Shaikh, Umair; Cervantes, Carmen Elena; Diaz, Raiko; Mohammadi, Oranus; Danckers, Mauricio; Hernandez, Felix; Heller, Daniel Author Information

Ingestion of toxic alcohols (TA) typically presents with a high anion gap (AG) metabolic acidosis, and elevated osmolar gap (OG). Hemodialysis (HD) has not been recommended in early phases of intoxication with high OG and normal AG metabolic acidosis. We describe the case of a 40-year-old male who was brought to our emergency department for reported paint thinner ingestion. He was unable to protect his airway and required intubation. Blood gas showed respiratory acidosis, an initial AG, corrected by albumin of 12.75, lactic acid 5.26 mmol/L, and an OG of 170. Patient was treated with bicarbonate drip, fomepizole and emergent HD, which improved his neurologic status. Days after his admission, alcohol levels came positive for a co-ingestion of ethylene glycol, diethylene glycol, and methanol. Most of the TA are metabolized into their toxic byproducts by the enzyme alcohol dehydrogenase (ADH). The kinetics of these alcohols will be altered when there is co-ingestion of multiple substances. Moreover, early ingestions will translate in a high OG without a high AG. False elevation of lactate can occur with the ingestion of ethylene glycol due to a cross-reaction with l-lactate oxidase in the analyzer. In our case, the administration of fomepizole followed by an early HD given the poor clinical improvement, was followed by a fast recovery of the neurological status and potentially prevented renal failure. A high index of suspicion for TA ingestion should be raised when encountering an individual with lactic acidosis, high OG, and normal AG.

Butt, Ifrah; Dave, Kairavee; Rindy, Lucas; Concepcion, Livasky; Heller, Daniel; Kaplan, Steven; Kasmin, Franklin; Rivas, John Author Information

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Butt, Ifrah; Shaikh, Umair; Fernandez, Marlena; Shaharyar, Sameer; Heller, Daniel Author Information

Learning Objectives: Transcatheter aortic valve replacement (TAVR) is widely accepted as an alternative to the surgical approach in high risk patients with critical aortic stenosis. Postprocedural complications are uncommon but potentially fatal. Understanding how the left ventricle adapts to long standing aortic stenosis and the hemodynamic sequelae to sudden afterload reduction post valvular replacement allows for reliable post-procedural management of patients. We present the case of a patient in the immediate post-TAVR period who developed suicide left ventricle and circulatory collapse after treatment of accelerated hypertension. Methods: An 83-year-old female with multiple comorbidities presented for evaluation of exertional dyspnea. An echocardiogram had shown parameters consistent with severe aortic stenosis (aortic valve area of 0.7 cm, mean gradient 47 mmHg, aortic jet velocity 4.5 m/s). She was considered a poor surgical candidate and was scheduled for elective TAVR. Within hours of procedure, she had remained in sinus bradycardia and had progressively developed elevated systolic blood pressures above 200 mmHg. She was given hydralazine. Shortly after its administration she started complaining of severe chest pain. She became hypotensive and developed pulseless electrical activity. Advanced cardiopulmonary life support (ACLS) was initiated. Epinephrine was administered. EKG showed diffuse precordial ST segment elevations. She subsequently developed refractory ventricular fibrillation. Despite resuscitative maneuvers, she passed away. Results: Suicide left ventricle is a rare yet important cause of hemodynamic collapse post-TAVR. In our case, the addition of a pure arterial vasodilator to control accelerated hypertension initiated a feedback loop that led to decreased cardiac output via peripheral vasodilation. Sudden reduction in afterload resulted in LV cavity obliteration as a hypertrophied ventricle contracts against a reduce afterload. Ionotropic effects of epinephrine worsening the intraventricular gradient exacerbating left ventricular outflow tract (LVOT) obstruction has been previously described by Dr. Braunwald and colleagues. Initial management of circulatory failure in patient with suspected suicide LV relies on fluid resuscitation for preload and LV cavity expansion as well as phenylephrine as a vasopressor of choice due to its ability to decrease the intraventricular gradient as a selective alpha 1 -adrenergic drug. CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MDCCM

Chu, Andrew; Cervantes, Carmen Elena; Heller, Daniel; Lemont, Michael Author Information