in horses with colic (2004-2012): 194 horses.

OBJECTIVE: To evaluate the role of intravenous fluid volume and electrolyte supplementation on the development of postoperative reflux (POR) in horses undergoing celiotomy for colic. DESIGN: Case-control study spanning 2004-2012 for horses undergoing celiotomy for colic. SETTING: University teaching hospital. ANIMALS: Sixty-seven client-owned horses >1 year of age with POR were each matched to 2 controls with similar surgical lesions that did not demonstrate POR. MEASUREMENTS AND MAIN RESULTS: Survival was significantly lower in cases (65.7%) than controls (96.1%). Factors found to be associated with POR included decreased net fluid volume administered on day 1 postoperatively, increased age, and performing a resection and anastomosis. Mean time until onset of POR was 20.4 hours postoperatively. PCV was significantly higher immediately following surgery and at 24 hours postoperatively in horses that developed POR compared with matched controls. There was no association between electrolyte values at presentation or administration of potassium, calcium, or magnesium in the postoperative period and the subsequent development of reflux. CONCLUSIONS: In the perioperative period, IV fluid volume overload and electrolyte abnormalities were not contributing factors in the development of POR in this population of surgical colic patients. Close postoperative monitoring with consideration and correction of pre- and postoperative fluid deficits is recommended.

Aspiration pneumonia due to polyethylene glycol-electrolyte solution (Golytely) treated by bronchoalveolar lavage.

Polyethylene glycol (PEG)-electrolyte solution (Golytely), is most commonly used for bowel preparation before colonoscopy, as well as for barium enema and colon surgery. In this case, a 70-year-old man developed ARDS following the administration of Golytely by mouth before a scheduled colonoscopy. Aspiration of PEG-electrolyte solution was suspected, and the patient was successfully treated by BAL. Therefore, early bronchoscopy and BAL should be considered as initial treatment for PEG aspiration, because removal of PEG is most important for managing the disease.

Safety and effectiveness of large-volume enema solutions.

The effectiveness and side effects of three types of enema solutions were compared in healthy subjects. Using a repeated-measures, double-blind design, the three different enemas (soapsuds, tap water, and polyethylene glycol-electrolyte solution) were given at 1-week intervals to 24 healthy volunteers. Soapsuds and tap water enemas produced significantly greater returns than polyethylene glycol electrolyte solution (PEG-ES) and were also more uncomfortable. Rectal biopsies showed surface epithelium loss after soapsuds and tap water but not after PEG-ES enemas. Before recommending changes in nursing practice, further research is needed to determine the mechanism for the surface epithelium damage and to determine if this damage produces a stronger defecation stimulus and discomfort.

Vitamins, supplements, herbal medicines, and arrhythmias.

Nutritional and herbal supplements may have harmful or beneficial effects on arrhythmias. Potential supplements that may have antiarrhythmic activity include omega-3 polyunsaturated fatty acids (N-3 PUFA), coenzyme Q10, and carnitine. Clinical studies show that N-3 PUFA or fish oil supplementation appears to reduce mortality and sudden death. Coenzyme Q10, used in treatment of heart failure, and carnitine and its derivatives may have beneficial effects on arrhythmias, although clinical studies have been limited. Antioxidant supplements may be beneficial, but large studies with vitamin E have been disappointing in that it does not reduce mortality. Correction of electrolyte disturbances has been long advised and magnesium supplementation has been beneficial in the treatment of torsades de pointes and in some studies after cardiac surgery. However, routine electrolyte supplementation with empiric potassium or magnesium in non-deficient patients has not been convincingly beneficial. Several herbal supplements have also been promoted to have antiarrhythmic activity. However, clinical studies are lacking to support routine use of these herbal medications. In addition, some herbal supplements may cause serious proarrhythmia, and many supplements significantly interact with warfarin and digoxin.

Manganese intake and cholestatic jaundice in neonates receiving parenteral nutrition: a randomized controlled study.

UNLABELLED: Infants requiring parenteral nutrition (n = 244) were randomized to receive either 1 (group 1, n = 121) or 0.0182 micromol/kg/d (group 2, n = 123) of manganese supplementation. The whole-blood manganese and serum direct bilirubin concentrations of the infants were monitored, as was the development of cholestasis (peak serum direct bilirubin concentration >50 micromol/L). Subgroup analysis was carried out on the data of 78 infants in group 1 and 82 in group 2 who had received manganese supplementation and more than three-quarters of their total daily fluid as parenteral nutrition for >14 d. Of all the infants randomized, the high manganese group (group 1) showed a trend towards developing higher peak whole-blood manganese concentration [group 1 versus group 2: median (interquartile range): 606.0 (421.0; 1005.0) vs 566.0 (336.0: 858.0); p=0.061] and higher peak serum direct bilirubin concentration [37.0 (10.5; 122.5) vs 19.0 (8.0; 112.5); p=0.153], but the differences between the 2 groups did not reach statistical significance. The 2 groups did not differ in terms of the occurrence of cholestasis during parenteral nutrition (63/121 vs 57/123; p=0.444). Subgroup analysis of infants who had received more than three-quarters of their total daily fluid as parenteral nutrition showed, however, that the high manganese group developed significantly higher whole-blood manganese concentration [743.5 (498.0; 1211.0) vs 587.0 (438.0; 982.0); p=0.037] and serum direct bilirubin concentration [84.0 (28.0; 170.0) vs 25.5 (9.0; 117.0): p < 0.001]. Although there was no significant difference in the occurrence of cholestasis (58/78 vs 49/82; p = 0.073), more infants in the high manganese group developed a more severe degree of direct hyperbilirubinaemia, with peak serum direct bilirubin >100 micromol/L (32/78 vs 20/82; p = 0.038). CONCLUSION: We conclude that the pathogenesis of parenteral nutrition-related cholestasis is probably multifactorial, and that high manganese intake is a significant contributory factor.

Transient thalamic changes on MRI in a child with hypernatremia.

Severe hypernatremia has been associated with a wide variety of central nervous system lesions. Neurologic sequelae are the usual outcome in those cases in which a lesion has been documented neuroradiologically. The authors report a 7-month-old male with severe hypernatremia who developed obtundation after correction of the electrolyte imbalance. Magnetic resonance imaging revealed bilateral thalamic signal changes that resolved on follow-up study, in accordance with complete clinical recovery. To the authors' knowledge, bilateral thalamic signal changes are previously unreported findings associated with hypernatremia. Pertinent literature and the clinical course of the authors' patient are the basis for questioning currently recommended guidelines for the rate of correction of hypernatremia.

Randomized comparison of two preoperative methods for preparation of the colon: oral administration of a solution of polyethylene glycol plus electrolytes and total parenteral nutrition.

BACKGROUNDS/AIMS: Two colon preparation methods were compared for their efficacy. The comparison was carried out between whole bowel irrigation using polyethylene glycol-electrolyte lavage solution (PEG-ELS) and total parenteral nutrition (TPN). METHODOLOGY: Twenty-six consecutive patients suffering from colorectal cancer without apparent obstruction were randomly divided into two groups. Twelve patients received 2 litres of PEG-ELS one day before the operation following two tablets of sennoside (24 mg) two days before the operation without restriction of food until PEG-ELS. Fourteen patients received magnesium citrate (34 g) and sennoside (24 mg) on the day before the operation with 7 days' TPN and fasting. RESULTS: The average time of defecation was 9 in the PEG-ELS group and 5 in the TPN group (p < 0.001), with little difference between the necessary times to complete defecation (PEG-ELS: 280 min. vs. TPN: 260 min.). However, although half of the PEG-ELS group complained of side effects of abdominal fullness the overall incidence of side effects in both groups were the same of 50%. There were no significant changes between the data of blood test and routine chemistry before and after the bowel preparation in both groups. The purity of the colorectum judged at operation in both groups were excellent, no residue at all, except in one patient of the TPN group. The total bacterial counts of the rectal samples obtained at operation of PEG-ELS group were fewer than that of TPN group but not statistically significant. CONCLUSION: Colon preparation using PEG-ELS is just as good as the 7-days' TPN treatment and fasting, and exceeds from the standpoint of saving time.

Comparison of two oral evacuants (Citromag and Golytely) for bowel preparation before barium enema.

Oral regimens for bowel preparation before barium enema examination are routinely used because of their convenience and simplicity, rather than the traditional method of colonic wash-out. We performed a prospective study comparing the side-effects and efficacy of two commonly used oral bowel evacuants (Citromag and Golytely) for bowel preparation before barium enema examination in 102 patients. The side-effects associated with the agents were assessed by analysing a questionnaire completed by the patients. There was no significant difference in the side-effects between the two agents although more patients taking Golytely (45.5%) deemed its taste unacceptable than those taking Citromag (25.9%). The results of the bowel preparation were assessed by two independent radiologists giving scores on the amount of faecal residue and the quality of mucosal coating. The amount of faecal residue was less in the Golytely group (p < 0.05). The quality of mucosal coating by barium was also better in the Golytely group than the Citromag group (p < 0.05).

A blinded clinical trial comparing conventional cleansing enema, Pico-salax and Golytely for barium enema bowel preparation.

UNLABELLED: An evaluator-blinded randomized clinical trial was undertaken to assess the effectiveness and patient acceptance of three bowel cleansing regimens: conventional cleansing enema, Pico-salax and Golytely. PATIENTS AND METHODS: One hundred and fifty patients, referred for barium enema examination, were allocated to one of the three regimens. Both the radiographers and the radiologists did not know the method of preparation. Radiographers were requested to enter the patients' data, the number of bowel openings, the patients' comments of the preparation and side effects. Films were reviewed independently by two experienced radiologists for the degree of bowel cleanliness and quality of barium coating. RESULTS: The mean (standard deviation) of bowel opening frequency for the cleansing enema, Pico-Salax and Golytely were 3.6(4.4), 8.3(4.8) and 7.1(4.2), respectively, with less bowel opening in the cleansing enema. There was less nausea associated with the cleansing enema (P = 0.006), more vomiting with Golytely (P = 0.008), less abdominal fullness with Pico-salax (P = 0.0006), less anorectal irritation with Golytely (P = 0.025), and no difference in the abdominal pain amongst three groups. There was no statistically significant difference in the number of bowel openings between the groups. Patients found that Pico-salax tasted better than Golytely (P = 0.0094) and Golytely was less accepted in the amount of fluid intake (P = 0.0018 and P < 0.0002 comparing Golytely with the cleansing enema and Pico-salax). Chi-squared testing showed no statistically significant difference in bowel cleanliness and quality of barium coating among the three preparations. CONCLUSIONS: There was no difference in the effectiveness of the three regimens. Pico-salax seems the most acceptable because it has the fewest side effects.

Colonic mucosal abnormalities associated with oral sodium phosphate solution.

BACKGROUND: Oral sodium phosphate (NaP) is increasingly used as a colonic cleansing agent for colonoscopy. It has been shown to be efficacious, well-tolerated, and safe. Mucosal abnormalities associated with NaP have recently been described. We carried out this controlled study to assess whether bowel cleansing preparations commonly used in colonoscopy are associated with colonic mucosal changes that may mimic inflammatory bowel disease (IBD). METHOD: All patients undergoing colonoscopy from January 1994 to June 1994 were considered for the study. Patients with history or symptoms suggestive of IBD were excluded. Patients were randomized to receive polyethylene glycol-based lavage (PEG-ELS) or NaP solution as their bowel cleansing preparation. Two gastroenterologists performing the colonoscopies were blinded to the type of preparation. Any mucosal abnormalities were noted and photographic documentation and biopsy specimens were taken. RESULTS: Ninety-seven patients were studied, 44 receiving PEG-ELS and 53 receiving NaP. Both groups were similar with regard to sex, age, and indication for colonoscopy. Fourteen patients were found to have nonspecific aphthoid-like erosions similar in appearance to Crohn's disease. These lesions, however, were not friable and biopsy results were not compatible with IBD. This mucosal abnormality was found in 13 patients who received NaP (24.5%) and only 1 patient who received PEG-ELS (2.3%). CONCLUSION: Nonspecific aphthoid-like mucosal lesions occur frequently in patients who received NaP for colonoscopy preparation. These lesions are endoscopically similar to those seen in Crohn's disease. Because of the potential for misinterpretation of these lesions, we do not recommend the use of NaP as a colonic cleansing preparation for patients with chronic diarrhea or in whom the diagnosis of IBD is suspected.

A randomized controlled trial of a new PEG-electrolyte solution compared with a standard preparation for colonoscopy.

The efficacy, tolerability and patient acceptance of a new flavoured PEG solution for gut lavage was compared with a standard preparation for bowel cleansing in a randomized controlled trial of patients undergoing colonoscopy. One hundred and sixty patients were randomly allocated either to a standard preparation (2-day semi-liquid diet, laxatives and cleansing enemas) or to gut lavage (fractionalized ingestion of lavage solution, two litres in the afternoon before and a third litre the morning of the examination). Adequacy of colon cleansing was scored evaluating residual stool in each colonic segment and overall mucosal visibility. Tolerability of methods was assessed by evaluating the incidence and severity of side-effects. Patient acceptance was graded (good, fair to good, poor) according to the patient's judgement about the ease of execution and interference with sleep and working activity. Less residual stool (p < 0.05) and better visualization of colonic mucosa (p < 0.05) were obtained with gut lavage than with standard preparation. Both methods were well-tolerated and a low incidence of side effects was recorded in both groups. Patient acceptance was good in more than 80% of patients in both groups. We conclude that gut lavage is a rapid, effective and well-tolerated method for bowel cleansing. The use of a flavoured solution in a fractionalized schedule seems to improve the tolerability and the patient acceptance of this method.

Bowel preparation for the total colonoscopy by 2,000 ml of balanced lavage solution (Golytely) and sennoside.

One of disadvantages of the Golytely preparation is that examinees have to drink as much as 4,000 ml of Golytely. To overcome this disadvantage, we designed a modified preparation regimen in which examinees have to drink only 2,000 ml of Golytely by taking sennoside orally. Bowel preparation was carried out in 297 examinees by this modified method. Examinees ate their usual diet and took 36 mg of sennoside orally on the night before the examination. On the day of the examination, the examinees drank a total of 2,000 ml of Golytely. No severe complications were noted and 97% of the examinees were able to drink the dose of 2,000 ml. Subjects who had also experienced bowel preparation by the modified method of Brown were asked to compare the two regimens, and only 1% preferred Brown's method while 73% preferred bowel preparation by our Golytely method. The result of bowel preparation by this method was excellent or good in 90 to 97% of the subjects at all sites in the colon and rectum. We conclude that bowel preparation for total colonoscopy using 2,000 ml of Golytely and sennoside is superior because it is highly acceptable to the examinees and provides excellent gut irrigation.

A new oral lavage solution vs cathartics and enema method for preoperative colonic cleansing.

Sulfate free-electrolyte lavage solution is a new osmotically balanced electrolyte gut lavage solution for colon surgery that has been formulated for improved taste and reduced water and electrolyte changes. Sixty patients were prospectively randomized to receive a 1-day preparation with sulfate free-electrolyte lavage solution or a 3-day preparation using a clear liquid diet, cathartics, and enemas. The patient groups were similar in age, race, male-female ratio, and the types of colonic resections performed. Colonic cleansing was better with sulfate free-electrolyte lavage solution (100% vs 63% "good" to "excellent" cleansing). Patient tolerance evaluated by a questionnaire showed more overall discomfort with sulfate free-electrolyte lavage solution but no difference between the preparations in individual symptoms of fullness, cramping, nausea, or vomiting. One patient developed a low level of serum potassium after a cathartic and enema preparation, while there were no complications with sulfate free-electrolyte lavage solution. Patient taste questionnaires showed a slight preference for sulfate free-electrolyte lavage solution (53%) over a polyethylene glycol electrolyte lavage solution (47%). This study confirms that sulfate free-electrolyte lavage solution is a safe and effective method of preoperative colonic cleansing.