Hyperglycemia and subsequent torsades de pointes with marked QT prolongation during refeeding.

OBJECTIVE: A fatal cardiac complication can occasionally present in malnourished patients during refeeding; this is known as refeeding syndrome. However, to our knowledge, hyperglycemia preceding torsades de pointes with QT prolongation during refeeding has not been reported. In the present study, we present a case in which hyperglycemia preceded torsades de pointes with QT prolongation during refeeding. The aim of this study was to determine the possible mechanism underlying QT prolongation during refeeding and indicate how to prevent it. METHODS: A 32-y-old severely malnourished woman (body mass index 14.57 kg/m2) was admitted to the intensive care unit of our institution after resuscitation from cardiopulmonary arrest due to ventricular fibrillation. She was diagnosed with anorexia nervosa. Although no obvious electrolyte abnormalities were observed, her blood glucose level was 11 mg/dL. A 12-lead electrocardiogram at admission showed sinus rhythm with normal QT interval (QTc 0.448). RESULTS: Forty mL of 50% glucose (containing 20 g of glucose) was intravenously injected, followed by a drip infusion of glucose to maintain blood glucose level within normal range. After 9 h, the patient's blood glucose level increased to 569 mg/dL. However, after 38 h, an episode of marked QT prolongation (QTc 0.931) followed by torsades de pointes developed. CONCLUSIONS: Hyperglycemia during refeeding can present with QT prolongation; consequently, monitoring blood glucose levels may be useful in avoiding hyperglycemia, which can result in QT prolongation. Furthermore, additional monitoring of QT intervals using a 12-lead electrocardiogram should allow the early detection of QT prolongation when glucose solution is administered to a malnourished patient with (severe) hypoglycemia.

The choleretic effect of nonsteroidal anti-inflammatory drugs in total parenteral nutrition-associated cholestasis.

Cholestasis is a frequent problem in patients on total parenteral nutrition (TPN) therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs), especially aspirin, cause choleresis in animals. We studied the effect of aspirin on bile flow and bile salt secretion in TPN-associated cholestasis in rats. Four groups of 6-10 animals each received either 154 mM NaCl (saline) or 2.5% amino acid solution (TRAVASOL, Travenol, Israel) and 10% glucose i.v. (TPN) for 3 h. During the second and third hours, taurocholate, the main bile salt in rats, was infused at a rate of 10 micromol/min per kg to prevent bile salt pool depletion. Aspirin, one of the main NSAIDs, was infused during the last 2 h into animals with or without TPN treatment at a rate of 100 mg/kg. Bile was directly collected from the common bile duct for 3 h. Rats given TPN showed a significant reduction in bile flow and bile salt secretion rate compared to control groups: 20.89 vs. 29.60 microl/min per kg (P <0.02) and 0.37 vs. 0.65 micromol/min per kg (P <0.0001), respectively. Aspirin had a significant choleretic effect and was able to overcome the bile flow and bile salt secretion rate reduction caused by TPN; 33.07 vs. 20.89 microl/min per kg (P <0.002) and 0.66 vs. 0.37 micromol/min per kg (P <0.0001), respectively. These results may have clinical implications for TPN-associated cholestasis.

The adverse effects of high oral osmolal mixtures in neonates. A review and a study of the osmolality of calcium preparations.

In both animals and humans, there are numerous clinical, physiologic, and morphologic alterations that occur when hypertonic solutions are introduced into the alimentary tract. The most serious adverse effect observed in the human infant is necrotizing enterocolitis. A short in vitro study analyzing osmolalities of drug-formula mixtures at various dilutions, conducted by the authors, showed that an unacceptable degree of high osmolality may be achieved in the preparation of common medications used in newborn nurseries. Although review of the literature confirms that, in general, the osmolalities of mixtures fed to newborns should not exceed 460 mOsm/kg H2O, lower levels would be preferable in ill and low birth weight newborns. When possible, consideration should be given to the use of parenteral medication for the critically ill neonate. Ideally, the osmolalities of mixtures fed to newborns should be measured if they are not known or cannot be calculated.

[Glucose-induced hyperlactatemias in thiamine deficiency]. / Glucoseinduzierte Hyperlactatämien bei Thiaminmangel.

Parenteral nutrition with carbohydrates is limited, inter alia, by the occurrence of a dose-dependent hyperlactataemia. Thiamine deficiency, which can be provoked by an eight weeks' diet which is deficient in thiamine, will produce clearly elevated lactate levels in rats, leading eventually to lactate acidosis as a result of glucose load, compared with a control group on a normal diet. It is recommended to initiate a high-dosage level thiamine therapy before parenteral feeding with carbohydrates, if thiamine deficiency appears possible on the grounds of previous history of the case (alcohol abuse) or because of the underlying disease (e.g. oesophageal strictures, carcinoma of the oesophagus).