Safety of a rapid outpatient hydration protocol for patients with renal impairment requiring intravenous iodinated contrast media for computed tomography.

INTRODUCTION: Patients receiving intravenous iodinated contrast media for computed tomography (CT) are predisposed to contrast-induced nephropathy. Chronic kidney disease is an important risk factor, and hydration is the mainstay of prevention. While inpatients can undergo intravenous hydration, limited knowledge exists regarding regimens for outpatients. We employed a rapid outpatient hydration protocol to reduce postponement of imaging appointments for patients with suboptimal estimated glomerular filtration rate (eGFR). METHODS: From June 2015, we amended our CT preparation protocol to mandate rapid hydration (oral, intravenous or both) for patients with an eGFR of 30-60 mL/min/1.73 m2. Patients receiving this hydration protocol from June to November 2015 were followed up for one month to monitor any admissions for fluid overload, and up to one year to determine the long-term effect on eGFR. RESULTS: 226 outpatients received the hydration protocol, which correlated with a 95% reduction in postponement of imaging appointments. No complications of fluid overload from hydration were encountered. A significant association was observed between age and decrease in eGFR, but this was not significant when stratified by drop in eGFR category. No statistical significance was found between decrease in eGFR and gender or race. Higher baseline eGFR was less likely to be associated with decrease in eGFR after imaging. Type of hydration was not related to a drop in eGFR category for patients with an eGFR of 45-59 mL/min/1.73 m2. CONCLUSION: We defined a shorter hydration regimen that is safe to use in the outpatient setting.

Methadone-induced Toxic Encephalopathy In Pediatric Patients: Two Case Reports.

Toxic encephalopathy is a wide spectrum of encephalopathy secondary to insult from toxic substances, with variable clinical presentations from minor cognitive impairment to severe neurological dysfunction and death. Methadone-induced toxic encephalopathy is an extremely rare form of toxic encephalopathy which typically demonstrates abnormal imaging findings in the dentate nuclei or cerebellum. This is a report of methadone-induced toxic encephalopathy in two toddlers secondary to accidental ingestion. They were brought in unconscious to the emergency department of a tertiary hospital and were found to be cyanotic and pulseless, requiring cardiopulmonary resuscitation and mechanical ventilation. Magnetic resonance imaging (MRI) of the brain of both patients showed similar findings of symmetrical hyperintense foci in bilateral cerebellar hemispheres on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences. These areas also demonstrated diffusion restriction on diffusion weighted imaging (DWI). Blood and urine toxicology results confirmed the presence of methadone in both patients. As the exact substance of accidental ingestion may not be known at the time of presentation, early radiological diagnosis of methadone-induced encephalopathy may prompt early initiation of treatment to prevent further life-threatening complications, particularly in vulnerable pediatric population.