Alterações hidroeletrolíticas em pessoas com cirrose / Hydroelectrolytic alterations in cirrhotic patients

O objetivo deste estudo foi evidenciar e discutir as principais alterações hidroeletrolíticas em pessoas com cirrose. Trata-se de uma revisão integrativa, de natureza qualitativa. Os artigos foram selecionados por meio da plataforma Medical Literature Analysis and Retrievel System Online. Os principais achados identificados a partir dos artigos selecionados foram a ocorrência de hiponatremia, o mau prognóstico diante da presença de distúrbios hidroeletrolíticos em relação à sobrevida em pessoas com cirrose e a importância da albumina. Indivíduos com cirrose são suscetíveis ao desenvolvimento de distúrbios hidroeletrolíticos devido às mudanças fisiopatológicas da doença e às condições clínicas apresentadas. A hiponatremia e a hipocalemia são os mais recorrentes, destacando, porém, a necessidade de atenção aos demais distúrbios. (AU)

The objective of this study was to show and discuss the main hydroelectrolytic alterations in cirrhotic patients. This is an integrative review, a qualitative study, in which articles were selected at the Medical literature Analysis and Retrieval System Online. The main findings identified in the articles selected were the occurrence of hyponatremia, the poor prognostic, due to the presence of hydroelectrolytic disorders, regarding cirrhotic individuals survival and the importance of albumin. Individuals with cirrhosis are susceptible to the development of hydroelectrolytic disorders due to the pathophysiological alterations of the disease and because of the clinical status presented. Hyponatremia and hypokalemia are the most recurrent, but attention shall be given to the other disorders too. (AU)

Alteraciones electrocardiográficas en anorexia nervosa: revisión crítica de la literatura / Electrocardiographic abnormalities in anorexia nervosa: a critical review of the literature

Introducción: La anorexia nervosa (AN) es un trastorno de la conducta alimentaria y, entre sus causas de mortalidad, las arritmias cardiacas y la muerte súbita son frecuentes, por lo que es indispensable la monitorización electrocardiográfica. Se han descrito muchos hallazgos con resultados contradictorios, por lo que es necesaria una revisión crítica de la literatura científica. Metodología: Revisión de los estudios relevantes sobre cambios electrocardiográficos en AN, consultados en PubMed desde 1974 hasta febrero de 2014, utilizando los términos MeSH: Eating disorders, nervosa anorexia, sinusal bradycardia, QT prolongation, QT dispersion, electrocardiography, EKG, electrocardiogram. Resultados y discusión: Las dos alteraciones más comunes reportadas incluyen la bradicardia sinusal y los cambios en la repolarización evidenciados en prolongación del QT e incremento de su dispersión. Los trastornos electrolíticos parecen ser la causa de estas alteraciones en algunos pacientes, pero otras razones se discuten en detalle, como la desviación del eje del QRS a la derecha, la alteración en variabilidad de la frecuencia cardiaca, R en derivación V6 de bajo voltaje, disminución de la amplitud del QRS y onda T y alargamiento del QRS. La mayoría de los autores hablan de reversibilidad de los cambios después del tratamiento. Conclusiones: Estos resultados siguen apoyando la necesidad de valorar a los pacientes con AN con electrocardiogramas inicial y de seguimiento, para el diagnóstico temprano y tratamiento de alteraciones cardiovasculares relacionadas con alta morbimortalidad. También apoyan la necesidad del uso racional de psicofármacos para no aumentar el riesgo de arritmias cardiacas y muerte súbita.

Background: Anorexia nervosa is an eating disorder in which cardiac arrhythmias and sudden death are frequent causes of mortality, which makes electrocardiographic monitoring indispensable in these patients. There are many suggestive findings but results are contradictory, making a critical review of the scientific literature is necessary. Methods: The most relevant studies on electrocardiographic (EKG) changes in patients with AN, found in PubMed from 1974 to February 2014, were reviewed using the MeSH terms: eating disorders, nervosa anorexia, sinus bradycardia, QT prolongation, QT dispersion, electrocardio graphy, EKG, and electrocardiogram. Findings and discussion: The two most common EKG findings reported in the literature are sinus bradycardia and changes in depolarization, as shown by prolongation and increased dispersion of the QT interval. Electrolyte disturbances seem to be the cause of these disturbances in some patients, but other reasons are also discussed in detail, such as QRS right axis deviation, disturbances of heart rate variability, low R wave voltage in V6, amplitude decrease of the QRS and T wave, and QRS prolongation. The majority of authors report that these changes are reversible after treatment of AN. Conclusions: These findings support the need for initial and follow-up EKGs in patients with AN and for early diagnosis and treatment of cardiovascular disturbances that are associated with morbidity and mortality. They also support the need for the rational use of psychop harmacology, and that does not increase the risk of arrhythmias and sudden death in these patients.

Cardiomiopatía inducida por estrés (Takotsubo) en una paciente con anorexia nerviosa / Stress (Takotsubo) cardiomyopathy in a patient with anorexia nervosa

Presentamos el caso de una mujer con diagnóstico de anorexia nerviosa que desarrolló cardiomiopatía de takotsubo precipitada por estrés emocional y alteraciones del medio interno. Evolucionó favorablemente con manejo conservador. Los casos de cardiomiopatía inducida por estrés, descriptos en pacientes con trastornos de la conducta alimentaria, suelen alcanzar mayor gravedad y se asocian con la prolongación del intervalo QT por desequilibrios electrolíticos, arritmias ventriculares e hipoglucemia. Se realiza una revisión del compromiso cardiovascular en pacientes con anorexia nerviosa.

We report the case of a woman with anorexia nervosa who developed takotsubo cardiomyopathy triggered by emotional stress and electrolyte disturbances. The patient improved with conservative management. Descriptions of stress-cardiomiopathy in association with eating disorders are often of higher severity and related to QT prolongation because of electrolyte abnormalities, ventricular arrhythmias and hypoglycemia. A review of cardiovascular compromise in patients with anorexia nervosa is performed.

Anorexia nervosa e síndrome de realimentação em adolescente: relato de caso / Anorexia nervosa and refeeding syndrome in adolescents: case report

Introdução: anorexia nervosa é um transtorno alimentar que acomete geralmente adolescentes e pode resultar em desnutrição grave. A síndrome de realimentação constitui-se em desordem hidroeletrolítica grave, potencialmente fatal, que ocorre após reintrodução abrupta da dieta. Objetivo: alertar quanto à gravidade dessa síndrome e identificar os pacientes em risco de desenvolvê-la, a fim de evitar sua ocorrência. Relato do caso: paciente de 13 anos de idade, admitida em unidade de terapia intensiva com índice de massa corpórea (IMC) de 9,9 kg/m2, hipotensão, bradicardia, hipotermia e níveis séricos baixos de potássio, cálcio e fosfato. A paciente evoluiu, após o início da dieta, com agravamento dos distúrbios hidroeletrolíticos, instabilidade hemodinâmica e pancitopenia. As alterações apresentadas foram diagnosticadas como síndrome de realimentação, sendo necessária suplementação eletrolítica e monitoração rigorosa. Conclusão: apesar da desnutrição causada pela anorexia nervosa ser potencialmente grave, a reintrodução da dieta deve ser cautelosa, priorizando a correção hidroeletrolítica, para evitar-se a síndrome de realimentação.

Introduction: anorexia nervosa is an eating disorder that usually affects teenagers and can result in severe malnutrition. The refeeding syndrome is a serious hydro electrolyte disorder, potentially fatal, occurring after the abrupt diet reintroduction. Objective: To warn about the seriousness of this syndrome and identify patients at risk of developing it in order to prevent its occurrence. Case report: a 13 years old patient, admitted at the intensive care unit with body mass index (BMI) of 9,9 kg/m2, hypotension, bradycardia, hypothermia and low serum levels of potassium, calcium and phosphate. After starting the diet, the patient developed increase of hydroelectrolyte imbalance, hemodynamic instability and pancytopenia. The alterations have been diagnosed as refeeding syndrome, requiring electrolyte supplementation and rigorous monitoring. Conclusion: Although malnutrition caused by anorexia nervosa is potentially serious, the reintroduction of the diet should be cautious, emphasizing the hydroeletrolytic correction, to avoid the refeeding syndrome.

Vasopressin serum levels and disorders of sodium and water balance in patients with severe brain injury

BACKGROUND: Disorders of water and sodium balance are frequently seen in patients with severe brain injury (SBI), and may worsen their prognosis. PURPOSE: To evaluate vasopressin (AVP) serum levels and sodium and water balance disorders during the first week post-injury in patients with SBI. METHOD: Thirty-six adult patients with SBI (admission Glasgow Coma Scale score < 8) and an estimated time of injury < 72 hours were prospectively studied. Clinical and laboratory data were recorded and AVP was measured in venous blood samples collected on the 1st, 2nd, 3rd and 5th days following inclusion. RESULTS: AVP serum levels remained within the normal range in SBI patients (either traumatic or non-traumatic), although tended to be greater in non-survivor than in survivor patients (p=0.025 at 3rd day). In-hospital mortality was 43 percent (15/36), and serum sodium and plasma osmolality variabilities were greater in non-survivor than in survivor patients during the observation period (p<0.001). CONCLUSION: AVP serum levels remained within the normal range values in these SBI patients, but those who died have shown higher incidence of abnormal sodium and water balance during the first week post-injury.

ANTECEDENTES: Desordens do balanço de água e sódio são frequentemente vistas em pacientes com lesão cerebral grave (LCG), podendo agravar o prognóstico. OBJETIVO: Avaliar os níveis séricos de vasopressina (AVP) e a incidência de distúrbios da água e sódio na primeira semana pós-lesão em pacientes com LCG. MÉTODO: Trinta e seis pacientes adultos com LCG (pontuação inicial na escala de coma de Glasgow < 8) e tempo estimado de lesão < 72h foram estudados prospectivamente. Dados laboratoriais e clínicos foram registrados e os níveis séricos de AVP foram mensurados no 1º, 2º, 3º e 5º dias pós-inclusão. RESULTADOS: A AVP manteve-se dentro da faixa de normalidade nestes pacientes, mas mostrando-se proporcionalmente mais elevada nos pacientes que não sobreviveram (p=0,025 no 3º dia). A mortalidade intra-hospitalar foi 43 por cento (15/36) e as variações do sódio e osmolalidade plasmáticos foram maiores nos pacientes que não sobreviveram durante o período de observação (p<0,001). CONCLUSÃO: Os níveis séricos de AVP mantiveram-se dentro da faixa de normalidade nestes pacientes com LCG, mas aqueles não sobreviventes mostraram maior incidência de anormalidades do balanço de água e sódio durante a primeira semana de evolução.

Dengue viral infections as a cause of encephalopathy.

The aim of this study was to determine the clinical characteristics and poor prognostic factors associated with high mortality in dengue encephalopathy. Fifteen patients with confirmed dengue infections, who developed encephalopathy, were recruited from two tertiary care hospitals in Colombo, Sri Lanka. Among the factors that contributed to encephalopathy were: Acute liver failure (73%), electrolyte imbalances (80%) and shock (40%). Five (33.3%) patients developed seizures. Disseminated intravascular coagulation was seen in five (33.3%). Secondary bacterial infections were observed in 8 (53.3%) of our patients. The overall mortality rate was 47%.

Sodium disturbances frequently encountered in a neurologic intensive care unit.

Most sodium disturbances in patients with CNS lesions result from disturbed water regulation. Possible systemic and iatrogenic causes must be evaluated prior to treatment. Insufficient secretion of ADH leads to hypernatremia if fluid intake is inadequate and can be treated with either fluid or hormone replacement. Care must be exercised in patients with acute diabetes insipidus because of the potentially variable and transient nature of the disturbance. Hyponatremia usually results from inappropriate secretion of ADH and should be managed aggressively in symptomatic patients with loop diuretics and hypertonic saline. However, very rapid correction or overcorrection should be avoided. Patients with SAH and hyponatremia should not be fluid restricted because of the risk of exacerbating vasospasm but treated with large volumes of isotonic or mildly hypertonic saline.

Successful management of hypokalaemia related conduction disturbances in acute aluminium phosphide poisoning.

A case of acute aluminium phosphide poisoning is described, who presented in shock secondary to electrolyte related cardiac rhythm disturbance and the judicious correction of the same could save his life without any consequence.

Mielinolisis central pontina / Central pontine myelinolysis

Se presenta un paciente de 23 años con quemaduras de 2do. y 3er. grado que comprometieron el 45%de la superficie corporal. A los 25 días de evolución se instaló un deterioro del nivel de conciencia, con somnoliencia asociada a hiperosmolaridad, hiperglucemia (341 mosm/kg; 210 mg.dl) e hipernatremia (151 mEq/l) sin signos de IRA. Corregido en 48 hs. el desequilibrio osmótico por aporte de fluidos, apareció luego un cuadro de obnubilación con tetraparesia que se completó en 24 hs. A los 24 días de ésta, una TC mostró una lesión hipodensa compatible con mielinolisis central pontina. Se concluye que la hiperosmolaridad asociada a una pérdida de osmoles idiogénicos, típico de estados hipercatabólicos, es la responsable de la mielinolisis central pontina