Dextrose Administration Research Articles

Temporomandibular Joint Injections and Lavage: An Overview of Reviews.

Objectives: This overview was conducted following the Preferred Reporting Items for Overviews of Reviews guidelines and aimed to collect and compare the results of systematic reviews on temporomandibular joint injection treatment. Methods: Systematic reviews of randomized clinical trials on temporomandibular disorders treated with lavage or intra-articular administrations were qualified for syntheses. The final searches were conducted on 27 February 2024, without time frame restrictions. Results: Of the 232 identified records, 42 systematic reviews were selected. The most evidence-based conclusions call into question the clinical differences between many therapeutic approaches, including the following: (1) injectable selection for the treatment of pain and hypomobility; (2) the method of performing arthrocentesis; (3) the use of imaging when rinsing the TMJ cavity; (4) the supplementation of the extracapsular administration of unprocessed blood with intracapsular deposition in the treatment of TMJ hypermobility. Conclusions: Systematic reviews based solely on randomized clinical trials proved the following differences: (1) in painful temporomandibular hypomobility, a better therapeutic effect is observed with arthrocentesis followed by I-PRF administration compared to lavage alone; (2) in painful temporomandibular hypomobility, inferior- or double-compartment injection leads to better results than superior-compartment injection; (3) in temporomandibular joint recurrent dislocation, hypertonic dextrose administration is superior to placebo, although (4) unprocessed blood has a better effect than hypertonic dextrose. PROSPERO registration number: CRD42024496142.

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69).

An objective and validated index of nausea and vomiting such as the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C] Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A] There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (AppendixIII). [Grade A] There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B] Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B] Because of the risk of extrapyramidal effects metoclopramide should be used as second-line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C] Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP] Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C] Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in AppendixIII. [GPP] Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D] All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C].

Effectiveness of hospital-based oral dextrose gel in prevention and treatment of asymptomatic newborns at risk of hypoglycemia

Objective To evaluate the effectiveness of using hospital-based 40% dextrose gel (DG) in preventing and treating asymptomatic hypoglycemia in infants of diabetic mothers (IDM), large for gestational age (LGA), and macrosomic neonates. Methods A medical chart review was conducted to compare data between before (April 2018 to March 2019, epoch 1) and after (September 2020 to November 2021, epoch 2) 40% DG implementation. DG, prepared by the hospital pharmaceutical unit, was applied within 30–45 min after birth, and three additional doses could be repeated during the first 6 h of life in combination with early feeding. The primary outcome was the rate of intravenous dextrose administration. Secondary outcomes were the incidence of hypoglycemia, first capillary blood glucose concentrations, and the length of hospital stay. Results Six hundred forty-three at-risk newborns were included (320 before and 323 after implementation of DG). Maternal and neonatal baseline characteristics were not different between the two epochs. The incidence of hypoglycemia was not different (17.8% in before versus 14.6% in after implementation, p = 0.26). The rate of intravenous dextrose administration after DG implementation was significantly lower than that before DG implementation (3.4% versus 10.3%, p < 0.001, risk reduction ratio = 0.33, 95% CI = 0.17–0.64). The length of hospital stay was not different between the two epochs. Conclusions Implementing a protocol for administration of hospital-based 40% DG can reduce the need of intravenous dextrose administration among IDM, LGA and macrosomic neonates.

IGF-2-mediated hypoglycemia: a case series and review of the medical therapies for refractory hypoglycemia.

Non-islet cell tumour hypoglycemia (NICTH), typically mediated by insulin-like growth factor 2 (IGF-2), is a rare but highly morbid paraneoplastic syndrome associated with tumours of mesenchymal or epithelial origin. Outside of dextrose administration and dietary modification which provide transient relief of hypoglycemia, resection of the underlying tumour is the only known cure for NICTH. Available medical therapies to manage hypoglycemia include glucocorticoids, recombinant growth hormone, and pasireotide. We report two cases of IGF-2 mediated hypoglycemia. The first was managed surgically to good effect, highlighting the importance of a timely diagnosis to maximise the likelihood of a surgical cure. The second patient had unresectable disease and was managed medically, adding to a growing number of cases supporting the efficacy of glucocorticoids and recombinant growth hormone in NICTH. Recurrent fasting hypoglycemia in the setting of a malignancy should raise suspicion of non-islet cell tumour hypoglycemia (NICTH), which is typically mediated by IGF-2. The initial workup for NICTH should include a serum glucose, C-peptide, insulin, insulin antibodies, beta-hydroxybutyrate, IGF-2, IGF-1, and sulphonylurea screen during a spontaneous or induced hypoglycemic episode. An IGF-2/IGF-1 ratio above 10 is highly suggestive of IGF-2-mediated hypoglycemia if the IGF-2 level is normal or elevated. False positives may be seen with sepsis and cachexia as both IGF-2 and IGF-1 are subnormal in these cases. A low IGF binding protein 3 (IGFBP3), such as in renal failure, may also result in a falsely normal or low IGF-2/IGF-1 ratio. Surgical resection of the associated tumour is curative in most NICTH cases. When the tumour is unresectable, moderate-dose glucocorticoids, low-dose glucocorticoids in combination with recombinant growth hormone, and pasireotide are medical therapies with promising results in controlling NICTH.

Acute severe hypoglycemia alters mouse brain microvascular proteome

Hypoglycemia increases the risk related to stroke and neurodegenerative diseases, however, the underlying mechanisms are unclear. For the first time, we studied the effect of a single episode (acute) of severe (ASH) and mild (AMH) hypoglycemia on mouse brain microvascular proteome. After four-hour fasting, insulin was administered (i.p) to lower mean blood glucose in mice and induce ∼30 minutes of ASH (∼30 mg/dL) or AMH (∼75 mg/dL), whereas a similar volume of saline was given to control mice (∼130 mg/dL). Blood glucose was allowed to recover over 60 minutes either spontaneously or by 20% dextrose administration (i.p). Twenty-four hours later, the brain microvessels (BMVs) were isolated, and tandem mass tag (TMT)–based quantitative proteomics was performed using liquid chromatography-mass spectrometry (LC/MS). When compared to control, ASH significantly downregulated 13 proteins (p ≤ 0.05) whereas 23 proteins showed a strong trend toward decrease (p ≤ 0.10). When compared to AMH, ASH significantly induced the expression of 35 proteins with 13 proteins showing an increasing trend. AMH downregulated only 3 proteins. ASH-induced downregulated proteins are involved in actin cytoskeleton maintenance needed for cell shape and migration which are critical for blood-brain barrier maintenance and angiogenesis. In contrast, ASH-induced upregulated proteins are RNA-binding proteins involved in RNA splicing, transport, and stability. Thus, ASH alters BMV proteomics to impair cytoskeletal integrity and RNA processing which are critical for cerebrovascular function.

Bilateral Abducens Nerve Palsy and Nystagmus Resolved Upon Intravenous Dextrose Administration in Hypoglycemic Young Female: A Case Report and Review of the Literature

Hypoglycemia can cause a variety of neurological symptoms ranging from mild confusion to seizures and coma. The brain depends heavily on glucose as its main energetic resource, and a decrease in glucose levels can lead to impaired cerebral function. A 38-year-old female presented to the Emergency department with a history of headache, dizziness and asymmetric reactive pupils in addition to bilateral medial strabismus, nystagmus and photophobia. A non-contrast brain Computed Tomography scan was performed showed no significant radiological findings. Laboratory tests were within normal ranges except for a clinically significant hypoglycemia (level II). Intravenous dextrose was administered and strabismus gradually resolved, and headache subsided gradually within an hour. Hypoglycemic state should be investigated first in any patient with sudden neurological deficit.

THU368 A Rare Case Of Glycogenic Hepatopathy With Persistent Lactic Acidosis

Abstract Disclosure: M. Shah: None. S. Challagulla: None. Background: Glycogenic hepatopathy (GH) is an under-recognized complication of poorly controlled diabetes. It is caused by abnormal glycogen accumulation in hepatocytes leading to hepatomegaly and transient elevation of liver transaminases. Diagnosis is often delayed as liver biopsy is needed to distinguish it from other causes of liver injury. Complete resolution can be achieved with intensive glucose control. We present a case of GH diagnosed in a patient who developed increasing liver transaminases and persistent lactic acidosis after resolution of DKA. Clinical Case: We present a 21-year-old female with uncontrolled Type 1 diabetes who presented with fatigue, nausea, and generalized body aches. Patient was hemodynamically stable. Laboratory work up on admission showed a serum glucose of 834 mg/dL, serum bicarbonate less than 5 mEq/L, beta hydroxybutyrate was elevated to 8.7 mmol/L (normal &amp;lt;0.4 mmol/L), lactic acid was also elevated to 7.9 mmol/L (normal &amp;lt;2.0 mmol/L). She was diagnosed with DKA and treated with IV fluids and insulin drip. Over the next five days the patient’s symptoms improved and DKA resolved with beta hydroxybutyrate falling to &amp;lt;0.1 mmol/L. Her lactic acidosis however persisted, she had no apparent infection and no episodes of hypotension to explain this finding. CT scan of the abdomen revealed hepatomegaly not compatible with steatosis. Liver enzymes on admission were mildly elevated AST 57 IU/L and ALT 61 IU/L however values continued to rise and peaked at AST 2372 IU/L and ALT 681 IU/L five days later. Further laboratory studies revealed no evidence of viral hepatitis, no presence of drugs or toxins. Chronic liver disease work up revealed normal ANA, AMA, SPEP, ceruloplasmin, and iron levels. Patient ultimately underwent liver biopsy which revealed glycogenic hepatopathy, mild steatosis, and mild fibrosis. Patient’s lactic acidosis eventually improved with supportive care, and she was discharged. On follow up 3 months later the patient's liver enzymes had returned to normal. Discussion: Glycogenic hepatopathy is a rare diagnosis usually seen in patients with uncontrolled diabetes and elevated liver transaminases. It is hypothesized that pathogenesis of GH involves insulin increasing glycogen synthesis in the liver resulting in congested hepatocytes. Persistent lactic acidosis can also be seen; it has been proposed that increased insulin and dextrose administration prevents gluconeogenesis in the liver, therefore decreased conversion of pyruvate to glucose and increased lactate production. GH is important to understand and differentiate from other causes of liver injury and disease as treatment and prognosis is unique. Prompt liver biopsy should be pursued to elucidate diagnosis of GH. If patients are treated with aggressive glycemic control, hepatopathy can completely resolve. Presentation: Thursday, June 15, 2023

Impact of Different Therapies on Haemtological Parameters and Therapeutic Outcome in Subclinical Endometritic Buffaloes

The objective of this study was to compare the effect of administration of intrauterine dextrose, s/c levamisol and intrauterine PGF2α on haematological indices and therapeutic response in endometritic buffaloes. Twenty eight repeat breeder buffaloes with subclinical endometritis were randomly assigned into four groups. Seven animals were kept as Control (untreated C), and the rests were assigned to three treatment group, i.e., T1 (Dextrose I/Ut, 50 mL 4 times on the day of estrus), T2 (Levamisol s/c, @ 2.5 mg/kg b.wt. on day 0, 7 and 14 of the cycle), and T3 (PGF2α I/Ut, @ 0.25 mg in 0.5 mL saline twice, on the day of first and next estrus). Following treatment the values of Hb, TEC and PCV elevated significantly and TLC values dropped to normal or near normal in all three treatment groups as compared to control group. Furthermore, the post-treatment neutrophils and lymphocytes counts were elevated significantly in all four groups. However, there was no any definite pattern of eosinophils and basophils. The therapeutic response (clinical recovery) was 14.29, 71.43, 85.71 and 42.86 % in T0, T1, T2 and T3 group, respectively. The corresponding conception rates were 0.00, 60.00, 66.67 and 66.67 %. The results conclude that, Dextrose intrauterine, Levamisol s/c, and PGF2α intrauterine can be used effectively to manage subclinical endometrtitis in buffaloes.

Quality improvement initiative to impact Golden Hour timeliness using a dedicated delivery team.

Golden Hour (GH) care impacts immediate and long-term outcomes for premature infants. We hypothesized that creation of a dedicated delivery team, the Stork Team, would improve delivery of GH care. A GH quality improvement initiative was created for infants born at <32 weeks and implemented in July 2018. Data were collected from GH checklists and the electronic medical record. Following Stork Team implementation there was special cause variation noted in the minute of life (MOL) for administration of dextrose containing fluids and antibiotics. Dextrose containing fluid time improved from 111 to 67 MOL, with an increase in the percentage of patients receiving fluids by 60 MOL. Antibiotic administration improved from 180 to 82.5 MOL. GH checklist completion increased from 77% to 98% and time to isolette closure improved from 88 to 62 MOL. Implementation of the Stork Team was associated with improvements in timeliness of GH care.

Abstract #1401109: Quetiapine-induced Hypoglycemia in an Elderly Non-diabetic Patient with Dementia

Quetiapine is a second-generation antipsychotic agent (SGA) widely prescribed for the treatment of psychotic and mood disorders. In elderly patients, quetiapine is often used to treat psychotic symptoms associated with dementia. A metabolic syndrome phenotype of weight gain, hyperglycemia, and hyperlipidemia is a potential adverse effect of SGA’s, though hypoglycemia caused by SGA’s is documented. We report a case of quetiapine-induced hypoglycemia in a non-diabetic patient. A 79-year-old male with Lewy body dementia was admitted to hospital for management of a myocardial infarction. The patient had no history of diabetes mellitus, renal failure, or hepatic insufficiency, and nobody living with the patient was treated for diabetes. Plasma glucose on admission was 84 mg/dL. Quetiapine was started to control delirium, but within 24 h the patient had worsening confusion and a capillary blood glucose (CBG) measurement of 52 mg/dL. Symptoms improved with administration of dextrose, and the patient ultimately required a 10% dextrose infusion to maintain CBG’s >80 mg/dL. An ACTH-stimulation test (30 min stimulated cortisol 24.8 μg/dL, expected >18) and hypoglycemic medications panel (sulfonylureas and meglitinides) were unremarkable. Quetiapine was stopped, and hypoglycemia resolved. No hypoglycemia occurred during a subsequent 48-h diagnostic fast followed by a mixed meal tolerance test. Due to the patient’s advanced age and comorbidities, it was decided not re-challenge with quetiapine and observe for recurrence of hypoglycemia. Hypoglycemia is a rare complication of SGA’s, and diagnosis may be delayed or missed in patients with baseline confusion or agitation. In addition to quetiapine, there are case reports of hypoglycemia occurring during treatment with risperidone, olanzapine, aripiprazole, and paliperidone. Clozapine and olanzapine increase insulin release from isolated pancreatic islets in vitro, though quetiapine did not demonstrate this effect. However, endogenous hyperinsulinemia has been documented in case reports of quetiapine-induced hypoglycemia. The physiologic pathway by which SGA’s increase insulin release is unknown; some authors have focused on the antagonism of M1 muscarinic receptors, but the muscarinic M1 receptor antagonist pirenzepine has been demonstrated to reduce insulin secretion induced by the muscarinic receptor agonist carbachol from isolated rat pancreatic islets in vitro. Though the mechanism by which hypoglycemia occurs is unclear, this case demonstrates that hypoglycemia should be considered in patients with worsening mental status during treatment with SGA’s.

The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics.

Studies using fast-acting subcutaneous (SQ) insulin analogs in diabetic ketoacidosis (DKA) have demonstrated efficacy, safety, and cost-effectiveness, allowing treatment of mild-to-moderate (MTM)-severity DKA patients in non-intensive care unit (ICU) settings. However, emergency department (ED)-based studies are few, with limited exploration of impacts on operational metrics. We implemented the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol for adults with MTM-severity DKA in an urban academic ED, collecting data from August 1, 2021, to February 28, 2022. We examined fidelity (frequency of required q2h glucose checks), safety (proportion of patients administered rescue dextrose for hypoglycemia), and ED length of stay (EDLOS) for the SQuID cohort compared to patients (non-ICU) treated with a traditional insulin infusion. We also examined ICU admission rate among MTM-severity DKA patients after introduction of SQuID to two historical control periods (pre-intervention and pre-COVID). We used Mann-Whitney U to test for differences in EDLOS distributions, bootstrapped (n= 1000) confidence intervals (CIs) for EDLOS median differences, and the two-sample z-test for differences in ICU admissions. We identified 177 MTM-severity DKA patients in the study period (78 SQuID, 99 traditional cohort) and 163 preintervention and 161 pre-COVID historical control patients. Fidelity to the SQuID pathway was good, with glucose checks exceeding the q2-h requirement. We found no difference in the proportion of rescue dextrose administration compared to the traditional pathway. We observed significant reductions in median EDLOS for the SQuID cohort compared to the traditional cohort during the study period (-3.0, 95% CI -8.5 to -1.4), the preintervention period (-1.4, 95% CI -3.1 to -0.1), and the pre-COVID control period (-3.6, 95% CI -7.5 to -1.8). In this single-center study at an academic ED, treatment of patients with MTM-severity DKA with a SQ insulin protocol was effective, demonstrated equivalent safety, and reduced ED length of stay.

Dextrose Administration and Resuscitation Outcomes in Patients with Blood Sugar Less Than 150 mg/dL during Cardiopulmonary Resuscitation: An Observational Data Analysis.

Low blood sugar is commonly found during cardiopulmonary resuscitation (CPR). However, current guidelines do not mention the importance of glucose testing and acute management for hypoglycemia during CPR. We intended to investigate the association between dextrose administration and resuscitation outcomes in patients with blood sugar less than 150 mg/dL during cardiac arrest in the emergency department (ED). We conducted a retrospective cohort study at a tertiary hospital between 2017 and 2020, including patients with intra-arrest blood glucose &lt;150 mg/dL. Logistic regression with inverse probability treatment weighting (IPTW) was used. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes included survival to hospital admission and hospital discharge and favorable neurological outcomes at discharge. A total of 865 patients received CPR at the ED during the study period. Of these, 229 with low blood sugar were included (60 in the treatment group and 169 in the non-treatment group). The mean age was 59.5 ± 21.4 years. After IPTW, dextrose administration during CPR was not associated with ROSC (adjusted OR [aOR] 1.44, 95% CI 0.30-0.69), survival to hospital admission (aOR 1.27, 95% CI 0.54-3.00), survival to hospital discharge (aOR 0.68, 95% CI 0.20-2.29), and favorable neurological status (aOR 2.21, 95% CI 0.23-21.42). Our findings suggested that dextrose administration during CPR at the ED might not lead to better or worse resuscitation outcomes. Owing to the design limitations and residual confounding factors, strong recommendations for dextrose administration could not be formulated. Further evidence is needed from prospective trials to confirm the efficacy of dextrose during CPR.

Effects of gruel feeding and oral dextrose on the survivability of pigs after weaning.

Two experiments were conducted in a 14,400 head nursery using 3,087 (experiment 1) and 988 (experiment 2) pigs to determine the effect of gruel feeding (experiment 1) and supplemental oral dextrose (experiment 2) on nursery pig survivability after weaning. Upon arrival to the nursery, for experiment 1, the smallest 10% of pigs were selected and randomly placed in pens with 61 to 108 pigs per pen. Pens of small pigs were assigned to one of two treatments in a completely randomized design. Treatments consisted of gruel feeding two or four times per day for 14 d postplacement. At each gruel feeding, approximately 1.13 kg of solid feed was added to a round bowl (Rotecna S.A., Agramunt, Spain) located at the front of each pen and water added at a decreasing rate over time. In experiment 2, every other pig removed for welfare considerations (lameness, sick, or unthrifty) from the general population or pens of small pigs received a single 10 mL oral dose of a 50% dextrose solution (Vet One, MWI Animal Health, Boise, ID), as a source of glucose, before being placed in a removal pen. All removed pigs were tagged and weighed, body temperature recorded, and blood glucose concentration measured prior to and 30 min after entering removal pens. Overall, gruel feeding small pigs two or four times per day for 14 d postplacement did not influence (P > 0.10) mortality from weaning to the end of gruel feeding (3.78% vs. 4.25%, respectively). Likewise, dextrose administration did not influence (P > 0.10) pig mortality after removal to approximately 38 d postweaning (21.4% vs. 23.4% respectively), even though blood glucose concentration increased (P < 0.001) 30 min after removal for pigs administered dextrose. An interaction was observed for blood glucose concentration and body temperature (P < 0.001) where pigs with blood glucose concentrations less than 70 mg/dL had increased mortality as body temperature increased. In contrast, pigs with a blood glucose concentration of 70 mg/dL or greater had decreased mortality as body temperature increased. Pigs weighing less than 4.5 kg also had increased mortality (P < 0.001) compared with pigs weighing greater than or equal to 4.5 kg at removal. In summary, gruel feeding four times per day vs. two times per day or providing a dextrose supplement to pigs removed from the general population did not improve the survivability of pigs after weaning. Additionally, pigs removed with decreased body weight or with body temperature or blood glucose concentrations below or above the normal range had decreased survivability.

P040: Reducing delays of dextrose administration in patients in acute metabolic crisis

P040: Reducing delays of dextrose administration in patients in acute metabolic crisis

Effect of methionine hydroxy analog (MHA) or dextrose supplementation on physiological responses and behaviours of sheep under transportation stress

Transportation causes sheep to experience stress and body weight loss due to physical stress during the process. This study aimed to evaluate the administration of protected methionine hydroxy analog (MHA) or dextrose before transportation on body weight loss, physiological responses, and post-transportation behaviours of sheep. The study used 42 thin-tailed sheep (body weight 18.28±2.11 kg) that were divided into three treatments, i.e., without MHA/dextrose supplementation (P1, control), supplementation of MHA 0.24 g/kg body weight (P2), and supplementation of dextrose 0.24 g/kg body weight (P3). Sheep were transported for a 6-hour journey in commercial vehicles. The results showed that P2 and P3 significantly reduced (P<0.05) the length of time for the sheep to reach their initial body weight before transportation. The P2 and P3 significantly decreased (P<0.05) pulse and respiratory rates as compared to P1. The resting behaviour of P1 was significantly higher (P<0.05) than P2 and P3, while the standing behaviour of P2 and P3 was significantly higher (P<0.05) than P1, which indicated an improvement of sheep condition in the P2 and P3. It can be concluded that the supplementation of MHA or dextrose before transportation improves the bodyweight recovery time, physiological conditions, and behaviours of sheep under transportation stress.

Treatment strategies for hyperkalemia secondary to urethral obstruction in 50 male cats: 2002-2017.

The aims of this study were: to describe the potassium-lowering treatment strategies used to manage moderate-to-severe hyperkalemia in male cats with urethral obstruction (UO); to determine how much dextrose was required per unit of insulin to prevent hypoglycemia; to determine whether early initiation of a dextrose continuous rate infusion (CRI) prevented hypoglycemia; and to determine whether in-hospital mortality was associated with presenting plasma potassium concentration ([K+]). The medical records of male cats presenting with a [K+] ⩾7.0 mEq/l due to UO that had another [K+] measured within 6 h were reviewed retrospectively. All [K+] values within the first 6 h, blood glucose concentrations, treatments for hyperkalemia and survival to discharge were recorded. Analyses were performed to test for associations between dextrose:insulin ratios or method of dextrose administration and the development of hypoglycemia; and for presenting [K+] and mortality. Normally distributed groups of continuous data were compared with a t-test and categorical data were compared with a Fisher's exact test. Fifty cats were included. Mean presenting [K+] was 8.9 ± 1.0 mEq/l, while the mean final [K+] within 6 h was 6.6 ± 1.4 mEq/l. Forty-two (84%) cats were treated with intravenous fluids and 40 (80%) were treated with dextrose and insulin. Median dextrose:insulin ratio was 2 g/u (range 0.4-100). No dextrose:insulin ratio was found to protect against hypoglycemia, and 3/8 cats that became hypoglycemic had received ⩾2 g dextrose per unit of insulin. There was no association between the early initiation of a dextrose-containing CRI and avoidance of hypoglycemia. No association was found between presenting [K+] and mortality. While no specific dextrose:insulin ratio was found to protect against hypoglycemia, there is evidence that the commonly recommended dextrose:insulin ratio of 2 g/u may be inadequate in preventing hypoglycemia in every cat. Severity of hyperkalemia was not associated with mortality.

Abstract 15313: Hypoglycemia: The Forgotten "H&amp;T" in Cardiac Arrest

Introduction: Hypoglycemia is known to cause cardiac arrhythmias and even sudden cardiac death by inducing oxidative stress, QT prolongation, and myocardial injury. Chromosomal deletion of 1p36 is associated with learning difficulty, progressive renal disease, and cardiomyopathy. To our knowledge, this is the first case of a patient with 1p36 deletion syndrome and end-stage renal disease (ESRD) who developed cardiac arrest due to hypoglycemia. Case Presentation: A 26-year-old female presented to the emergency department with generalized itching, weakness, and progressive dyspnea after missing multiple hemodialysis (HD) sessions. She was admitted for HD and her stay was complicated by an episode of coffee-ground emesis and she was nil per oral (NPO) for an endoscopy. That night, the patient became bradycardic and had a cardiac arrest with pulseless electrical activity (PEA). Fingerstick blood glucose was undetectable during resuscitation and ROSC was achieved instantaneously after dextrose administration. The patient had no history of diabetes and was refusing glucose checks while NPO. She had a remarkable neurological recovery post-cardiac arrest. However, her glucose levels remained persistently low despite maximally tolerated feeds. An extensive workup for persistent hypoglycemia including peptide C levels, hba1c, and insulin level were within normal limits. Her cortisol level was appropriately raised. CT scan of the head performed was normal. Cardiac catheterization revealed no coronary artery disease. Discussions: Hypoglycemia was removed from the Advanced Cardiovascular Life Support (ACLS) algorithm as a reversible cause of cardiac arrest in 2010. Our case is a reminder of a life-threatening yet quickly reversible cause of cardiac arrest. Conclusions: ESRD increases the risk of hypoglycemia due to decreased insulin clearance and must be carefully monitored while NPO. Physicians have to be aware that routine dextrose administration during cardiac resuscitation does not improve survival and neurological outcomes.

PSUN370 Refractory Hypoglycemia Associated with a Metastatic Neuroendocrine Tumor Producing Multiple Hormones

Abstract Introduction Neuroendocrine tumors are rare. They are derived from hormone-producing and nerve cells mostly found in GI tract, lung or pancreas. In about half of the cases, work-up does not detect any tumor-related hormone secretion. Even less common, the tumor produces several hormones which may be associated with clinical symptoms. Clinical Case A frail 81-year-old male with mild-to-moderate dementia and no history of diabetes presented to the emergency department with complaints of generalized weakness, fatigue, weight loss, poor appetite, diarrhea and shortness of breath for 1-2 weeks. Physical examination was pertinent for cachexia, general pallor, dry oral mucosa and having heme positive stool. Initial laboratory work-up found anemia (Hg 5.8g/dl), low glucose of 43 mg/dL, hypoalbuminemia (Alb 1.9 gm/dL). CT angiogram of abdomen did not show any active bleed but showed incidental diffuse hepatic lesions favoring metastatic disease, pancreatic ductal dilatation and fluid-filled loops of small and large bowel compatible with enteritis. Subsequent endoscopy and colonoscopy were negative for malignancy. Findings of multiple liver lesions prompted a CT-guided liver biopsy which showed a metastatic, well differentiated neuroendocrine tumor WHO grade II/III with positive stains for chromogranin A, synaptophysin, cytokeratin Oscar (Ki-67 less than 20%). MRCP abdomen examination of pancreas showed no focal pancreatic lesions but was suboptimal due to motion artefacts and lack of contrast. Workup for the tumor revealed increased serum serotonin (772 ng/ml), increased 5-HIAA (3,175 ng/ml), increased chromogranin A (48,436 ng/ml) and an increased 24hr Urine 5-HIAA (162mg/24hr). Further workup for the persistent and hypoglycemia showed a random cortisol 24.6mcg/dl. During hypoglycemia, insulin and C-peptide levels were 4.3 uU/L and 1.4ng/ml indicating inappropriately "normal" insulin production consistent with an insulinoma. IGF 1 and IGF 2 levels were withing the normal range. The hypoglycemia was initially managed with continuous intravenous administration of dextrose and optimization of oral intake, glucagon and octreotide 50 mcg every 8 hours. However, the response to octreotide was insufficient and we were unable to wean the patient off the dextrose. Subsequently we started prednisone 20 mg oral daily and glucose tablets which allowed us to discontinue the intravenous dextrose and the octreotide. Patient was discharged home on hospice care. Conclusion Hypoglycemia is a potentially life-threatening condition necessitating prompt action including the administration of intravenous dextrose. The results of the workup indicate that the neuroendocrine tumor produced excessive amounts of both serotonin and insulin contributing to prolonged refractory hypoglycemia. Treatment of this rare condition is challenging and often empirical. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PMON38 Severe Refractory Hypoglycemia in a Patient with Metastatic Neuroendocrine Tumor

Abstract Background Neuroendocrine tumors(NETs) differ in origin, location, behavior and response to treatment. In most cases, they secrete hormones or vasoactive substances. Pancreatic NETs (PNETs) are rare tumors and account for 1-2% of all pancreatic tumors. They arise from the endocrine tissue of the pancreas. Fifty to seventy percent of PNETs are not functioning. Functioning tumors can secrete insulin, glucagon, gastrin, vasoactive intestinal peptide depending on their origin. Insulinomas are the most common type of PNETs with an incidence rate of 1-4 per 1000,000 per year. They are usually indolent tumors and rarely malignant. Insulinomas are characterized by fasting hypoglycemia with elevated serum insulin and c-peptide levels. Symptoms can range in severity from confusion, visual changes, palpitations, diaphoresis, and tremulousness to seizures, amnesia or coma. Clinical Case We report a case of a 71 year old male who was referred for an evaluation of ongoing hypoglycemia. He was diagnosed with metastatic carcinoid cancer by fine needle aspiration of the tail of pancreas and liver which showed a well-differentiated neuroendocrine type tumor. A month later, the patient underwent an exploratory laparotomy, pancreatectomy, splenectomy, appendectomy. PNET was identified in the spleen and pancreas. Less than a year later, the neuroendocrine cancer metastasized to the thoracic vertebrae (T8 Biopsy: Positive stains: Pancytokeratin, CD56, Synaptophysin, Chromogranin and Ki-67 [20%]). He received chemotherapy with doxorubicin and streptozocin. He had multiple interventional radiology guided liver chemoembolization. Throughout this time, his hypoglycemia rapidly worsened requiring aggressive medical management. His lab findings (hemoglobin A1C 5.4%, serum glucose 114 mg/dL, c-peptide 26 ng/mL [4.4ng/mL UNL], GFR&amp;gt;60 ml/min/1.73 m2, random insulin levels 123 mIU (24.9 mIU UNL) with serum glucose 108 mg/mL, serum chromogranin A 2616 ng/mL [102 ng/mL UNL]) and clinical progression suggested that his PNETs were insulin producing. He was started on sandostatin and later on diazoxide to control his blood glucose levels. Use of Diazoxide lead to anasarca. Patient was not able to tolerate prolonged fasting due to hypoglycemia that continued to worsen. He required multiple admissions with IV dextrose administration. Later, octreotide was stopped due to concerns of paradoxical hypoglycemia due to glucagon suppression and hypoglycemia initially improved. However, a few weeks later hypoglycemia again worsened and we decided to increase the diazoxide and furosemide. The patient's hypoglycemia continued to progress in frequency and severity and his overall condition continued to deteriorate. The patient therefore chose hospice care and passed away shortly after. Conclusion This is a rare case of rapidly progressing metastatic PNET with severe refractory hypoglycemia in a patient despite treatment with multiple modalities. More research is needed to further characterize PNETs and improve current available management. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Anesthesia management in living-donor liver transplantation in a patient with carbamoyl phosphate synthetase deficiency: a case report

BackgroundCarbamoyl phosphate synthetase deficiency (CPS1D) is a urea-cycle disorder (UCD). We report successful perioperative management of pediatric living donor liver transplantation (LDLT) in a CPS1D patient.Case presentationA 10-year-old female patient with CPS1D underwent LDLT. Proper administration of dextrose 50% and 60 kcal/kg/day with l-arginine and l-carnitine resulted in the avoidance of intraoperative hyperammonemia induced by hypercatabolism. Serum ammonia level transiently increased to 61 mmol/L in the anhepatic phase and decreased to 44 mmol/L after reperfusion.ConclusionsWe suggest anesthesia management with administration of dextrose to avoid hyperammonemia during LDLT in patients with CPS1D.