Administration Of Potassium Chloride Research Articles

Ketamine-induced prevention of SD-associated late infarct progression in experimental ischemia

Spreading depolarizations (SDs) occur frequently in patients with malignant hemispheric stroke. In animal-based experiments, SDs have been shown to cause secondary neuronal damage and infarct expansion during the initial period of infarct progression. In contrast, the influence of SDs during the delayed period is not well characterized yet. Here, we analyzed the impact of SDs in the delayed phase after cerebral ischemia and the potential protective effect of ketamine. Focal ischemia was induced by distal occlusion of the left middle cerebral artery in C57BL6/J mice. 24 h after occlusion, SDs were measured using electrocorticography and laser-speckle imaging in three different study groups: control group without SD induction, SD induction with potassium chloride, and SD induction with potassium chloride and ketamine administration. Infarct progression was evaluated by sequential MRI scans. 24 h after occlusion, we observed spontaneous SDs with a rate of 0.33 SDs/hour which increased during potassium chloride application (3.37 SDs/hour). The analysis of the neurovascular coupling revealed prolonged hypoemic and hyperemic responses in this group. Stroke volume increased even 24 h after stroke onset in the SD-group. Ketamine treatment caused a lesser pronounced hypoemic response and prevented infarct growth in the delayed phase after experimental ischemia. Induction of SDs with potassium chloride was significantly associated with stroke progression even 24 h after stroke onset. Therefore, SD might be a significant contributor to delayed stroke progression. Ketamine might be a possible drug to prevent SD-induced delayed stroke progression.

ABHD6 and MAGL control 2-AG levels in the PAG and allodynia in a CSD-induced periorbital model of headache.

The high prevalence and severe symptoms of migraines in humans emphasizes the need to identify underlying mechanisms that can be targeted for therapeutic benefit. Clinical Endocannabinoid Deficiency (CED) posits that reduced endocannabinoid tone may contribute to migraine development and other neuropathic pain conditions. While strategies that increase levels of the endocannabinoid n-arachidonoylethanolamide have been tested, few studies have investigated targeting the levels of the more abundant endocannabinoid, 2-arachidonoylgycerol, as an effective migraine intervention. Cortical spreading depression was induced in female Sprague Dawley rats via KCl (potassium chloride) administration, followed by measures of endocannabinoid levels, enzyme activity, and neuroinflammatory markers. Efficacy of inhibiting 2-arachidonoylglycerol hydrolysis to mitigate periorbital allodynia was then tested using reversal and prevention paradigms. We discovered reduced 2-arachidonoylglycerol levels in the periaqueductal grey associated with increased hydrolysis following headache induction. Pharmacological inhibition of the 2-arachidonoylglycerol hydrolyzing enzymes, α/β-hydrolase domain-containing 6 and monoacylglycerol lipase reversed and prevented induced periorbital allodynia in a cannabinoid receptor-dependent manner. Our study unravels a mechanistic link between 2-arachidonoylglycerol hydrolysis activity in the periaqueductal grey in a preclinical, rat model of migraine. Thus, 2-arachidonoylglycerol hydrolysis inhibitors represent a potential new therapeutic avenue for the treatment of headache.

Evaluation of the effectiveness of potassium chloride in the management of out-of hospital cardiac arrest by refractory ventricular fibrillation: Study protocol of the POTACREH study.

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC). A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic. No patient is currently included in the study. Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs. ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611.

PS-R07-1: CASE OF PSEUDOHYPERALDOSTERONISM WITH IMPROVEMENT OF HYPERTENSION AND HYPOKALEMIC WEAKNESS BY DISCONTINUATION OF PEONY AND LICORICE FORMULA.

Case: An 80-year-old woman was admitted to our hospital with lower extremity weakness. She was treated for hypertension (HT), type 2 diabetes, and Alzheimer's disease. Her medications included brotizolam 0.25 mg, rivastigmine tape 18 mg, celecoxib 200 mg, sofarcon 50 mg, losartan 50 mg, hydrochlorothiazide 12.5 mg, rosuvastatin 2.5 mg, propiverine 10 mg, empagliflozin 10 mg, linagliptin 5 mg, esomeprazole 20 mg, peony and licorice formula (PLF) 7.5 grams, and olopatadine 5 mg. On admission her blood pressure (BP) was 191/73 mmHg. Manual muscles testing (MMT) for the upper limbs was 4/5 bilaterally throughout. Lower limb MMT included iliopsoas 1/5, quadriceps 1/5, hamstrings 1/5, anterior tibialis 4/5, gastrocnemius 4/5 bilaterally, respectively. Basic blood tests revealed serum K + 2.0 mEq/L, urinary K + 21.0 mEq/L, creatinine kinase 1,488 U/L, renin activity 0.8 ng/mL/hr, and aldosterone 4.0 pg/mL (CLEIA method). During admission to the intensive care unit, frequent blood sampling was performed to correct the serum K + level. A calcium channel blocker (CCB) was commenced for HT on admission day. Spironolactone was commenced on post-admission day (PAD) 1. The serum K+ level stabilized, and potassium chloride administration was terminated PAD 6. BP also improved over time, and the CCB was discontinued on PAD 23. On the same day, she was discharged from the hospital with continuation of spironolactone. In this case, there were a total of 11 prescription drugs including PLF from three clinics. We diagnosed HT and lower extremity weakness due to pseudohyperaldosteronism (PHA). The HT improved after discontinuation of PLF. Licorice is found in about 70% of Chinese herbal medicines. Risk factors for PHA include short stature and weight, elderly and female, renal dysfunction, and diuretic administration. As Japan has entered a super-aging society, the number of patients using geriatric healthcare facilities and chronic care wards is increasing. The frequency of blood sampling is particularly low in such facilities, so it is difficult to notice hypokalemia among such patients. PHA and hypokalemic myopathy due to licorice should be considered in the case of lower limb weakness in elderly patients. In conclusion, it is important to identify PHA caused by licorice-containing Chinese herbal medicines in elderly patients with HT. In addition, healthcare facilities for the elderly it is advised that serum K+ is checked in patients with worsening HT, weakness and polypharmacy.

Evaluation of knowledge and practices about administration and regulations of high alert medications among hospital pharmacists in Pakistan: findings and implications

Background A death of a nine months old child in Pakistan following the rapid administration of potassium chloride raised serious concerns on the awareness of appropriate use of high alert medications (HAMs) among healthcare professionals (HCPs). This study aimed to ascertain HAMs-related knowledge among hospital pharmacists in Pakistan. Methodology A cross-sectional study using exponential non-discriminative snowball sampling was conducted among hospital pharmacists in healthcare settings in Punjab, Pakistan. A validated study tool was used to determine knowledge on administration, regulation, and practices related to the HAMs. Barriers to conducting HAMs training in the hospitals were assessed from an open-ended question. All quantitative data were analyzed using SPSS 22.0 while the content analysis was performed on the qualitative data. Results A total of 202 hospital pharmacists were included in the study. The mean knowledge score for HAMs administration and regulation were 5.86 ± 1.89 (95% CI 5.60–6.12) and 7.25 ± 1.70 (95% CI 7.02–7.49), respectively. Approximately half of the respondents (49.5%) achieved scores ≥ 70%, demonstrating sufficient knowledge of HAMs. In the multivariable-adjusted model, increasing age and work experience were found to be the positive predictors of good HAMs knowledge. The mean practice score was 36.42 ± 1.97 (95% CI 34.05–38.77), with 62.4% of pharmacists following good HAMs-related practices. We identified several barriers to conducting HAMs training through qualitative analysis. These barriers included lack of knowledge, poor attitude and behavior of medical and paramedical staff, false beliefs, lack of active support by hospital administration, lack of cooperation between HCPs, lack of opportunities, heavy workload, insufficient human resources, financial constraints, and lack of motivation. Conclusions A significant proportion of the hospital pharmacists had unsatisfactory knowledge and practices of HAMs. These findings underscore that training on HAMs should be conducted periodically as a part of hospital-based pharmacy education to maximize drug safety.

Effects of Acute Potassium Chloride Administration on Ventricular Dysrhythmias after Myocardial Infarction in a Rat Model of Ischemia/Reperfusion.

Background: Acute myocardial infarction is an important cause of morbidity. This study aimed to investigate the effects of the administration of potassium chloride (KCl) on reperfusion-induced injuries in a rat model of myocardial ischemia/reperfusion. Methods: Thirty-six male Wistar rats, weighing 200 to 250 g, were randomly assigned to 3 experimental groups: control, K1 (10 µg/kg of KCl), and K2 (20 µg/kg of KCl). Twenty minutes before ischemia, a single dose of 10 and 20 µg/kg of KCl was intraperitoneally administered in the K1 and K2 groups, respectively. The coronary artery was occluded for 30 minutes (ischemia); thereafter, it was opened for 60 minutes (reperfusion) to measure hemodynamic parameters and ventricular arrhythmias. Blood sampling was performed after the reperfusion period to determine the serum levels of lactate dehydrogenase, troponin I, creatine kinase (CK)-MB, malondialdehyde, and pro-oxidant-antioxidant balance. Results: Serological parameters significantly decreased in the potassium groups compared with the control group. In particular, the decline was more pronounced for the serum levels of lactate dehydrogenase (1180.25±69.48 vs 1556.67±77.02 U/L; P=0.011), troponin I (21.98±0.61 vs 28.76±1.65 ng/mL; P=0.020), and pro-oxidant-antioxidant balance (15.51±0.72 vs 20.63±1.42 HK; P=0.041) in the K2 group compared with the K1 group. Moreover, the administration of 20 µg/kg of KCl significantly decreased the incidence of ventricular tachycardias and fibrillations compared with the control group (P=0.002). Additionally, no considerable differences were observed between the control group and the groups with 10 µg/kg and 20 µg/kg of KCl regarding the number of ventricular ectopic beats. Conclusion: The administration of KCl before ischemia could reduce ventricular arrhythmias and reperfusion-induced injuries by reducing oxidative stress.

Clinical Course of 60 Cesarean Scar Pregnancies.

Early diagnosis and therapy are important in a cesarean scar pregnancy (CSP), which can cause uterine rupture with resultant massive bleeding. However, there are some reports of CSPs continued to term. The optimal management of CSPs remains unclear; therefore, we investigated the clinical courses of CSPs diagnosed and treated at perinatal institutions in the Chugoku and Shikoku regions of Japan. We enrolled 60 women diag-nosed with CSP at 21 institutions from January 2006 to December 2015. Of the 60 women diagnosed with CSP, 57 were treated. Pregnancy was terminated in 48 women and continued in 9. Thirteen women underwent transabdominal hysterectomy; they experienced no postoperative complications or allogeneic blood transfu-sion. Nine women received therapies such as dilation and curettage, and 26 received non-surgical therapies such as methotrexate and topical administration of potassium chloride. Among 9 women who chose to con-tinue with their CSP, 7 successfully delivered newborns, 2 had uterine ruptures in the second trimester, and all women required transabdominal hysterectomy. Diagnosis and therapy in the first trimester of pregnancy are important in the management strategy of a CSP. When continuing a CSP, the risk of uterine rupture and trans-abdominal hysterectomy must be considered.

A Case of Recurrent Paralysis and Low Potassium: Is It the Thyroid?

Introduction: Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that is characterized by episodes of hypokalemia and acute weakness. Although hyperthyroidism is more common in females, over 95% of cases of TPP have been observed in males, especially in Asian males with an incidence of 2% among hyperthyroid patients. In non-Asian populations, the incidence in hyperthyroid patients is estimated to be around 0.1 to 0.2% [1]. We describe a case of TPP seen in a Hispanic male. Case Report: A 36-year-old Hispanic male with no past medical history presents with weakness in all extremities and difficulty breathing after consuming a carbohydrate heavy meal the night prior. He reports a recent, similar episode evaluated in another ER, which resolved after given potassium supplementation. He denied any vomiting, diarrhea, polyuria, diaphoresis, use of insulin or other medications, or any family history of paralysis.His labs were significant for hypokalemia of 1.9, TSH of <0.005 (0.358-3.740), free T4 of 2.22 (0.76-1.46), and total T3 of 2.7 (0.60-1.81). Thyroid stimulating immunoglobulin was 0.12 (0.0-0.55). His symptoms improved and potassium levels normalized following the administration of potassium chloride. He was discharged on propranolol and advised to follow up for further workup of his hyperthyroidism with radioactive iodine uptake scan. Discussion: Thyrotoxic periodic paralysis is a potentially life-threatening condition associated with cardiac arrhythmias and respiratory failure. Hyperthyroidism increases response to β-adrenergic stimulation, which increases activity of the sodium-potassium ATPase and causes hyperpolarization of skeletal muscle [2]. Hyperthyroid patients are prone to episodes of paralysis due to their increased susceptibility to the hypokalemic action of insulin, which activates the sodium-potassium ATPase pump, and epinephrine, which stimulates β-adrenoreceptors. Management of an acute attack of TPP includes potassium administration. In cases where paralysis and hypokalemia are not reversed, intravenous propranolol has been shown to resolve the attack by blocking the β-adrenergic receptors. Definitive treatment of TPP includes managing the hyperthyroid state with medical therapy, radioactive iodine therapy, or surgery. Until the euthyroid state is reached, a β-blocker can prevent episodes of acute paralysis. Avoidance of carbohydrate heavy meals, exercise, and stress are recommended as these factors can potentially exacerbate hypokalemia. In patient with acute paralysis, it is important to consider the diagnosis of TPP as this condition can be prevented once euthyroidism is achieved. Diagnosis and management will lead to prevention of morbidity and mortality associated with the hypokalemia.

Electrocardiographic changes in the acute hyperkalaemia produced by intragastric KCl load in rats.

What is the central question of this study? This study presents a new model for studying the rapid onset of severe, acute hyperkalaemia in rats with intact kidney function by administering an intragastric KCl load. What is the main finding and its importance? This new model of intragastric KCl load produces a reliable and reproducible model for studying the rapid onset of severe, acute hyperkalaemia in rats with intact kidney function. We report unprecedented rapid changes (30min) in ECG, blood pressure and various arterial blood analyses with this new model, providing a solid foundation for future experiments in this field. A variety of animal models have been proposed to study hyperkalaemia, but most of them have meaningful limitations when the goal is to study the effect of potassium overload on healthy kidneys. In this study, we aimed to introduce a new approach for induction of hyperkalaemia in a reliable and reproducible animal model. We used intragastric administration of potassium chloride [KCl 2.3M, 10ml/(kg body weight)] to male Holtzman rats (300-350g) to induce hyperkalaemia. The results showed that this potassium load can temporarily overwhelm the renal and extrarenal handling of this ion, causing an acute and severe hyperkalaemia that can be useful to study the effect of potassium imbalance in a variety of scenarios. Severe hyperkalaemia (>8meqiv/l) and very profound ECG alterations, characterized by lengthening waves and intervals, were seen as early as 30min after intragastric administration of KCl in rats. In addition, a transient increase in arterial blood pressure and time-dependent bradycardia were also seen after the KCl administration. No metabolic acidosis was present in the animals, and the potassium ion did not increase proportionally to chloride ion in the blood, leading to an increased anion gap. In conclusion, the results suggest that intragastric KCl loading is a reliable model to promote rapid and severe hyperkalaemia that can be used for further research on this topic.

Responses of spinal trigeminal neurons to noxious stimulation of paranasal cavities - a rat model of rhinosinusitis headache.

The pathophysiology of headaches associated with rhinosinusitis is poorly known. Since the generation of headaches is thought to be linked to the activation of intracranial afferents, we used an animal model to characterise spinal trigeminal neurons with nociceptive input from the dura mater and paranasal sinuses. In isoflurane anaesthetised rats, extracellular recordings were made from neurons in the spinal trigeminal nucleus with afferent input from the exposed frontal dura mater. Dural and facial receptive fields were mapped and the paranasal cavities below the thinned nasal bone were stimulated by sequential application of synthetic interstitial fluid, 40 mM potassium chloride, 100 µM bradykinin, 1% ethanol (vehicle) and 100 µm capsaicin. Twenty-five neurons with input from the frontal dura mater and responses to chemical stimulation of the paranasal cavities were identified. Some of these neurons had additional receptive fields in the parietal dura, most of them in the face. The administration of synthetic interstitial fluid, potassium chloride and ethanol was not followed by significant changes in activity, but bradykinin provoked a cluster of action potentials in 20 and capsaicin in 23 neurons. Specific spinal trigeminal neurons with afferent input from the cranial dura mater respond to stimulation of paranasal cavities with noxious agents like bradykinin and capsaicin. This pattern of activation may be due to convergent input of trigeminal afferents that innervate dura mater and nasal cavities and project to spinal trigeminal neurons, which could explain the genesis of headaches due to disorders of paranasal sinuses.

EVALUATION OF IN-VITRO VASORELAXANT EFFECT (POTENTIAL ANTIHYPERTENSIVE) OF KIGELIA AFRICANA FRUIT METHANOL EXTRACT ON POTASSIUM CHLORIDE AND PHENYLEPHRINE INDUCED TENSION IN WISTAR RAT AORTA

This research on Kigelia africana was conducted in order to ascertain its ability to relax excited vascular smooth muscle in rat aorta. Preliminary investigation on whether the plant exhibits antihypertensive property was done before the evaluation of in vitro vasorelaxant effect. The vasorelaxant activity was determined using in vitro method on rat aorta with the aid of perfusion apparatus with a detachable organ bath. The administration of potassium chloride (KCl) raised the tension from 1.0 to 1.31 indicating that the aorta got to its peak of contraction. At 10 and 20mg/kg, the tension dropped significantly, showing relaxation of the smooth muscle while at 5mg/kg, drop in tension was insignificant at p˂0.05. However, at some of the doses, towards the end of experiment, there was steady resurge in tension showing that the aorta resumed contraction. On the application of phenylephrine (PE), the tension rose to 1.18g. On administration of the extract, the tension dropped slightly showing mild vascular smooth muscle relaxation. From the results obtained, there was seeming similarity in the action of the K. africana compared to amlodipine/Ramipril in KCl and PE induced tension in aorta respectively. However, at 10 and 20mg/kg, a substantial decrease in tension was noted indicating that the extract action is dose dependent. Thus, from this in-vitro smooth muscle relaxation study in rats, the methanol extract of K. africana has depressant property that was likely expressed by enhancing the closing of voltage operated calcium channel and ACE inhibiting activity in KCl and Phenylephrine induced tension respectively.

Identification of compound mutations of SLC12A3 gene in a Chinese pedigree with Gitelman syndrome exhibiting Bartter syndrome-liked phenotypes

BackgroundGitelman syndrome is a rare salt-losing renal tubular disorder associated with mutation of SLC12A3 gene, which encodes the Na-Cl co-transporter (NCCT). Gitelman syndrome is characterized by hypokalemia, metabolic alkalosis, hypomagnesemia, hypocalciuria, and renin-angiotensin-aldosterone system (RAAS) activation. Different SLC12A3 variants may lead to phenotypic variability and severity.MethodsIn this study, we reported the clinical features and genetic analysis of a Chinese pedigree diagnosed with Gitelman syndrome.ResultsThe proband exhibited hypokalaemia, hypomagnesemia, metabolic alkalosis, but hypercalciuria and kidney stone formation. The increased urinary calcium excretion made it confused to Bartter syndrome. The persistent renal potassium wasting resulted in renal tubular lesions, and might affect urinary calcium reabsorption and excretion. Genetic analysis revealed mutations of SLC12A3 gene with c.433C > T (p.Arg145Cys), c.1077C > G (p.Asn359Lys), and c.1666C > T (p.Pro556Ser). Potential alterations of structure and function of NCCT protein due to those genetic variations of SLC12A3 are predicted. Interestingly, one sibling of the proband carried the same mutant sites and exhibited similar clinical features with milder phenotypes of hypokalemia and hypomagnesemia, but hypocalciuria rather than hypercalciuria. Family members with at least one wild type copy of SLC12A3 had normal biochemistry. With administration of spironolactone, potassium chloride and magnesium supplement, the serum potassium and magnesium were maintained within normal ranges.ConclusionsIn this study, we identified compound mutations of SLC12A3 associated with varieties of clinical features. Further efforts are needed to investigate the diversity in clinical manifestations of Gitelman syndrome and its correlation with specific SLC12A3 mutations.

Post-injection thrombophlebitis in patients undergoing peripheral IV catheterization in a tertiary care hospital: incidence and risk factors

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Intravenous catheters cause endothelial damage and trauma, which can predispose to venous thrombosis. Peripheral vein infusion thrombophlebitis occurs in 25- 35% of hospitalized patients with intravenous catheters and has both patient-related implications (e.g., sepsis) and economic consequences (e.g., extra nursing time). This study is designed to address this issue, by assessing the potential risk factors in those who have developed phlebitis, and deriving conclusions based on the same.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 830 patients were observed over a period of 2 months. All details of the patient were collected. Thrombophlebitis was graded using Visual Infusion Phlebitis Score. Each case was compared with a matching control. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 53 of 830 patients observed, developed thrombophlebitis giving an incidence of 6.4%. 92.5% had IV cannulation flushed after insertion. IV cannula had to be changed at least 2 times during the hospital stay. All had an average IV cannulation for 5 days. All had insertion of same size cannula (20G). Level 1 Phlebitis was identified in 64.15% patients, level 2 Phlebitis in 33.96% patients and Level 3 Phlebitis was seen 1.88% patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Significant association was noted between the number of times the catheter was changed since admission and administration of Potassium chloride and Certain Medications such as Piperacillin through the cannula.&lt;/p&gt;

The role of anaesthesiologists in lethal injection: a call to action.

In 2006, Michael Angelo Morales, a California death-row inmate, was scheduled to be executed by lethal injection. 1 Gawande A When law and ethics collide–why physicians participate in executions. N Engl J Med. 2006; 354: 1221-1229 Crossref PubMed Scopus (68) Google Scholar Morales challenged the state's lethal injection protocol in court, arguing that administration of pharmaceutical drugs without oversight by personnel with medical expertise or training would violate his Eighth Amendment rights. 2 Michael Angelo Morales v Roderick Q Hickman. Number C 06 219 JF. District Court, Northern District of California, CA, USA. Feb 14, 2006. Google Scholar The basis of his claim was that the protocol created foreseeable and undue risk of excessive pain, given the potential for consciousness during drug administration. 2 Michael Angelo Morales v Roderick Q Hickman. Number C 06 219 JF. District Court, Northern District of California, CA, USA. Feb 14, 2006. Google Scholar The California protocol called for an injection of a three-drug cocktail: thiopental, a barbiturate intended to render the inmate unconscious; pancuronium, a neuromuscular blocking drug that induces paralysis and causes cessation of breathing; and potassium chloride, to induce cardiac arrest. 3 Schwarzenegger A Tilton JE State of California lethal injection protocol review. https://files.deathpenaltyinfo.org/legacy/files/pdf/CALethInject.pdfDate accessed: August 6, 2019 Google Scholar Morales argued that the potential for consciousness during the administration of pancuronium and potassium chloride constituted cruel and unusual punishment. 2 Michael Angelo Morales v Roderick Q Hickman. Number C 06 219 JF. District Court, Northern District of California, CA, USA. Feb 14, 2006. Google Scholar

Battlefield Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Feasibility Study During Military Exercises.

To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.

Life threatening perioperative arrhythmias and hypokalemia

Background: Perioperative arrhythmia is a common general anesthesia complication of cardiothoracic surgeries. Sudden or acute onset of life threatening perioperative arrhythmias are rare clinical events in non-cardiac surgical patients.1,2 Electrolytes imbalance, particularly hypokalemia and dyskalemia, is one of the main possible underlining cause for the occurrence of these arrhythmias.3,4,5 We present two cases of severe hypokalemia leading to life threatening cardiac arrhythmias in the post-operative period. Case 1: A 30-year old healthy female patient without significant past medical history had emergency laparoscopic cholecystectomy and appendicectomy. Pre- and intra-operative periods were uneventful. Her pre-operative potassium level was 3.7 mmol/L. 18 hours post-operatively, she suddenly developed palpitations and went into ventricular fibrillation (VF) cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated followed by defibrillation which reverted the heart to a sinus rhythm. She was transferred to the intensive care unit (ICU) sedated and connected to the ventilator. In ICU, her serum electrolytes showed severe hypokalemia (serum potassium level 2.2 mmol/L) (Figure 1) so she was immediately started on 20 mmol of potassium chloride (KCl) over 30 minutes through central venous catheter (CVC) with complementary intravenous fluids with KCl. In the next 36 minutes she had four episodes of VF requiring CPR and defibrillation with a positive outcome. She received amiodarone infusion as well as continuous KCl supplementation and calcium gluconate 2 g. She received 100 mmol of KCl in 6 hours and a total of 220 mmol of KCl in 24 hours, and then she became stable. She was extubated after 48 hours. Echocardiogram and cardiac conduction studies showed no pathological changes. Cardiac conduction studies (electrophysiology study - EPS) were normal. She was discharged home and followed in the outpatient clinic. Case 2: A 78-year old known hypertensive male patient on angiotensin converting enzyme inhibitors was admitted to intensive care unit (ICU) for observation after laparoscopic cholecystectomy. Pre-operative serum electrolytes were within normal range. After one hour he started to have tachycardia and then went into pulseless ventricular tachycardia requiring defibrillation. His serum electrolytes results showed severe hypokalemia (2.4 mmol/L) (Figure 1) so this was corrected by rapid potassium chloride administration through CVC and supplementation of KCl in intravenous fluids. After 10 minutes he went into VF requiring defibrillation and a bolus of amiodarone. In the next 20 minutes he had three more episodes of VF requiring CPR and defibrillation.In six hours he required 90 mmol of KCl to reach a serum potassium level of 3.7 mmol/L. A total of 210 mmol of KCl was needed in 24 hours. He was extubated after 24 hours. He was transferred to the ward on day 3 and discharged home on day 6, and later followed in the outpatient clinic. Conclusion: Perioperative severe hypokalemia can lead to life threatening cardiac arrhythmias. Early recognition and aggressive correction through perioperative potassium supplementation is essential for better outcome. Daily potassium level assessment and supplementation should be done in the perioperative period.

Evaluation of the safety and efficacy of the central venous administration of potassium chloride including the measurement of intracardiac potassium concentrations

This study examined the safety and efficacy of the intravenous administration of 20 mEq potassium chloride (KCl) dissolved in a 100 cc 5% dextrose in sterile water bolus over 1 hour through a subclavian central vein catheter in critical care unit patients for the treatment of low and low to normal serum potassium concentrations. We studied seven patients with morning serum potassium between 2.4 and 3.6 mEq/L who had intravenous KCl boluses ordered by their treating physician. Intracardiac and peripheral venous potassium levels were obtained before, during, and after infusion. Holter and electrocardiogram assessment of rhythm, supraventricular and ventricular ectopy, and electrical intervals were recorded before, during, and after the intravenous KCl bolus. The cardiac rhythm, heart rates, and electrocardiographic intervals remained unchanged throughout the infusion and postinfusion phases. In six of the seven patients, there was no new or worsening supraventricular or ventricular ectopy temporally related to the infusion. Postinfusion potassium levels increased in all patients, with an average peripheral vein serum potassium increase of 0.4 mEq/L. In conclusion, within the limitations of our sample size, our study demonstrated the safety and efficacy of the central venous infusion of 20 mEq KCl in 100 cc 5% dextrose in sterile water administered over 1 hour.

Inadvertent administration of potassium chloride in the epidural space: How to prevent the inevitable.

Inadvertent administration of potassium chloride in the epidural space: How to prevent the inevitable.

Conservative treatment of abnormally located intrauterine pregnancies (cervical and cesarean scar pregnancies): a multicenter analysis (Polish series)

Objectives: To analyze the effectiveness and outcome of conservative treatment in cases of abnormally located intrauterine pregnancies (cervical and cesarean scar).Study design: A retrospective analysis was performed of 30 pregnant women hospitalized due to abnormally located intrauterine pregnancies. The analyzed group comprised 24 pregnant women with abnormally located pregnancies. The patients were divided into two groups: the first group consisted of patients treated systemically with methotrexate, while the second of those treated locally by administration of methotrexate (MTX) and/or potassium chloride (KCl) by gestational sac puncture.Results: The analyzed group comprised 24 pregnant women with abnormally located pregnancies. Eight patients were diagnosed with cervical pregnancy (CP) and 16 patients were diagnosed with cesarean scar pregnancy (CSP). Six patients were excluded from the study: two with spontaneous abortions, two heterotopic pregnancies, and two cornual pregnancies. Twelve analyzed patients underwent MTX systemic administration (five patients with CP, seven with CSP). In five patients, systemic treatment was ineffective; they were qualified for additional local therapy with gestational sac (GS) puncture and MTX or KCl administration to the sac and additional administration of MTX to the trophoblast area. In second group of 12 patients (three CP, nine CSP), local treatment (GS puncture with MTX or MTX + KCl) was used as the first line treatment. One patient underwent combined treatment (local + systemic).Conclusions: Conservative treatment should be the gold standard procedure in abnormally located intrauterine pregnancies. It is noticeable that MTX / KCl is more effective in a direct administration to the GS. In four cases, systemic MTX did not produce the desired effects. In these cases, the treatment was assisted by local administration of MTX or KCl, resulting in the termination of an abnormally located pregnancy.

Selective Fetal Reduction of Conjoined Twins in Twin Pregnancy

ABSTRACT Background The incidence of conjoined twins is rare. In early pregnancy, transvaginal ultrasound may facilitate diagnosis and prompt intervention can be done. Case Report A 35 years old patient with history of infertility for 17 years conceived after In vitro fertilization–embryo transfer with donor oocytes due to ovarian factor; three embryos were transferred. Transvaginal sonography was done on 21st day after transfer and it revealed three gestational sacs with fetal pole in all the sacs. Repeat TVS done on 65th day post embryo transfer revealed one gestational sac with single live embryo, second sac with two embryos joined at thorax and abdomen with a common heart, and two heads. Couple was then counseled for fetal reduction in view of expected poor outcome of conjoined twins. Selective fetal reduction was done at 12 weeks gestation with intra-cardiac potassium chloride administration. Pregnancy is now ongoing with an apparently normal live singleton fetus. Conclusion When conjoined twins are detected early, fetal reduction is a good modality of management. These pregnancies are associated with severe complications, maternal and fetal morbidity and mortality. Hence, the sooner the fetal reduction is, the better the management of conjoined twins. How to cite this article Choudhary S, Mishra V, Aggarwal R, Agarwal H. Selective Fetal Reduction of Conjoined Twins in Twin Pregnancy. J South Asian Feder Obst Gynae 2017;9(3):277-279.