Diuretic Infusion Research Articles

Furosemide infusion in children with dengue fever and hypoxemia

ObjectivesTo study the role of furosemide infusion in the management of Acute respiratory distress syndrome (ARDS) associated with dengue fever.MethodsChildren between the ages of 1 month to 18 years, who fulfilled the WHO clinical criteria for dengue infection and American European Consensus Criteria criteria for ARDS with Dengue IgM positivity, were evaluated. Patients were studied as group D (receiving diuretic therapy alone) and group B (both ventilation and diuretics), and compared to a historical control group V (ventilation alone). Furosemide infusion was administered at 0.05–0.1 mg/kg/hour for 48 hours, maintaining a urine output of 2–4 mL/kg/hour.ResultsThere was a significant difference in survival in the three groups. Significant difference was noted between pre- and postintervention arterial blood gases with respect to PCO2 (P=0.02), pO2 (P=0.003), PaO2/FaO2 ratio (P<0.001) and alveolar-arteriolar oxygen gradient (P=0.002).ConclusionDiuretic infusion improves outcome in dengue with ARDS.

An update in the management of acute decompensated heart failure

This review will provide an overview of recent advances in the management of acute decompensated heart failure, focusing on major publications from the past few years. There have been several publications investigating different strategies in the management of acute decompensated heart failure. Trials have investigated the role of ultrafiltration, diuretic infusions and recombinant B-type natriuretic peptide for the treatment of these patients. In patients with acute decompensated heart failure, the use of ultrafiltration in place of diuretics, diuretic infusions, and B-type natriuretic peptide has not shown benefit in recent trials. Unfortunately, there have been no major advances in the management of patients with acute decompensated heart failure.

Part of the Solution—Outpatient Palliative Care for Patients with Decompensated Heart Failure (FR405)

1.Define unmet palliative care needs of ambulatory patients with advanced heart failure and outline key components of a palliative care evaluation specific to this population.2.Describe an innovative multidisciplinary model of triage and intervention for ambulatory patients with decompensated heart failure that includes triggers for and access to outpatient palliative care consultation.3.Identify opportunities for improved interdisciplinary collaboration between the fields of palliative care and cardiology to improve care for patients with advanced heart failure and their families. Patients with advanced heart failure experience a significant symptom burden, have poor understanding of their likely trajectory of illness or prognosis, often receive ineffective and burdensome medical interventions at the end of life, and underuse interventions that promote quality of life such as timely hospice referrals. Emerging evidence supports the integration of specialty-level palliative care for these patients, but the role and outcomes of palliative care consultation for these patients are not well defined. New models of collaboration between heart failure and palliative care specialists are needed. The Ambulatory Cardiac Triage, Intervention, and Education (ACTIVE) Heart Failure Unit, which opened in May of 2013, is a multidisciplinary ambulatory heart failure treatment initiative at the Brigham and Women’s Hospital with the capacity for intravenous infusion of diuretics and other therapies to ameliorate heart failure symptoms that would typically require hospital admission. In addition to patient education, counseling regarding medication adherence, and delivery of intravenous therapy to manage heart failure when needed, all patients will be screened at initial triage for palliative care consultation. Those who meet the criteria will receive outpatient palliative care consultation adjacent to the treatment area, unless their referring physician declines, in which case the reasons will be captured. Triggers for consultation include a likely prognosis of less than 6 months, refractory symptoms despite maximal medical therapy, concern that the patient’s or family’s understanding or goals of care are not aligned with the disease severity and treatment plan, three visits to the hospital or ACTIVE Unit in the last year, and home inotropic therapy without definitive advanced therapy options. We hypothesize that advanced care planning and palliative interventions may help to decrease admissions for both heart failure and non-heart failure causes, and could be particularly important in providing a shift in priorities to outpatient and hospice palliation during the terminal phase of illness.

Continuous versus bolus intermittent loop diuretic infusion in acutely decompensated heart failure: a prospective randomized trial.

IntroductionIntravenous loop diuretics are a cornerstone of therapy in acutely decompensated heart failure (ADHF). We sought to determine if there are any differences in clinical outcomes between intravenous bolus and continuous infusion of loop diuretics.MethodsSubjects with ADHF within 12 hours of hospital admission were randomly assigned to continuous infusion or twice daily bolus therapy with furosemide. There were three co-primary endpoints assessed from admission to discharge: the mean paired changes in serum creatinine, estimated glomerular filtration rate (eGFR), and reduction in B-type natriuretic peptide (BNP). Secondary endpoints included the rate of acute kidney injury (AKI), change in body weight and six months follow-up evaluation after discharge.ResultsA total of 43 received a continuous infusion and 39 were assigned to bolus treatment. At discharge, the mean change in serum creatinine was higher (+0.8 ± 0.4 versus -0.8 ± 0.3 mg/dl P <0.01), and eGFR was lower (-9 ± 7 versus +5 ± 6 ml/min/1.73 m2P <0.05) in the continuous arm. There was no significant difference in the degree of weight loss (-4.1 ± 1.9 versus -3.5 ± 2.4 kg P = 0.23). The continuous infusion arm had a greater reduction in BNP over the hospital course, (-576 ± 655 versus -181 ± 527 pg/ml P = 0.02). The rates of AKI were comparable (22% and 15% P = 0.3) between the two groups. There was more frequent use of hypertonic saline solutions for hyponatremia (33% versus 18% P <0.01), intravenous dopamine infusions (35% versus 23% P = 0.02), and the hospital length of stay was longer in the continuous infusion group (14. 3 ± 5 versus 11.5 ± 4 days, P <0.03). At 6 months there were higher rates of re-admission or death in the continuous infusion group, 58% versus 23%, (P = 0.001) and this mode of treatment independently associated with this outcome after adjusting for baseline and intermediate variables (adjusted hazard ratio = 2.57, 95% confidence interval, 1.01 to 6.58 P = 0.04).ConclusionsIn the setting of ADHF, continuous infusion of loop diuretics resulted in greater reductions in BNP from admission to discharge. However, this appeared to occur at the consequence of worsened renal filtration function, use of additional treatment, and higher rates of rehospitalization or death at six months.Trial registrationClinicalTrials.gov NCT01441245. Registered 23 September 2011.

Recurrence of fatal venous air embolism.

Venous air embolism (VAE) often occurs in the operating theatre. Squeals have not been reported much in most recovering patients. Our patient recovered from a venous air embolism during surgery but experienced cardiac arrest in the intensive care unit the next day, and died. A review of the chest X-ray revealed pulmonary edema and intracardiac air. A 42-year-old male patient was admitted for surgery on a right occipital brain meningioma. The patient had no specific medical history. The right subclavian vein was cannulated dur ing the preoperative period. In the operating theatre, non-invasive blood pressure, electrocardiograph, pulse oximeter (SpO2), end-tidal carbon dioxide (ETCO2) and central venous pressure (CVP) monitoring were initiated. Anesthesia was maintained with oxygen, air, target-controlled infusion of remifentanil and propofol, and rocuronium with controlled ventilation. The left dorsalis pedis artery was cannulated for continuous arterial blood pressure monitoring (ABP). The surgery was performed in the semi-sitting position. One hour after beginning the surgery, an abrupt CVP elevation from 8 to 18 cmH2O was detected. ETCO2 decreased from 20 to 14 mmHg, and systolic ABP decreased from 110 to 92 mmHg. After injecting 5 mg ephedrine, blood pressure increased but decreased again. Although we suspected a pneumothorax during cannulation of the central line, both lung sounds were symmetrical and a post-procedural X-ray did not reveal a pneumothorax. Sinuses had not been cut yet, but under strong suspicion of a VAE, BP decreased, heart rate (HR) slowed, and ventricular premature complexes occurred. Surgeon sprayed water over the operative field and wrapped the wound with wet surgical pads. The surgery was stopped and the patient was repositioned in the head down position. Aspiration of blood through the central line showed air bubbles. The vital signs stabilized after 1,000 ml of mixed blood and air were aspirated. The cardiologist confirmed that the right heart was enlarged and deviated to the left side on a trans-thoracic echocardiograph (TTE). However, no intracardiac air was detected. When the surgery was being delayed and the surgeon sutured the wound, vital signs became unstable again. We aspirated air from the central line again, and vital signs stabilized. After wound closure, a trans-esophageal echocardiograph (TEE) revealed no intracardiac air. Intracardiac shunts such as foramen ovale were also not detected in TEE. The patient was moved to the ICU without extubation. In the ICU, BP was 140/70 mmHg, HR, 88 beats/min; CVP, 3 cmH2O; and SpO2, 100%. The ventilator was connected with a tidal volume of 450 ml, respiratory rate of 16 breaths/min, fraction of inspiratory oxygen of 1.0, a positive end-expiratory pressure (PEEP) of 5 cmH2O. After a chest X-ray revealed pulmonary edema, the surgeon injected furosemide 20 mg. The Glasgow coma scale score recovered to 9 and after 1 and half hour the patient removed the endotracheal tube accidently. A rebreathing mask with 10 L/min O2 was used, and SpO2 90% was adjusted to 90%. After 30 min, SpO2 decreased to 85% so the patient was reintubated and a diuretic infusion was started. Vital signs were; BP, 140/80 mmHg; HR, 150 bpm; PEEP increased to 7 cmH2O, and fluid was restricted. BP dropped to 70/50 mmHg and a norepinephrine infusion was started 2 hr later. A chest anteroposterior view and brain computed tomography (CT) scan were conducted. The brain CT revealed no other abnormality. Although we increased the norepinephrine dosage, the patient

Loop diuretic strategies in patients with acute decompensated heart failure: A meta-analysis of randomized controlled trials

PurposeThe safety and efficacy of continuous infusion vs bolus injection of intravenous loop diuretics to treat acute decompensated heart failure were debated. Our aim is to compare the administration routes of diuretics in hospitalized patients with acute decompensated heart failure. MethodsA systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of continuous infusion vs bolus administration of loop diuretics in patients with acute decompensated heart failure. The primary end points were urine outputs, body weight loss, all causes of mortality, and death from cardiovascular causes. Secondary end points were electrolyte imbalance, change in creatinine levels, tinnitus or hearing loss, and days of hospitalization. ResultsTen randomized controlled trials with 518 patients were identified. Continuous infusion of diuretics was associated with a significantly greater weight loss (weighted mean difference, 0.78; 95% confidence interval, 0.03-1.54) compared with bolus injection. Urine output, the incidence of electrolyte imbalance, change in creatinine level, length of hospitalization, the incidence of ototoxicity, cardiac mortality, and all-cause mortality showed no significant differences between the 2 groups. ConclusionMeta-analysis of the existing limited studies did not confirm any significant differences in the safety and efficacy with continuous administration of loop diuretic, compared with bolus injection in patients with acute decompensated heart failure.

Dexmedetomidine Sedation Effective for a Case with Catecholamine- and Diuretics-resistant Systolic Heart Failure

A 82-year-old male visited emergency room in September 2012, complaining of dyspnea at rest. Physical findings were edematous legs and dilated jugular vein. Chest Roentogenogram showed pulmonary congestion and cardiomegaly. Echocardiography revealed the generalized hypokinesis of left ventricle and the reduced ejection fraction of 22%. He was diagnosed as severe heart failure and admitted into our hospital. Our initial strategy was non-invasive pressure support ventilation with continuous infusion of catecholamine (dopamine 3μg/hr) and diuretics (carperitide 0.025μg/hr, furosemide 80mg/day), being apparently successful because of good urination (2500ml) on the first day of his admission.

A meta-analysis of continuous vs intermittent infusion of loop diuretics in hospitalized patients

BackgroundSeveral studies have examined the potential benefits of continuous vs intermittent (bolus) intravenous loop diuretic administration in hospitalized patients with conflicting results. We conducted a meta-analysis to compare the efficacy of these 2 strategies in hospitalized adults and children with extracellular fluid volume expansion. MethodsWe searched MEDLINE (through October 2012) and prior meta-analyses for randomized controlled trials comparing the efficacy of continuous vs intermittent infusion of loop diuretics. Random-effects model meta-analyses were performed to examine several outcomes, including net change in urine output and body weight. ResultsWe identified 7 crossover and 11 parallel-arm randomized controlled trials (936 patients) of adults and children. In the 15 studies of adults, continuous loop diuretic infusion resulted in a nonsignificant net increase in daily urine output of 334 mL (95% confidence interval [CI], −74 to 742; P = .11) relative to the bolus infusion. In the 8 studies that used a loading dose, continuous loop diuretic infusion resulted in a significant net increase in daily urine output of 294 mL (95% CI, 31-557; P = .03) relative to the intermittent infusion. There was also a significant net decrease in body weight of 0.78 kg (95% CI, −1.54 to −0.03; P = .04) in the continuous relative to the intermittent loop diuretic infusion. In the 3 studies of children, there was no demonstrable effect on daily urine output or body weight. ConclusionContinuous infusion of loop diuretics preceded by a loading dose results in greater diuresis in hospitalized adults with extracellular fluid volume expansion compared with intermittent dosing regimens. Further studies are required to examine whether these benefits translate into improved clinical outcomes.

Acute respiratory distress syndrome (ARDS) in children with Rickettsial infection – A timely diagnosis saving lives

Abstract Background and aim The objective of this paper is to describe the clinical profile of children with acute respiratory distress syndrome (ARCS) due to Rickettsial fever. Methods This was a prospective study done in the PICU of a tertiary care children's hospital. AECC criteria for ARDS were used as case definitions and Rickettsial fever was diagnosed based on clinical features and the Weil–Felix test. Results 14 (5.3%) children with Rickettsial fever developed ARDS. The mortality rate was 14.2%. 71.4% were ventilated by pressure support ventilation, with 80% survival. 28.6% received diuretic infusion of which all survived. Of the 9 children who had associated shock, 7 did not survive. Conclusion ARDS is a complication of Rickettsial infection which needs to identified and treated early, with relatively good outcome.

Baseline Albumin Is Associated with Worsening Renal Function in Patients with Acute Decompensated Heart Failure Receiving Continuous Infusion Loop Diuretics

To identify baseline predictors of worsening renal function (WRF) in an acute decompensated heart failure (ADHF) patient population receiving continuous infusion loop diuretics. Retrospective observational analysis. Academic tertiary medical center. A total of 177 patients with ADHF receiving continuous infusion loop diuretics from January 2006 through June 2009. The mean patient age was 61 years, 63% were male, ~45% were classified as New York Heart Association functional class III, and the median length of loop diuretic infusion was 4 days. Forty-eight patients (27%) developed WRF, and 34 patients (19%) died during hospitalization. Cox regression time-to-event analysis was used to determine the time to WRF based on different demographic and clinical variables. Baseline serum albumin 3 g/dl or less was the only significant predictor of WRF (hazard ratio [HR] 2.87, 95% confidence interval [CI] 1.60-5.16, p=0.0004), which remained significant despite adjustments for other covariates. Serum albumin 3 g/dl or less is a practical baseline characteristic associated with the development of WRF in patients with ADHF receiving continuous infusion loop diuretics.

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Introduction: Continuous infusions (CI) of loop diuretics provide constant delivery of drug to site of action in the kidney, resulting in a continuous natriuretic effect. Data supporting the efficacy/safety of CI of high dose bumetanide (CIHDB) are sparse. A detailed review of a single institution’s experience will help fill the gap in literature. Hypothesis: CIHDB are effective in inducing diuresis and achieving dry weight in critically ill cardiac and cardiothoracic (CT) surgery patients (pts) with significant volume overload without causing new-onset acute renal failure. Methods: A retrospective electronic/paper chart review of all pts treated with a CIHDB at a single institution was performed. Pts receiving an infusion of 1-2 mg/hr bumetanide with sufficient data were included. Pts were excluded if the infusion rate remained <1 mg/hr or if receiving concomitant renal replacement therapy (RRT) or aquaphoresis. Data collected included weights, dosing of intermittent loop diuretics and CIHDB, urine output (UOP), serum creatinine, need for RRT. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to stage severity of acute kidney injury (AKI). Results: Thirty-eight pts treated for a mean of 53 hours were included. All pts received at least one dose of IV loop diuretics in the 24 hours preceding CIHDB, while 74% received a bolus of bumetanide IV 2-4 mg within 2 hours preceding CIHDB. Prior to initiation of CIHDB, mean volume overload was +6.2 kg (-1.8 to 11.8 kg) above dry weight; mean UOP was 0.9 cc/kg/hr (0.2-3 cc/kg/hr). After the first 24 hours, UOP increased to 1.6 cc/kg/hr (p<0.001) and to 1.9 cc/kg/hr (p<0.001) after the second 24 hours. Mean weight loss following CIHDB was 5.2 kg. At baseline, 16 (42%) had stage 1-2 AKI. Following CIDHB, 6 (38%) of these pts progressed to stage 3 AKI, but were maintained on CIHDB for 3-48 hours prior to RRT. After CIHDB, an additional 12 pts had stage 1-2 AKI, 10 of which were new onset. Conclusions: CIHDB is effective at improving UOP and achieving significant weight loss in critically ill cardiac and CT surgery pts. Optimizing diuretic therapy may potentially delay/avoid RRT. Further randomized, controlled studies are needed to support these results.

Efficacy and safety of loop diuretic therapy in acute decompensated heart failure: a clinical review

Intravenous loop diuretics are widely used to treat the symptoms and signs of fluid overload in acute heart failure (AHF). Although diuretic therapy is widely used and strongly recommended by most recent clinical guidelines, prospective studies and randomized clinical trials are lacking and so reliable evidence is missing about the best therapy in terms of doses and methods of administration. In addition, clinical efficacy and safety outcomes are often affected by the presence of contrasting evidence. The efficacy of loop diuretics is impaired by diuretic resistance characterized by a decreased diuretic and natriuretic effect. This review focuses on the current management of AHF with diuretic therapy. Continuous diuretic infusion seems to be a good choice, from a pharmacokinetic point of view, when fluid overload is refractory to conventional therapy. Some available evidence comparing bolus injection to continuous infusion of loop diuretics proved the latter to be an effective and safe method of administration. Continuous infusion seems to produce a constant plasmatic concentration of drug with a more uniform daily diuretic and natriuretic effect and a greater safety profile (fewer adverse events such as worsening renal failure, electrolyte imbalances, ototoxicity). The analyses of the published studies did not provide conclusive data about the effects on clinical outcomes (mortality, rate of hospital readmissions, length of hospital stay and adverse events). Furthermore, recent studies focus their attention on alternative strategies of fluid removal, such as vasopressin antagonists, adenosine antagonists and ultrafiltration but available data are often inconclusive.

Effect of admission oral diuretic dose on response to continuous versus bolus intravenous diuretics in acute heart failure: An analysis from Diuretic Optimization Strategies in Acute Heart Failure

Results from the DOSE-AHF study suggest that an initial continuous infusion of loop diuretics is not superior to bolus dosing with regard to clinical endpoints in acute heart failure. We hypothesized that outpatient furosemide dose was associated with congestion and poorer renal function and explored the hypothesis that a continuous infusion may be more effective in patients on higher outpatient diuretic doses. The DOSE-AHF study randomized 308 patients within 24 hours of admission to high versus low initial intravenous diuretic dose given as either a continuous infusion or bolus. We compared baseline characteristics and assessed associations between mode of administration (bolus vs continuous) and outcomes in patients receiving high-dose (≥120 mg furosemide equivalent, n = 177) versus low-dose (<120 mg furosemide equivalent, n = 131) outpatient diuretics. Patients on higher doses of furosemide were less frequently on renin-angiotensin system inhibitors (P = .01) and had worse renal function and more advanced symptoms. There was a significant interaction between outpatient dose and mode of therapy (P = .01) with respect to net fluid loss at 72 hours after adjusting for creatinine and intensification strategy. Admission diuretic dose was associated with an increased risk of death or rehospitalization at 60 days (adjusted hazard ratio 1.08 per 20-mg increment in dose, 95% CI 1.01-1.16, P = .03). In acute heart failure, patients on higher diuretic doses have greater disease severity and may benefit from an initial bolus strategy.

Bumetanide continuous-infusion dosing in critically ill pediatric patients

Continuous infusions of loop diuretics are used in neonatal and pediatric intensive care units to induce a more-controlled diuresis with less hemodynamic instability. Although furosemide is the most commonly used loop diuretic administered via continuous infusion in children, recent drug shortages

Diuretic Agent and Normal Saline Infusion Technique for Ultrasound-Guided Percutaneous Nephrostomies in Nondilated Pelvicaliceal Systems

Percutaneous nephrostomy (PCN) in a nondilated pelvicaliceal system is technically challenging. We describe an effective method to achieve transient dilatation of the pelvicaliceal system via induction of diuresis using infusion of a diuretic agent in normal saline, therefore allowing easier access to the pelvicaliceal system. Under real-time ultrasound guidance, the technique had been tested in 22 nephrostomies with nondilated system (a total of 20 patients with 2 patients having bilateral nephrostomies) during a 5-year period. Patients were given 40 mg of furosemide in 250 ml of normal saline solution intravenously by rapid infusion. As soon as maximum calyceal dilatation of more than 5 mm was observed, which is usually 15 min later after the end of rapid infusion, patients were positioned obliquely, and PCN procedure under ultrasound guidance was performed. The procedure was successful in 19 of the nephrostomies in 17 patients with a success rate of 86.36 % per procedure and 85 % per patient in nondilated pelvicaliceal systems. No major nephrostomy-, drug-, or technique-related complications were encountered. The technique failed to work in three patients due to the presence of double J catheters and preexisting calyceal perforation which avoided transient dilation of the pelvicaliceal system with diuresis. Diuretic infusion in saline is a feasible and effective method for PCN in nondilated pelvicaliceal systems.

Continuous infusion versus bolus injection of loop diuretics in acute heart failure: a literature review

Intravenous loop diuretics are increasingly used to treat symptoms and signs of fluid overload in acute heart failure, a clinical condition associated with high morbidity and mortality rates. Although diuretic therapy is widely used and strongly recommended by most recent clinical guidelines, prospective studies and randomized clinical trials are lacking and hence there is no reliable evidence regarding the best therapy in terms of doses, ways and methods of administration. With heart failure progression, the efficacy of loop diuretics is impaired by diuretic resistance characterized by a decreased diuretic and natriuretic effect of drugs. This review focuses on the current management of acute heart failure with diuretic therapy. Continuous diuretic infusion seems to be a good choice, from a pharmacokinetic point of view, when fluid overload is refractory to conventional therapy. Several available studies comparing bolus injection to continuous infusion of loop diuretics proved the latter to be an effective and safe method of administration. Continuous infusion seems to produce a constant plasma drug concentration with a more uniform daily diuretic and natriuretic effect and a greater safety profile (fewer adverse events such as worsening renal failure, electrolyte imbalance, ototoxicity). In addition, the analysis of available literature data did not provide conclusive evidence about the effects on clinical outcomes (mortality, rehospitalization rates, adverse events).

Continuous Furosemide Infusion in the Management of Ascites

BackgroundThe current therapy for patients hospitalized with ascites requires titration of oral diuretics and often needs several days. A faster method for predicting the response to a given dose of...

Application of obstruction of Glission pedicle combined with partial occlusion obstruction of inferior vena cava in regional liver resection

This study aims to investigate the clinical effect of Glission pedicle obstruction combined with partial obstruction of inferior vena cava in regional liver resection. A total of eight liver cancer patients were retrospectively analyzed. They underwent regional liver resection using a combined method of Glission pedicle obstruction and partial obstruction of inferior vena cava. Among these cases, three received right liver resection, two received left liver resection and others received right posterior lobe resection. Operation time and blood loss were measured. After operation, aspartate transaminase (AST), alkaline phosphate (ALP), albumin, ascites and enterocinesia recovery time were calculated, respectively. Preoperative evaluation of these cases showed that they shared the features of indocyanine green (ICG)-15 min retention rate of 40%. The operation time ranged from 60 to 90 min, and the average blood loss was 100 to 200 ml. There were no significant differences in AST and ALP before and after operation. The postoperative albumin decreased by about 10 g. Ascites occurred in all cases after operation, but after infusion of albumin,diuretics disappeared, and enterocinesia was restored two days later. Glission pedicle obstruction combined with partial obstruction of the inferior vena cava can notably shorten the operation time of regional liver resection and reduce the blood loss. Key words: Glission pedicle, partial obstruction of the inferior vena cava, regional liver resection.

Heroin addict with gangrene of the extremities, rhabdomyolysis and severe hyperkalemia

Long-time consumption of narcotics leads to altered mental status of the addict. It is also connected to damages of different organic systems and it often leads to appearance of multiple organ failure. Excessive narcotics consumption or abuse in a long time period can lead to various consequences, such as atraumatic rhabdomyolysis, acute renal failure and electrolytic disorders. Rhabdomyolysis is characterized by injury of skeletal muscle with subsequent release of intracellular contents, such as myoglobin, potassium and creatine phosphokinase. In heroin addicts, rhabdomyolysis is a consequence of the development of a compartment syndrome due to immobilization of patients in the state of unconsciousness and prolonged compression of extremities, direct heroin toxicity or extremities ischemia caused by intraluminal occlusion of blood vessels after intraarterial injection of heroin. Severe hyperkalemia and the development of acute renal failure require urgent therapeutic measures, which imply the application of either conventional treatment or a form of dialysis. We presented a male patient, aged 50, hospitalized in the Emergency Center Kragujevac due to altered mental status (Glasgow Coma Score 11), partial respiratory insufficiency (pO2 7.5 kPa, pCO2 4.3 kPa, SpO2 89%), weakness of lower extremities and atypical electrocardiographic changes. Laboratory analyses, carried out immediately after the patient's admission to the Emergency Center, registered the following disturbances: high hyperkalemia level (K+ 9.9 m mol/L), increased levels of urea (30.1 mmol/L), creatinine (400 micromol/L), creatine phosphokinase--CK (12,0350 IU/L), CK-MB (2500 IU/L) and myoglobin (57000 microg/L), with normal levels of troponin I (< 0.01 microg/L), as well as signs of anemia (Hgb 92 g/L, Er 3.61 x 10(12)/L), infection (C-reactive proteine 184 microg/mL, Le 16.1 x 10(9)/L) and acidosis (base excess--18.4 mmol/L, pH 7.26. Initial examination of the patient revealed swelling and paleness of the right lower leg, signs of gangrene of the right foot and the 1st and the 4th toes of the left foot. The patient had normal values of arterial pressure (130/80 mmHg) and heart rate (64/min(-1)); roentgenographic lungs examination and computerized tomography (CT) brain examination did not reveal pathological changes in lung and brain parenchyma; toxicological analyses confirmed the presence of heroin in patient's organism. The patient was treated by intensive conventional treatment (infusion of crystalloid solutions, 8.4% solution of sodium bicarbonate, i.v. infusion of diuretics, calcium gluconate and short-acting insulin), and also by antibiotics and anticoagulants. Normalization of kalemia and fast regression of electrocardiographic changes were registered. The patient refused the suggested surgical treatment (fasciotomy, foot amputation). After stabilization of kidney function and improvement of his mental state, the patient agreed to undergo surgical procedure. Therefore, on the day 30 of hospitalization the above-knee amputation of the right leg was performed, and on the day 38 the transmetatarsal amputation of the left foot was carried out. After 46 days of hospital treatment, the patient was released and sent to home treatment. The routine laboratory diagnostics, which implies determining of the levels of potassium, urea, creatinine and CK in the serum of all hospitalized heroin addicts can contribute to timely detection of hyperkalemia and acute kidney weakness and undertaking of appropriate therapeutic measures.

A case of cardiopulmonary arrest caused by laxatives-induced hypermagnesemia in a patient with anorexia nervosa and chronic renal failure

We report a case of laxatives induced severe hypermagnesemia complicated with cardiopulmonary arrest. A 55-year-old woman, with nephritic syndrome and anorexia nervosa, was later transported to our emergency room (ER) because of oliguria and consciousness disturbance. During transfer to the intensive care unit from the ER, cardiopulmonary arrest suddenly occurred. Cardiopulmonary resuscitation was immediately performed, and spontaneous circulation was restored after 3 min. Thereafter, administration of dopamine, norepinephrine, and epinephrine was required to maintain systolic blood pressure at 80 mmHg. Arterial blood gas analysis showed severe metabolic alkalosis, and blood biochemical tests revealed hypermagnesemia (serum magnesium concentration, 18.5 mg/dl) and renal dysfunction. Continuous infusion of diuretics followed by massive hydration and continuous hemodiafiltration (CHDF) was started. Five days after starting CHDF, magnesium concentration was almost normalized and administration of catecholamine was stopped. It was thought that progression of renal dysfunction that occurred in the patient taking a magnesium product for chronic constipation caused reduction in magnesium excretion ability, resulting in hypermagnesemia-induced cardiopulmonary arrest. To avoid a rebound phenomenon following magnesium flux from cells, continuous blood purification seems to be an effective treatment for symptomatic hypermagnesemia.