Severe Alkalemia and hypokalemia after chronic exposure to alkaline water.

Consumption of alkaline electrolyzed water (AEW) has become increasingly popular for consumer use. Although these alkaline water products are now commonly used, they are of questionable health benefit. Some individuals believe that it may help their dyspepsia. Furthermore, there is a paucity of evidence on its toxicologic profile and adverse effects. This is a single case report of a 42-year-old female with a past medical history of gestational diabetes, necrotizing pancreatitis, presented to the Emergency Department for 3 weeks of lethargy, weakness, difficulty walking, and vomiting. She endorsed consuming 5  liters (L) of alkaline water daily for the past month. Initial labs showed pH 7.69, potassium 1.6meQ/L, sodium 133 meQ/L, chloride 65 mmol/L, magnesium 0.9 meQ/L, and bicarbonate 46 mmol/L, and lactate of 13.2 mmol/L. EKG showed sinus tachycardia with QTc of 630 milliseconds. Patient was treated supportively with intravenous fluids and electrolyte replacement. The potassium rose to 6.6 meQ/L, which then the patient was treated for hyperkalemia. After four days of intravenous fluid and electrolyte replacement, the patient's electrolytes and acid-base status normalized, and she was transferred to the medical floors for further management. This case report illustrates severe metabolic alkalosis and hypokalemia in the setting of chronic alkaline water exposure. It also is an example of alkalemia with hyperlactatemia, or "lactic alkalosis". To our knowledge, there is no previous literature reporting serious adverse effects of alkaline bottled water products.

Rebound hyperkalemia in a dog with albuterol toxicosis after cessation of potassium supplementation.

OBJECTIVE: To describe the presentation of rebound hyperkalemia as a delayed side effect of albuterol toxicity in a dog. CASE SUMMARY: A 3-year-old female neutered mixed-breed dog was presented for albuterol toxicosis that led to a severe hypokalemia, hyperlactatemia, and hyperglycemia. The dog also experienced sinus tachycardia and generalized weakness. Treatment was instituted with intravenous fluid therapy and potassium supplementation, and the dog was monitored with a continuous electrocardiogram. Resolution of hypokalemia was documented 12 hours after initial presentation, at which time fluid therapy and potassium supplementation were discontinued. There were no further periods of sinus tachycardia, but instead the dog developed ventricular ectopy with rapid couplets (instantaneous rates of 300/min). An echocardiogram revealed normal cardiac size and function. Twenty-four hours after presentation, the patient developed severe hyperkalemia, despite discontinuation of fluids and potassium supplementation for 12 hours. Serial venous and urinary electrolytes were performed for determination of the fractional excretion of electrolytes. These data confirmed rebound hyperkalemia (7.0 mmol/L), consistent with a markedly increased fractional excretion of potassium, and secondary to the release of potassium from inside the cells. Fluid therapy with dextrose supplementation was provided until 36 hours postpresentation. The hyperkalemia resolved, and the dog was discharged after 44 hours of hospitalization. NEW OR UNIQUE INFORMATION PROVIDED: This case documents rebound hyperkalemia following treatment of albuterol toxicosis in a dog. This case highlights the importance of understanding the distribution of total body potassium when treating serum hypokalemia. Transcellular shifts of potassium, as in the case of albuterol toxicosis, can lead to rebound hyperkalemia even after discontinuation of potassium supplementation. This case further explores the utility of fractional excretion of electrolytes in elucidating the etiology and management of electrolyte disturbances.

Disorders of Potassium.

Abnormalities in serum potassium are commonly encountered in patients presenting to the emergency department. A variety of acute and chronic causes can lead to life-threatening illness in both hyperkalemia and hypokalemia. Here we summarize the relevant causes, risks, and treatment options for these frequently encountered disorders.

Common Pitfall in Post Operative Fluid and Electrolyte Management: A Retrospective Study in Two Tertiary Centers in Bangladesh.

Evaluation of our practice and recommend an appropriate fluid regime to maintain the fluid and electrolyte balance in the post operative period. The drug chart and clinical notes were retrospectively analysed manually of 758 patients who underwent surgery from January 2020 to January 2022 in Enam Medical College Hospital and Ibnsina Medical College Hospital, Dhaka, Bangladesh were reviewed by 3 individual clinicians and the obtained data were analysed. Total 407 patients met the inclusion criteria for the study. Fifty seven (57) patients underwent emergency operation and 350 patients had elective surgery. The average fluid replacement was 2.5 L/day, average Sodium- 154 mmol/day, average potassium 2.0 mmol/day and average glucose 125 mmol/day. Post operatively 97 patients developed hypokalemia. Among them 25 patients developed severe hypokalemia. A simple pathway for prescribing post operative fluid and electrolyte was proposed so that patients during 1st post operative day requiring maintenance fluid will have 25-30 ml/kg/day of water, approximately 1-2 mmol/kg/day Sodium and chloride, 1 mmol/kg/day of potassium and approximately 50-100 gm/day of glucose.

Hypokalemia/Hyperkalemia and Hyponatremia/Hypernatremia.

Electrolyte disorders are very common in the pediatric population. Derangements in serum sodium and potassium concentrations are among the most frequently seen given the risk factors and comorbidities unique to children. Pediatricians, in both outpatient and inpatient settings, should be comfortable with the evaluation and initial treatment of disturbances in these electrolyte concentrations. However, to evaluate and treat a child with abnormal serum concentrations of sodium or potassium, it is critical to understand the regulatory physiology that governs osmotic homeostasis and potassium regulation in the body. Comprehension of these basic physiologic processes will allow the provider to uncover the underlying pathology of these electrolyte disturbances and devise an appropriate and safe treatment plan.

Recommendations for the management of hypokalemia in patients with cancer.

Hypokalemia is a common electrolyte disorder in cancer patients that may be associated with the primary disease or a complication of treatment. In this article, we provide a brief description of hypokalemia and its appropriate management in cancer patients.

La hipokalemia es un trastorno hidroelectrolítico común en pacientes con cáncer que puede estar asociado a la enfermedad primaria o a una complicación del tratamiento. En este artículo nos enfocamos en entregar una breve descripción de la hipokalemia y su adecuado manejo en pacientes con cáncer.

Hypothermia for neuroprotection in adults after cardiac arrest.

BACKGROUND: Good neurological outcome after cardiac arrest is difficult to achieve. Interventions during the resuscitation phase and treatment within the first hours after the event are critical for a favourable prognosis. Experimental evidence suggests that therapeutic hypothermia is beneficial, and several clinical studies on this topic have been published. This review was originally published in 2009; updated versions were published in 2012 and 2016. OBJECTIVES: To evaluate the benefits and harms of therapeutic hypothermia after cardiac arrest in adults compared to standard treatment. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 30 September 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in adults comparing therapeutic hypothermia after cardiac arrest with standard treatment (control). We included studies with adults cooled by any method, applied within six hours of cardiac arrest, to target body temperatures of 32 °C to 34 °C. Good neurological outcome was defined as no or only minor brain damage allowing people to live an independent life. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcome was 1. neurological recovery. Our secondary outcomes were 2. survival to hospital discharge, 3. quality of life, 4. cost-effectiveness and 5. ADVERSE EVENTS: We used GRADE to assess certainty. MAIN RESULTS: We found 12 studies with 3956 participants reporting the effects of therapeutic hypothermia on neurological outcome or survival. There were some concerns about the quality of all the studies, and two studies had high risk of bias overall. When we compared conventional cooling methods versus any type of standard treatment (including a body temperature of 36 °C), we found that participants in the therapeutic hypothermia group were more likely to reach a favourable neurological outcome (risk ratio (RR) 1.41, 95% confidence interval (CI) 1.12 to 1.76; 11 studies, 3914 participants). The certainty of the evidence was low. When we compared therapeutic hypothermia with fever prevention or no cooling, we found that participants in the therapeutic hypothermia group were more likely to reach a favourable neurological outcome (RR 1.60, 95% CI 1.15 to 2.23; 8 studies, 2870 participants). The certainty of the evidence was low. When we compared therapeutic hypothermia methods with temperature management at 36 °C, there was no evidence of a difference between groups (RR 1.78, 95% CI 0.70 to 4.53; 3 studies; 1044 participants). The certainty of the evidence was low. Across all studies, the incidence of pneumonia, hypokalaemia and severe arrhythmia was increased amongst participants receiving therapeutic hypothermia (pneumonia: RR 1.09, 95% CI 1.00 to 1.18; 4 trials, 3634 participants; hypokalaemia: RR 1.38, 95% CI 1.03 to 1.84; 2 trials, 975 participants; severe arrhythmia: RR 1.40, 95% CI 1.19 to 1.64; 3 trials, 2163 participants). The certainty of the evidence was low (pneumonia, severe arrhythmia) to very low (hypokalaemia). There were no differences in other reported adverse events between groups. AUTHORS' CONCLUSIONS: Current evidence suggests that conventional cooling methods to induce therapeutic hypothermia may improve neurological outcomes after cardiac arrest. We obtained available evidence from studies in which the target temperature was 32 °C to 34 °C.

Potassium Disorders: Hypokalemia and Hyperkalemia.

Hypokalemia and hyperkalemia occur when serum potassium levels are less than 3.5 mEq per L or greater than 5.0 mEq per L, respectively. The World Health Organization recommends a potassium intake of at least 3,510 mg per day for optimal cardiovascular health. Hypokalemia is caused by decreased intake, renal losses, gastrointestinal losses, or transcellular shifts. Severe features of hypokalemia that require urgent treatment include a serum potassium level of 2.5 mEq per L or less, electrocardiography abnormalities, or neuromuscular symptoms. The underlying cause should be addressed, and potassium levels replenished. An oral route is preferred if the patient has a functioning gastrointestinal tract and a serum potassium level greater than 2.5 mEq per L. Hyperkalemia is caused by impaired renal excretion, transcellular shifts, or increased potassium intake. Electrocardiography identifies cardiac conduction disturbances but may not correlate with serum potassium levels. Emergent treatment is recommended for patients with clinical signs and symptoms (e.g., muscle weakness, paralysis) or if electrocardiography abnormalities are present. Acute treatment may include intravenous calcium, insulin, sodium bicarbonate, diuretics, and beta agonists. Dialysis may be considered in the presence of end-stage renal disease, severe renal impairment, or ongoing potassium release. Patiromer and sodium zirconium cyclosilicate are newer potassium binders and may be used in chronic or acute hyperkalemia. Sodium polystyrene sulfonate is associated with serious gastrointestinal adverse effects. Long-term management of potassium disturbances includes correcting underlying conditions, dietary counseling, and adjusting causative medications.

Therapeutic Plasma Exchange (TPE) Complications in Patients With Multiple Sclerosis (MS) and Clinically Isolated Syndrome (CIS): A Report From a Tertiary Center.

BACKGROUND: Therapeutic plasma exchange (TPE) is a conventional second-line treatment for patients with multiple sclerosis (MS) or clinically isolated syndrome with steroid-refractory relapses. METHODS: MS and clinically isolated syndrome patients with a steroid-refractory relapse, who fulfilled the indications for TPE were enrolled in this study. An expert nurse recorded the data comprising age, sex, type of MS, disease modifying therapy, disease duration, relapse rate, vital signs at the beginning, during and at the end of each plasma exchange session, plasma exchange volume, normal saline volume, and TPE complications. Ultimately, the statistical association was estimated amongst the variables. RESULTS: A total of 122 cases were assessed. Twelve cases (9.8%) received plasmapheresis for the second time. The mean age was 32.2±8.7 years and 107 (87.7%) were female. In total, 609 plasma exchange sessions were completed. Hypotension and skin reaction were the most clinical complications. Hemoglobin loss and hypokalemia were the most laboratory complications. Fifty-four cases (44.3%) had no complications, 40 (32.8%) had 1 complication, 21 (17.2%) 2 complications, 6 (4.9%) had 3 complications, and 1 (0.8%) disclosed 4 complications. The relapse rate in the past 12 months and the mean plasma volume exchange were significantly different between the groups. CONCLUSIONS: We revealed that TPE could be considered as a safe second-line therapy in MS relapses. Hypotension, skin reaction, hemoglobin loss, and hypokalemia were the most complications of TPE in our patients.

Liddle syndrome.

Liddle syndrome is an inherited form of arterial hypertension with autosomal dominant pattern of inheritance. It is caused by activating mutation of genes coding of the epithelial sodium channel in distal nephron. Mutation leads to excessive reabsorbtion of sodium ions and volume expansion resulting in arterial hypertension. Antoher typical laboratory findings are hypokalaemia, low levels of serum aldosteron and metabolic alkalosis. Phenotypic variability makes it difficult to identify patients with Liddle syndrome, often resulting in misdiagnosis and severe complications at early age. Genetic studies should be done to confirm the diagnosis. Therapy of Liddle syndrome is based on administration of epithelial sodium channel blocker amilorid.

[A case of arrhythmia caused by barium carbonate poisoning].

Barium carbonate poisoning is mostly caused by mistaken ingestion in clinical cases, and self-administration of poisoning is rare. In November 2020, Tianjin Occupational Disease Prevention Hospital admitted a patient with severe hypokalemia complicated with arrhythmia after taking poison. It is very important to take timely and effective potassium supplementation, symptomatic and detoxification treatment in the course of treatment. At the same time, closely observing the changes of vital signs and taking quick and accurate rescue measures in the event of malignant arrhythmia are the keys to ensuring the success of rescue. In this paper, the clinical data of the case were retrospectively analyzed, providing reference for the diagnosis and treatment of similar clinical cases.

Paint-thinner-induced Acute Kidney Injury: A Case Series and Review.

Occupational health hazards contribute significantly to the morbidity and mortality of workers in factories. Toluene has become a widely abused inhaled volatile drug. The spectrum of toluene-induced renal injury includes rhabdomyolysis, myoglobinemia, distal renal tubular acidosis (RTA), acute tubular necrosis, glomerulonephritis, and interstitial nephritis. We describe two patients with paint-thinner-induced kidney injury who were affected through different routes of exposure and recovered well, with one requiring dialysis support; the second patient, who had developed Type 1 distal RTA and mild kidney injury, was managed with conservative measures. Toluene can cause acute neurological symptoms, accompanied by severe metabolic alterations, as well as organ injury and dysfunction. A common association of the development of hypokalemic paralysis and metabolic acidosis with toluene intoxication was observed. Liver injury and rhabdomyolysis are also common. Vomiting, dehydration, tubular injury, and rhabdomyolysis are all possible additional causes of acute renal failure in toluene intoxication. Type 1 distal RTA, which is characterized by an inability to lower urine pH despite acidemia, results in hyperchloremic metabolic acidosis with hypokalemia. The management of acute toluene toxicity is largely conservative, consisting of correcting the electrolytes and the acid-base balance, fluid alterations, and renal replacement therapy in severe acute kidney injury. A clinical suspicion of organ failure and prompt supportive care leads to encouraging results. Adequate protective steps for workplaces involved in the use of such substances in confined spaces include prior risk assessment, using low-toxicity chemical products, ensuring adequate ventilation, safety training, and using appropriate personal protective equipment.

Epidemiology, prognosis and management of potassium disorders in Covid-19.

Coronavirus disease (Covid-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently the largest health crisis facing most countries. Several factors have been linked with a poor prognosis for this disease, including demographic factors, pre-existing comorbidities and laboratory parameters such as white blood cell count, D-dimer, C-reactive protein, albumin, lactate dehydrogenase, creatinine and electrolytes. Electrolyte abnormalities particularly potassium disorders are common among Covid-19 patients. Based on our pooled analysis, hypokalemia and hyperkalemia occur in 24.3% and 4.15% of Covid-19 patients, respectively. Potassium level deviation from the normal range may increase the chances of unfavorable outcomes and even death. Therefore, this article reviewed the epidemiology of potassium disorders and explained how hypokalemia and hyperkalemia are capable of deteriorating cardiac outcomes and the prognosis of Covid-19 for infected patients. The article finishes by highlighting some important considerations in the management of hypokalemia and hyperkalemia in these patients.

Bidirectional ventricular tachycardia induced by respiratory alkalosis mediated hypokalemia in a patient with acute ischemic heart failure.

Bidirectional ventricular tachycardia (BVT) is a rare arrhythmia that is generally observed in patients with catecholaminergic ventricular tachycardia or digoxin overdose. Herein, we present a case of BVT and electrical storm (ES) in an acute ischemic heart failure patient that is typically induced by hypokalemia. The patient was in invasive mechanical ventilator (MV) support and hypokalemia was related to acute respiratory alkalosis and that caused refractory hypokalemia despite intravenous (IV) potassium replacement. We also discuss our approach to solve refractory hypokalemia caused by respiratory alkalosis.

Acute Trimethyltin Poisoning Caused by Exposure to Polyvinyl Chloride Production: 8 Cases.

This manuscript aimed to describe and analyze acute trimethyltin poisoning caused by exposure to polyvinyl chloride production and review the literature. Combined with an analysis of occupational hygiene survey data, the clinical data of 8 cases of acute trimethyltin poisoning were analyzed retrospectively. The clinical manifestations of acute trimethyltin poisoning are mainly related to central nervous system damage, hypokalemia and metabolic acidosis in patients with severe poisoning. Early positive potassium supplementation and symptomatic treatment are beneficial to the improvement of the condition. The early recognition of central nervous system manifestations and hypokalemia is beneficial for early diagnosis and correct treatment.

Pheochromocytoma crisis in a patient with newly diagnosed neurofibromatosis type 1.

Pheochromocytoma occasionally engenders catecholamine-induced hypertension crisis. Pheochromocytoma is clinically identified in 0.1%-5.7% of patients with neurofibromatosis type 1 (NF1), which is 10 times more frequently than in healthy individuals. This report describes a case of newly diagnosed NF1 presenting with pheochromocytoma crisis, with severe electrolyte depletion and deteriorating recurrent ventricular tachycardia storm. Characteristic skin lesions such as café-au-lait macules and neurofibromas contributed to the diagnosis of NF1 and pheochromocytoma. No recurrence of electrolyte depletion was found after the adrenalectomy. Primary care physicians must distinguish the characteristic skin lesions of NF1, such as café-au-lait macules and neurofibromas and recognise the risk for pheochromocytoma.

Dyskalemia: a management problem for students.

BACKGROUND: Although dyskalemia is common, its management can be problematic for students and general practitioners, especially when it occurs in patients with heart and renal failure. The basic academic knowledge of general medicine students, who have often not yet encountered clinical situations of dyskalemia, remains unclear in this regard. OBJECTIVES: The purpose of this study was to evaluate the knowledge and reflexive practices of general medicine students in regard to dyskalemia. METHODS: A cross-sectional survey, based on a self-questionnaire, of all of the students enrolled in general medicine studies at the Faculty of Medicine at the University of Nancy (France) at the end of their degree. The students were asked questions pertaining to specific clinical situations. The answers were compared to the information provided in the medical curriculum as well as to the relevant European guidelines. RESULTS: We collected 290 of the questionnaires (participation rate: 81.2%). The hyper- and hypokalemia thresholds considered pathological (3.5-5.0 mmol/L) were known by 78% and 67% of the students, respectively. The perception of danger in case of severe hypokalemia was underestimated by 62.7% of them. In most cases, the proposed management of hyperkalemia in heart and renal failure did not comply with the relevant guidelines. The students tended to favor permanent discontinuation of the administration of converting enzyme inhibitors (ACE) and/or mineralocorticoid receptor antagonists (MRA) without considering the need for their reintroduction (51.6%). Sodium polystyrene sulfate was frequently seen as an appropriate first-line treatment for hyperkalemia (45%). CONCLUSIONS: The knowledge and competence of general medicine students appear to be lacking for hyperkalemia in heart and renal failure, and they are long way from full compliance with the relevant European guidelines. Exposure to complex clinical situations as part of the medical curriculum, therefore, seems essential to improve the way dyskalemia is managed in France.