Intravenous Sodium Research Articles

Euthanasia of Dogs by Australian Veterinarians: A Survey of Current Practices.

Euthanasia techniques utilised by veterinarians impact the welfare of many dogs in their final moments. Despite euthanasia guidelines, little is known about euthanasia techniques used in practice. We administered an online survey of Australian veterinarians who had euthanised at least one dog in the previous 12 months. We found that 668 (96.8%) had euthanised a dog in the previous 12 months, almost all using intravenous pentobarbitone sodium (n = 651, 99.7%). For non-emergency euthanasia (n = 653), the majority (n = 442, 67.7%) administered a premedication or sedation prior to euthanasia versus less than half for emergency euthanasia (n = 286, 46.4%). Practices and views about euthanasia varied. Female veterinarians and veterinarians located in metropolitan regions were more likely to administer a premedication or sedation prior to non-emergency euthanasia (p < 0.05). Veterinarians in private mixed animal practices were less likely to administer a premedication or sedation prior to a non-emergency euthanasia (p < 0.05). For non-emergency and emergency euthanasia, veterinarians who worked in "other" practice types were more likely to administer a premedication or sedation than private companion animal practices (p < 0.05). The possible reasons for differences in euthanasia practices are explored, and scope for refinement is identified.

Route of Arsenic Exposure Differentially Impacts the Expression of Genes Involved in Gut-Mucosa-Associated Immune Responses and Gastrointestinal Permeability.

First-pass metabolism alters arsenic biotransformation and its immunomodulatory activities. This study aims to determine the mRNA expression of intestinal-immunity- and permeability-associated genes, levels of cytokine/chemokines and levels of immunoglobulin isotypes when CD-1 mice were exposed to a single dose of intravenous (IV) sodium arsenite (50 µg/kg body weight (BW)) and to compare these responses to exposure via oral gavage (OG) (50 µg/kg BW). Samples were collected at 1, 4, 24 and 48 h post IV exposure and 24 and 48 h post OG. Sodium arsenite IV exposure led to a transient modulation of mRNA expression and protein levels of immunity-related genes involved in inflammation/apoptotic pathways and production of cytokines/chemokines, whereas it also led to downregulated expression of genes encoding tight junction, focal adhesion, and gap junction proteins, which are responsible for maintaining cell permeability. Oral exposure perturbed fewer cell-permeability-related genes at 24 and 48 h post exposure. At 24 h post exposure, OG decreased IgA and IgG2b levels; however, IV exposure significantly increased IgG2b, IgG3 and IgA in ileal tissue. Earlier, we showed significant downregulation of mRNA expression of genes involved in the immune-related pathways during OG in the intestinal mucosa of the same animals. Cumulatively, these results provide evidence that the exposure route of a xenobiotic can differentially impact the intestinal responses due to the impact of first-pass metabolism.

Fluorescein Mapping in Vulvar Paget Disease.

Vulvar Paget disease often requires extensive and, in some cases, multiple resections to treat. A fluorescein-mapping procedure followed by a staged vulvectomy may be an effective technique to tailor resection and identify clinically occult lesions. We describe a two-step procedure; first, intravenous fluorescein sodium is injected, and the vulva is illuminated with a Wood's lamp. Representative biopsies are obtained and correlated on final pathology with the extent of disease to develop a final plan for excision. Second, using fluorescein to identify the confirmed areas of disease, the appropriate excisional procedure is performed once mapping biopsy pathology is known. We describe our experience with eight patients with vulvar Paget disease undergoing fluorescein mapping biopsies and staged vulvectomy. Using intravenous fluorescein sodium, all patients were found to have Paget disease beyond the visible margins of their gross lesions. No patients experienced a recurrence of Paget disease within a median follow-up time of 32 months, comparable with other directed methods of surgical resection. We report a technique for the injection of fluorescein sodium for the visualization of vulvar Paget disease capable of providing accurate surgical margins and identification of occult satellite lesions with a high degree of safety and a favorable cost profile. This staged approach to vulvectomy could offer improved accuracy of resection for vulvar Paget disease with few drawbacks.

Special considerations in the design and implementation of pediatric otoprotection trials.

Cisplatin-induced hearing loss (CIHL) is a common late effect after childhood cancer treatment having profound, lifelong consequences that lower quality of life. The recent identification of intravenous sodium thiosulfate (STS) as an effective agent for preventing pediatric CIHL represents a paradigm shift that has created new opportunities for expanding STS usage and developing additional otoprotectants. The purpose of this paper is to discuss key considerations and recommendations for the design and implementation of future pediatric otoprotection trials. An approach synthesizing published data and collective experience was used. Key issues were identified in the categories of translational research, trial designs for systemic and intratympanic agents, measurement of ototoxicity, and biostatistical challenges. Future pediatric otoprotection trials should emphasize (1) deep integration of preclinical and early-phase studies; (2) an embedded or free-standing design for systemic agents based on mechanistic considerations; (3) use of suitable audiologic testing batteries for children, SIOP grading criteria, and submission of raw audiologic data for central review; and (4) novel endpoints and innovative study designs that maximize trial efficiency for limited sample sizes. Additional recommendations include routine collection of DNA specimens for assessing modifying effects of genetic susceptibility and meaningful inclusion of patient/family advocates for informing trial development. Changing the historical paradigm from acceptance to prevention of pediatric CIHL through expanded research with existing and emerging otoprotectants will dramatically improve quality of life for future childhood cancer survivors exposed to cisplatin.

Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients

Selenium contributes to antioxidative, anti-inflammatory, and immunomodulatory pathways, which may improve outcomes in patients at high risk of organ dysfunctions after cardiac surgery. To assess the ability of high-dose intravenous sodium selenite treatment to reduce postoperative organ dysfunction and mortality in cardiac surgery patients. This multicenter, randomized, double-blind, placebo-controlled trial took place at 23 sites in Germany and Canada from January 2015 to January 2021. Adult cardiac surgery patients with a European System for Cardiac Operative Risk Evaluation II score-predicted mortality of 5% or more or planned combined surgical procedures were randomized. Patients were randomly assigned (1:1) by a web-based system to receive either perioperative intravenous high-dose selenium supplementation of 2000 μg/L of sodium selenite prior to cardiopulmonary bypass, 2000 μg/L immediately postoperatively, and 1000 μg/L each day in intensive care for a maximum of 10 days or placebo. The primary end point was a composite of the numbers of days alive and free from organ dysfunction during the first 30 days following cardiac surgery. A total of 1416 adult cardiac surgery patients were analyzed (mean [SD] age, 68.2 [10.4] years; 1043 [74.8%] male). The median (IQR) predicted 30-day mortality by European System for Cardiac Operative Risk Evaluation II score was 8.7% (5.6%-14.9%), and most patients had combined coronary revascularization and valvular procedures. Selenium did not increase the number of persistent organ dysfunction-free and alive days over the first 30 postoperative days (median [IQR], 29 [28-30] vs 29 [28-30]; P = .45). The 30-day mortality rates were 4.2% in the selenium and 5.0% in the placebo group (odds ratio, 0.82; 95% CI, 0.50-1.36; P = .44). Safety outcomes did not differ between the groups. In high-risk cardiac surgery patients, perioperative administration of high-dose intravenous sodium selenite did not reduce morbidity or mortality. The present data do not support the routine perioperative use of selenium for patients undergoing cardiac surgery. ClinicalTrials.gov Identifier: NCT02002247.

Transversus Abdominis Plane Block with or without Intravenous Diclofenac Sodium as a Component of Multimodal Postoperative Analgesia Following Laparoscopic Cholecystectomy: A Randomised Clinical Study

Introduction: Multimodal analgesia is the recommended approach for treating post-operative pain after laparoscopic cholecystectomy. The Transversus Abdominis Plane (TAP) block is a recently introduced technique showing promising results. To control visceral and somatic pain adequately and to avoid use of opioids intra-operative diclofenac sodium, combined with TAP block as part of a multimodal approach, may be beneficial. Aim: To evaluate the efficacy of TAP block with or without intraoperative diclofenac sodium aqueous injection for controlling post-operative pain following laparoscopic cholecystectomy. Materials and Methods: A randomised, double-blinded study was conducted from February 2022 to October 2022 at Nil Ratan Sircar Medical College, Kolkata, West Bengal, India. Forty American Society of Anaesthesiology (ASA) physical status-I and II patients aged 20-50 years scheduled for elective laparoscopic cholecystectomy were divided into two groups of 20 patients each. Group A patients received bilateral Ultrasonography (USG) guided TAP block using 20 mL of 0.125% Bupivacaine on each side of the abdomen at the end of surgery. Group B patients received intravenous injection of diclofenac sodium aqueous 75 mg intravenous, intraoperatively, along with bilateral USG guided TAP block using 0.125% Bupivacaine. The primary outcome was the duration of post-operative analgesia (measured by the first request for rescue analgesia after the end of the operation at a VAS score of 4). Secondary outcomes included the total post-operative analgesic requirement (diclofenac sodium), pain score (VAS) over 24 hours in the post-operative period, and the incidence of complications such as nausea, vomiting, hypotension, and bradycardia. Patient Satisfaction Score (PSS) was recorded for each patient before discharge. Statistical analysis was performed using Statistical Package for Social Sciences(SPSS) version 24.0 software. Continuous variables were expressed as mean and standard deviation, and categorical variables were expressed as percentages. Independent t-tests and chi-square tests were used for between-group comparisons, with a p-value ≤0.05 considered statistically significant. Results: Amongst total 40 patients included, divided into group A(mean age: 32.95±8.74 years, 6 males and 14 females) and group B(31.90±9.16 years, 5 males and 15 females) with 20 patients each, the demographic characteristics such as age, gender, height, and weight were similar in both groups. The duration of post-operative analgesia was longer in Group B (16.32±1.29 hours) than in Group A (7.85±1.04 hours). The total post-operative analgesic requirement was lower in Group B (32.95±20.9 mg) compared to Group A (58.33±17.14 mg). Visual Analogue Scale (VAS) scores were lower in Group B than in Group A. PSS was significantly higher in Group B patients (8.14±1.06) than in Group A patients (6.16±1.38). Conclusion: TAP block, along with intra-operative intravenous diclofenac sodium aqueous, as part of a multimodal regimen, provides superior post-operative analgesia compared to TAP block alone. It is also associated with improved patient satisfaction.

Ibuprofen-Induced Renal Tubular Acidosis: Case Report on a Not-So-Basic Clinical Conundrum

Rationale: Renal tubular acidosis (RTA) is a cause of non-anion gap metabolic acidosis (NAGMA) that is infrequently diagnosed and is due to various underlying etiologies that impair the kidney’s ability to retain bicarbonate or excrete acid. Ibuprofen is an over-the-counter non-steroidal anti-inflammatory medication that is used by patients widely for a variety of reasons. Although it is well known that ibuprofen and other non-steroidal anti-inflammatory drugs may have nephrotoxic effects, the role of ibuprofen as a cause of RTA and hypokalemia is not well recognized. Presenting Concerns: A 66-year-old man with chemotherapy-treated lymphoma in remission and ongoing heavy ibuprofen use for chronic pain presented to hospital with a 1-week history of increasing lethargy and otherwise unremarkable review of systems. Investigations showed acute kidney injury, hypokalemia, hyperchloremia, and NAGMA with elevated urinary pH and positive urine anion gap. Diagnoses: The final diagnosis of distal RTA secondary to ibuprofen was made after ruling out gastrointestinal bicarbonate loss and additional secondary causes of RTA, including other medications, autoimmune conditions, and obstructive uropathy. Interventions: The patient was admitted and treated with intravenous sodium bicarbonate for 24 hours with correction of hypokalemia via oral supplementation. His ibuprofen-containing medication was discontinued. Outcomes: His acute kidney injury and electrolyte abnormalities resolved within 48 hours of initiating treatment with concurrent resolution of his lethargy. He was discharged home and advised to stop taking ibuprofen. Lessons Learned: We report a case of patient with hypokalemia and NAGMA secondary to ibuprofen and highlight the importance of monitoring for this side effect in patients taking ibuprofen.

Intravenous sodium valproate as a promising treatment option for comorbid anxiety in patients with bipolar disorder

Intravenous sodium valproate as a promising treatment option for comorbid anxiety in patients with bipolar disorder

Intravenous diclofenac sodium versus ibuprofen as a component of multimodal post operative analgesic plan after caesarean section, a double blinded randomised comparative study.

Intravenous diclofenac sodium versus ibuprofen as a component of multimodal post operative analgesic plan after caesarean section, a double blinded randomised comparative study.

565 UNUSUAL LIFE-THREATENING FLECAINIDE TOXICITY: A CASE REPORT

Abstract Background Anti-arrhythmic drug therapy has often a narrow therapeutic index and could be responsible of toxic side effects including malignant arrhythmias and life-threatening hemodynamic deterioration. Flecainide toxicity can occur even at normal serum levels in the setting of electrolyte disturbances such as hyponatremia. We report a case of flecainide toxicity, likely due to dual mechanism: reduced excretion and potentiation of the toxic effects due to concomitant hyponatremia. Case description A 82-year-old woman was admitted to our hospital for syncope. The ECG at admission showed atrial fibrillation, complete atrio-ventricular (AV) block and a wide QRS escape rhythm. She has a history of hypertension, COPD and atrial fibrillation. She was currently taking flecainide at a dosage of 150 mg per die. Laboratory tests reported an elevated lactate concentration (4.6 mmol/L), hyponatremia (128 mmol/L), severe reduction of renal function (eGFR 19 ml/min), and NT-proB-type Natriuretic Peptide 17563 pg/ml, (ULN&amp;lt;450). Echocardiography showed a reduced left ventricular ejection fraction (EF=35%). Suspecting flecainide poisoning, we started intravenous sodium bicarbonate and temporary pacing for severe bradycardia and pauses. However, despite numerous attempts of lead reposition and the use of maximum output, we failed to document ventricular capture in the immediate post-operative. Half hour later, dopamine infusion was started for sustained severe hypotension. The day after we were able to obtain ventricular capture. At serial ECG examination, she also developed progressive QRS narrowing with concomitant clinical improvement. Discussion Flecainide toxicity is a rare but potentially life-threatening condition. The excess of sodium channel blockade causes in fact delayed conduction through the AV node, His-Purkinje system, and ventricles with possible AV block, ventricular tachycardia, ventricular fibrillation, and asystole. In addition, hemodynamic instability can develop rapidly in flecainide intoxication due to chronotropic and inotropic incompetence. The majority of flecainide intoxication reported cases are due to a drug overdose. However, flecainide toxicity can occur with serum levels within the range of normality. Particularly, this can occur in the setting of hyponatremia. The observed pacemaker malfunction was also due to flecainide intoxication. In our case, the patient was taking therapeutic doses of this drug. The toxic effect was probably due to the reduced excretion (secondary to kidney failure) and the simultaneous presence of hyponatremia. The main treatment for flecainide intoxication is sodium bicarbonate and supportive care. However, there is currently no recommended standardized protocol for flecainide toxicity. The inotropic agents could be helpful in case of cardiogenic shock, but their use may be limited by the rate-dependent effect of flecainide and the increased risk ventricular arrhythmias. Left ventricular assist devices have been also used to support hemodynamic through flecainide-induced cardiogenic shock.

Non-opioid Intravenous Drugs for Pain Management in Patients Presenting with Acute Migraine Pain in the Emergency Department: A Comprehensive Literature Review.

Migraine is one of the most common causes of disability worldwide and the sixth cause of loss of life years due to disability. Migraine is reported mainly in young and middle-aged people, so it can cause a person to face many problems in doing daily tasks. The emergency department annually accepts 1.2 million patients with migraine. Therefore, timely diagnosis of the disease, knowledge of valuable drugs in an emergency, knowing how to use them, and finally, early treatment can play an essential and decisive role in improving patients' symptoms and reducing the disability caused by the disease. An essential and valuable drug category in the emergency department to manage pain is non-opioid intravenous (IV) drugs. Therefore, this study aimed to evaluate non-opioid IV drugs to manage pain in patients with acute migraines in the emergency department. This study conducted a comprehensive literature review to access the latest scientific studies and documents using keywords (acute migraine, non-opioid IV drugs, pain management) in reliable databases such as PubMed, Scopus, Web of Science, Cochrane, and Google Scholar. We reviewed 87 articles, 53 of which were evaluated and compared. A review study considers intravenous acetaminophen as a suitable option for the first-line treatment of acute migraine in the emergency department if the patient does not tolerate aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). Various studies have obtained positive effects of NSAIDs and dihydroergotamine (DHE) in treating acute migraine. Prescribing anti-dopaminergic drugs can effectively reduce associated symptoms such as nausea and vomiting. Dexamethasone and magnesium sulfate are effective in preventing migraine and severe attacks. Intravenous sodium valproate is effective in moderate to severe migraine attacks or treatment-resistant migraines. In the emergency department, prescribing intravenous haloperidol, lidocaine, and propofol can help manage migraine and improve other associated symptoms, such as nausea or vomiting. Non-opioid IV drugs are essential to manage pain and improve other migraine symptoms in the emergency setting. Knowing the above drugs and their optimal use has a decisive role in managing patients with acute migraine in the emergency department.

A case of refractory hypoxia and shock due to drug overdose successfully managed with ECMO first time ever in Bangladesh

A 36 -year-old female developed refractory cardiac and respiratory failure after self-declared ingestion of unknown amount of propranolol, benzodiazepine and few other unknown drugs in unknown dose. She also had vomiting followed by aspiration pneumonia. Despite giving adequate I/V fluid, antibiotics, activated charcoal, lipid emulsion, intravenous sodium bicarbonate and inotropic support, she became hypotensive and developed acute heart failure with pulmonary edema. This patient was managed with extracorporeal membrane oxygenation (ECMO) for 72 h, she survived without any deficit. This records country’s first ever use of extracorporeal membrane oxygenation in any patient. In this particular case when traditional antidotes were insufficient to prevent collapse, ECMO was introduced in the form of extracorporeal life support (ECLS) to maintain perfusion, reduce vasopressor requirements, and maintain oxygenation and carbon dioxide removal from blood. With increasing expertise and availability, extracorporeal membrane oxygenation should be considered in patients who develop cardiac or respiratory failure due to any cause, refractory to conventional therapy. Bangladesh Crit Care J September 2022; 10(2): 142-145

Safety and Tolerability of 23.4% Hypertonic Saline Administered Over 2 to 5 Minutes for the Treatment of Cerebral Herniation and Intracranial Pressure Elevation.

Hyperosmolar therapy is the cornerstone of medical management of sustained elevated intracranial pressure from cerebral edema. Acute intracranial hypertension and herniation is a medical emergency that requires rapid treatment and stabilization to prevent secondary brain injury or death. Intravenous hypertonic sodium chloride (NaCl) 23.4% is an effective treatment modality commonly used in this setting. Because of its high osmolarity, use has historically been limited primarily to central venous line administration as an intermittent infusion due to concerns about thrombophlebitis, injection site pain, and tissue necrosis or injury with extravasation. The objective of this analysis was to prospectively evaluate the safety of administration of 23.4% NaCl as a rapid intravenous push over 2-5min. A prospective analysis of patients admitted between April 2021 and December 2021 who received 23.4% NaCl intravenous push over 2-5min in a central or peripheral line was performed. Safety end points included incidence of new onset hypotension [defined as systolic blood pressure (SBP) < 90mm Hg or SBP decrease of at least 20mm Hg], bradycardia (defined as heart rate < 50 beats per minute), and infusion site reactions documented within 1h of administration. For secondary safety outcomes, highest and lowest SBP and lowest heart rates documented within 1h before 23.4% NaCl administration were compared with values collected within 1h post administration and evaluated by mixed-design analysis of variance test with adjustment for peripheral versus central line administration. We identified 32 patients who received 79 administrations of 23.4% NaCl through a central line or peripheral line during the study period. An SBP decrease of at least 20mm Hg was observed in 13% of patients, an SBP < 90mm Hg occurred in 16% of patients, and bradycardia occurred in 3% of patients who received 23.4% NaCl. Injection site pain was reported by one patient without documented thrombophlebitis, cellulitis, or tissue damage. Pain was not reported during two subsequent administrations in the same patient. There was no documented occurrence of soft tissue injury or necrosis in any patient. Compared with baseline vital signs before 23.4% NaCl administration, no difference in vital signs post administration was observed. Central and peripheral administration of 23.4% NaCl over 2-5min was well tolerated, and incidence of hypotension, bradycardia, or infusion site-related adverse events was rare.

A 21-Year-Old Woman with Suspecting Gitelman Syndrome

&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Gitelman syndrome (GS), is a hereditary condition marked by a specific kidney function impairment. GS symptoms do not normally manifest until beyond the age of six years. We present a rare case of a 21-year-old woman with a background in generalized weakness muscle cramps with tetany, fever, and dyspnea. The goal of this study is to give a case report of Gitelman syndrome suspicion.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Result:&lt;/strong&gt; Gitelman syndrome is identified through clinical indicators and lab testing, such as low potassium and magnesium levels in the blood, metabolic alkalosis, and low calcium levels in the urine. We do a variety of physical and laboratory tests to determine the disease and rule out other possibilities. Molecular proof is difficult to get due to a lack of resources and the high expense of genetic testing, which has become one of our case report's flaws. This patient was diagnosed as suspecting Gitelman syndrome and treated for electrolyte imbalances. The patients were given replacement therapy, which comprised intravenous potassium, sodium, and chloride therapy, as well as calcium therapy. In addition, we also provided some symptomatic therapy. She was discharged five days later in fine condition.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion :&lt;/strong&gt; This is one of the few reports of a 21-year-old lady being suspected of having Gitelman syndrome (GS). We conduct a battery of physical and laboratory tests to diagnose the disease and rule out other possibilities. We provide the appropriate therapies in accordance with the guidelines, and the outcomes are favorable.&lt;em&gt;&lt;/em&gt;&lt;/p&gt;

Incidence of nephrotoxicity associated with intravenous colistimethate sodium administration for the treatment of multidrug-resistant gram-negative bacterial infections

Colistimethate sodium (CMS) is the inactive prodrug of colistin, CMS has a narrow antibacterial spectrum with concentration-dependent bactericidal activity against multidrug-resistant gram-negative bacteria, including Pseudomonas aeruginosa and Acinetobacter baumannii. This study aimed to analyze potential correlations between clinical features and the development of CMS-induced nephrotoxicity. This retrospective cohort study was conducted in a tertiary-care university hospital between 1 January 2015 and 31 December 2019. A total of 163 patients received CMS therapy. 75 patients (46%) developed nephrotoxicity attributable to colistin treatment, although only 14 patients (8.6%) discontinued treatment for this reason. 95.7% of CMS were prescribed as target therapy. Acinetobacter baumannii spp. was the most commonly identified pathogen (72.4%) followed by P. aeruginosa (19.6%). Several risk factors associated with nephrotoxicity were identified, among these were age (HR 1.033, 95%CI 1.016–1.052, p < 0.001), Charlson Index (HR 1.158, 95%CI 1.0462–1.283; p = 0.005) and baseline creatinine level (HR 1.273, 95%CI 1.071–1.514, p = 0.006). In terms of in-hospital mortality, risk factors were age (HR 2.43, 95%CI 1.021–1.065, p < 0.001); Charlson Index (HR 1.274, 95%CI 1.116–1.454, p = 0.043), higher baseline creatinine levels (HR 1.391, 95%CI 1.084–1.785, p = 0.010) and nephrotoxicity due to CMS treatment (HR 5.383, 95%CI 3.126–9.276, p < 0.001). In-hospital mortality rate were higher in patients with nephrotoxicity (log rank test p < 0.001). In conclusion, the nephrotoxicity was reported in almost half of the patients. Its complex management, continuous renal dose adjustment and monitoring creatinine levels at least every 48 h leads to a high percentage of inappropriate use and treatment failure.

39-Year-Old Woman With Severe Weakness

39-Year-Old Woman With Severe Weakness

The pharmacokinetics and pharmacodynamics of dexamethasone following epidural SP-102 or intravenous dexamethasone sodium phosphate injection in subjects with lumbosacral radicular pain.

To evaluate the pharmacokinetics, pharmacodynamics (PD), safety, and tolerability of epidural SP-102 (10 mg dexamethasone sodium phosphate injectable gel) compared to an intravenous injection of 10 mg dexamethasone sodium phosphate, USP (IV USP). Subjects with lumbosacral radiculopathy received a single dose of epidural SP-102, followed by a single dose of IV USP 4 weeks later. Dexamethasone plasma levels, cortisol levels, white blood cells (WBC), and blood glucose levels were assessed. Twelve subjects entered and completed the study. The mean total dexamethasone exposure (AUClast and AUCinf) following SP-102 by epidural injection was equivalent to the total exposure following IV USP. A lower mean plasma Cmax (~50% lower) was observed following epidural administration compared to IV injection. PD parameters were similar between treatments. Adverse events (AEs) were mild, with no serious AEs or study discontinuations due to AEs. In this small study, epidural SP-102 injection was well tolerated, was not associated with greater systemic dexamethasone exposure than IV USP, and both treatments had similar PD effects on cortisol suppression, blood glucose, and WBC levels.

33396 Nonuremic calciphylaxis precipitated by COVID 19 infection

A 40-year-old female with a medical history of hypertension, anxiety, and COVID-19 pneumonia in May 2021 that was complicated by cardiac arrest, presented in July 2021 with bilateral lower extremity wounds. Wounds initially were described as ‘sunburns’ that progressed to form multiple large retiform purpura with black necrotic eschars and surrounding induration on bilateral thighs and lower legs. A telescoping punch biopsy was performed showing calciphylaxis with intravascular thrombosis. Labs were significant for a mildly elevated phosphorus, PT/PTT, lupus anticoagulant antibody, and positive ANA. Creatinine, BUN, calcium, PTH, and GFR were within normal limits. Patient had no prior personal or family history of coagulopathies or renal dysfunction. The patient was diagnosed with nonuremic calciphylaxis (NUC) precipitated by a COVID-19 induced coagulopathy. Intravenous sodium thiosulfate and sevelamer was started for treatment. NUC is a rare disease characterized by arterial calcification leading to ischemia and skin necrosis that occurs in the setting of normal renal function. Other conditions associated with NUC include prothrombotic states like Protein C and S deficiency, antithrombin III deficiency, antiphospholipid antibody, cryofibrogenemia, and malignancy. COVID-19 has been demonstrated to generate a prothrombotic state leading to hypercoagulability. The patient’s recent COVID-19 infection and positive lupus anticoagulant antibody together promoted a hypercoagulable state that was the nidus for cutaneous calciphylaxis and making this case of NUC induced by COVID-19 hypercoagulability a novel presentation of an uncommon disease.

Pseudohypobicarbonatemia in a patient with amyloidosis.

We report a case of a patient who had critically low serum bicarbonate (HCO3 -) levels ranging from 8 to 11mmol/L on repeated venous measurements using an enzymatic/photometric assay. This prompted hospitalization and treatment with intravenous sodium bicarbonate (NaHCO3) followed by oral NaHCO3. He was evaluated for potential causes of high anion gap metabolic acidosis without any etiology found. He continued to have low serum HCO3 - levels despite maintenance oral NaHCO3 therapy and was referred for a second opinion where further laboratory work was pursued. An arterial blood gas was obtained, which revealed normal whole blood pH and HCO3 - levels. A different enzymatic/photometric assay revealed a normal serum HCO3 - level at 21mmol/L. Additional workup revealed paraproteinemia, which was thought to interfere with the enzymatic process by which his serum HCO3 - was measured, resulting in erroneous values.

Ocular Migraine With Amaurosis Fugax of the Left Eye: A Case Report

In amaurosis fugax, there is a sudden loss of vision in one eye. Patients gain their vision after a few minutes. The most common underlying cause is atherosclerosis of the internal carotid artery. Other underlying causes include vasospasm of the internal carotid artery, which leads to hypoperfusion and is seen in vasculitis, ocular migraines, and systemic lupus erythematosus. In this case study, a 44-year-old male with a past medical history of migraine with aura presented to the emergency room with transient vision loss in the left eye, which lasted for two minutes. A computed tomography scan of the brain was negative for stroke. The patient was treated with intravenous fluid, aspirin, and enoxaparin sodium and instructed to follow up with neurology. A medical emergency such as amaurosis fugax caused by ocular migraine must be managed aggressively, and prompt imaging is necessary to exclude other causes.