Timely Hemodialysis for Successful Treatment of Acute Salicylate Overdose in a Young Adult Female - A Case Report.

Salicylates are often used in clinical practice as antiplatelets as well as analgesics. Its overdose is not uncommon due to its easy availability over the counter. Mortality is high in severe cases when a lethal dose is consumed. Treatment of overdose is difficult due to the non-availability of an antidote. Hemodialysis is an underutilized treatment modality in such cases. We discuss here a case of a young female who presented to us 2.5 h after the consumption of a lethal dose of salicylate with symptoms of only tinnitus. She was successfully treated with two sessions of hemodialysis. Her drug levels on admission were remarkably high, and early hemodialysis was justified in view of high-dose consumption with minimal symptoms.

Euglycemic diabetic ketoacidosis: A missed diagnosis.

Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.

Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers.

INTRODUCTION: Cytokine-release syndrome (CRS) in COVID-19 patients can cause multiorgan failure and higher mortality. We used a structured protocol based on clinical, biochemical, and interleukin 6 (IL-6) criteria for the identification of the subset of patients with CRS and analyzed the use of tocilizumab for their treatment. MATERIALS AND METHODS: We did a retrospective case-control analysis of all COVID-19 patients between 15 March and 15 May 2020 with severe to critical disease in ICU. They were evaluated for CRS, and 22 patients who met the criterion were given tocilizumab. The primary objective was to evaluate the effect of tocilizumab on escalation of respiratory support and ICU mortality. The secondary objectives were ICU length of stay, trends of inflammatory markers, and any adverse effects. RESULTS: The need for escalation of respiratory support was significantly lower in the tocilizumab group as compared to standard treatment (p = 0.001). The mortality at day 7 and 28 was also significantly lower in the tocilizumab group (p = 0.007 and p = 0.001 respectively). There was a significant reduction in C-reactive protein (CRP) who received tocilizumab (p = 0.033). CONCLUSION: In our limited number of patients, timely intervention with tocilizumab in COVID-19 patients with CRS significantly improved overall ICU outcome by reducing the need for invasive ventilation and mortality. HOW TO CITE THIS ARTICLE: Nasa P, Singh A, Upadhyay S, Bagadia S, Polumuru S, Shrivastava PK, et al. Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers. Indian J Crit Care Med 2020;24(9):771-776.