Ethylene glycol intoxication: Disparate findings of immediate versus delayed presentation

Ethylene glycol is a common household substance responsible for a large number of ingestions in the U.S. each year. In 2001, nearly 5,000 ethylene glycol exposures were reported with more than 1,600 patients requiring medical treatment. There were 16 deaths attributed to ethylene glycol in 2001, second only to ethanol overdose for lethal ingestions. Diagnosis of ethylene glycol ingestion is relatively straight-forward when an individual with a history of exposure is found to have a high anion-gap metabolic acidosis and an elevated osmolar gap. Appropriate treatment can be immediately employed and the diagnosis confirmed by the finding of elevated ethylene glycol levels in the serum. In the absence of exposure history, the differential diagnosis of a high anion-gap metabolic acidosis and an elevated osmolar gap will also lead to consideration of ethylene glycol ingestion. This well-recognized presentation of ethylene glycol toxicity includes findings expected in individuals who present for care soon after their ingestion. A less well-known pattern may be seen in those for whom care is delayed. We present a patient with delayed presentation of ethylene glycol ingestion and review the physiology and biochemistry that underlies this different presentation. Unfortunately, without history or strong laboratory evidence, ethylene glycol ingestion may be easily overlooked in individuals with delayed presentation.     

代谢性酸中毒犬脑脊液［HCO－_3］与Pco_2的关系

作者旨在探讨代谢性酸中毒时脑脊液（ＣＳＦ）［ＨＣＯ－３］与ＰＣＯ２的相互关系。两组代谢性酸中毒模型均由静脉内输入０．２ｍｏｌ／ＬＨＣＩ产生，［ＨＣＯ－３］ａ１ｈ内下降到（１２２）ｍｍｏｌ／Ｌ。实验６ｈ时ＣＳＦ［ＨＣＯ－３］：１组（正常碳酸血性代酸）下降了１．６ｍｍｏｌ／Ｌ；组（低碳酸血性代酸）下降了７．０ｍｍｏｌ／Ｌ．ＣＳＦ［ＨＣＯ－３］与ＣＳＦＰｃｏ２，显著正相关（ｒ＝０．８３４，Ｐ＜０．０ｌ）．结果说明代谢性酸中毒时ＣＳＦ［ＨＣＯ－３］并不受［ＨＣＯ－３］ａ的明显影响，主要取决于ＣＳＦＰｃｏ２的变化，其调节机制与脉络丛上皮细胞内ＣＯ２的水化作用和ＣＡ活性有关。     

Ethylene glycol poisoning

Seven men with ethylene glycol poisoning were treated at our institution during a ten-year period. Six patients survived. Ethylene glycol levels on admission did not directly correlate with the severity of metabolic abnormalities or subsequent complications. The timing of the patients' admissions altered the clinical picture and results of therapy. Patients who came to our facility later than 12 to 24 hours after ingestion had established renal failure and required prolonged hospitalization. We were able to prevent renal failure in the one patient started on dialysis less than 23 hours after ingestion. Our patients exhibited the metabolic, CNS, cardiopulmonary and renal manifestations of ethylene glycol poisoning.     

连续性血液净化治疗糖尿病肾病酮症酸中毒合并急性肾损伤临床分析

目的观察连续性血液净化(continuous blood purification,CBP)治疗糖尿病肾病酮症酸中毒合并急性肾损伤(acute kidney injury,AKI)的临床疗效。方法回顾性分析四川大学华西医院2008～2011年期间收治的16例2型糖尿病肾病(diabetic nephropathy,DN)合并酮症酸中毒(diabetic ketoacidosis,DKA)的AKI患者。患者一经确诊在常规治疗的基础上均采用持续性静-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)的干预方式,治疗时间不少于48h,观察患者治疗前后各项临床及生化指标的变化及AKI的临床转归。结果 16例AKI患者中1例入院10h后经抢救无效死亡,其余15例患者经CVVH治疗12h后二氧化碳结合力(carbondioxide combining power,CO2CP)显著提高(P<0.01),动脉血pH值改善;治疗48h后不仅降低了血尿素氮(BUN)(P<0.05)、血肌酐(SCr)(P<0.05)、血糖(Glu)(P<0.01)、血钾(K+)(P<0.01),还改善了血液高渗透压状态(P<0.05),从而有效纠正患者的酮症酸中毒;16例AKI患者中有11例均在入院(12±5)d后进入多尿期,(18±12)d后肾功能恢复。结论糖尿病肾病酮症酸中毒合并AKI属临床危重症,早期积极的CVVH干预治疗可稳定血流动力学、迅速改善内环境、为补液及营养支持及后续的药物治疗创造条件,能获得满意疗效。     

The Acid-Base Status in Cyanotic Congenital Heart Disease

The relation between oxygen consumption, metabolic status and prognosis was studied in two infants with identically low arterial oxygen tensions (20 mm. Hg) due to cyanotic congenital heart disease. The first patient had low oxygen consumption, arterial blood acidosis and increased arterial lactate, and died at the age of 36 hours. The second had normal oxygen consumption, arterial acid-base balance, lactate and pyruvate, and survived. Since arterial oxygen tensions were similar in both, it was concluded that compensatory factors, such as cardiac output, pulmonary and systemic blood flow and increased oxygen saturation at normal pH levels (Bohr effect), are important in maintaining tissue oxidation and preventing anaerobiosis and lactate production. The importance of a knowledge of acid-base status in the immediate prognosis of cyanotic congenital heart disease is stressed. The treatment of acidosis by buffer therapy may be an important palliative, improving cardiac output and tissue oxidation, and should be undertaken as soon as possible before irreversible cellular damage has occurred.     

慢性重型肝炎患者的酸碱平衡特点分析

目的探讨慢性重型肝炎患者血气特点及可能原因。方法用微量血气分析仪测定慢性重型肝炎126例患者动脉血气参数,用静脉血同步测定血钾、血钠、血氯和血尿素氮、血肌酐。先用Kassirer公式初步判断单纯或混合酸碱失衡（ABD）,再按各型酸碱失衡预计代偿公式计算,同时计算阴离子隙（AG）值和潜在碳酸氢根（PB）,判断多重酸碱失衡。结果126例次血气分析中,发生酸碱失衡115例次（91．3％）。其中呼吸性碱中毒合并代谢性碱中毒发生率最高,占31．7％;其次为呼碱合并代酸（25．4％）及单纯呼碱（22．2％）。三重酸碱失衡也以呼碱型TABD为主。肝硬化基础慢重肝与慢性肝炎基础慢重肝患者发生单纯酸碱失衡分别为31．4％、22．5％,发生多重酸碱失衡为65．1％、57．5％,两者相比,无显著性差异。本组共发生低氧血症34例次,占27．0％。pH〈7．35的患者均出现在死亡组。结论慢性重型肝炎患者的酸碱失衡以碱血症为主,呼吸性碱中毒为基本酸碱失衡类型。酸碱失衡与发生慢重肝的基础病变无关。慢重肝患者较易出现轻度低氧血症。血pH值降低是慢重肝死亡的重要因素。     

Renal tubular acidosis during therapy for diabetic ketoacidosis.

A young woman presented with typical diabetic ketoacidosis. Five hours after insulin had been given hyperchloremic metabolic acidosis developed. This could not be attributed to gastrointestinal loss of bacarbonate, ingestion of HCI or carbonic anhydrase inhibitor, or the administered fluids and electrolytes. The combination of hyperchloremic metabolic acidosis and a urine pH of 5.6 during acidemia prompted specific studies that established the presence of disorders of renal acidification. A transient defect of hydrogen ion secretion in the distal nephron was suggested by the decrease in urine-blood Pco-2 gradient after administration of sodium bicarbonate. Proximal renal tubular acidosis was indicated by the reduced bicarbonate threshold that persisted for approximately 7 weeks.     

慢性阻塞性肺疾病呼吸衰竭并发低钠

目的：探讨慢性阻塞性肺疾病合并呼吸衰竭患者并发低钠血症的影响因素,寻找最佳的防治措施。方法：回顾性分析2010-2013年本院收治的106例慢性阻塞性肺疾病呼吸衰竭并发低钠血症患者,通过分析临床资料,找出低钠血症发生的原因及有效的治疗方案。结果：106例患者除原发疾病外,有85例伴随不同程度的精神症状和体征,全部患者的血钠平均水平为（119.77±6.53）mmol/L,伴有代偿性呼吸性酸中毒的患者18例,伴有失代偿性呼吸性酸中毒的患者52例,呼吸性酸中毒合并代谢性碱中毒17例,呼吸性酸中毒合并代谢性酸中毒14例。在综合治疗的基础上补钠,纠正电解质紊乱,治疗后患者痊愈77例,好转26例,病情恶化死亡3例。死亡的3例患者中,2例死于多器官衰竭,1例死于重度低钠血症。结论：慢性阻塞性肺疾病呼吸衰竭的患者并发低钠血症的发生率较高,临床医生需要仔细观察患者表现,做到早期发现、明确诊断、有效干预。     

198例尿毒症患者呼吸困难常见病因分析

目的：探讨尿毒症患者呼吸困难常见病因,以指导抢救及预防措施。方法对住院的198例尿毒症出现呼吸困难患者的临床资料进行回顾性分析。结果198例均予加强血液透析3次/周,同时结合其他内科治疗,196例好转,2例死亡。结论尿毒症患者呼吸困难常见原因为急性左心衰、重度代谢性酸中毒、急性左心衰合并重度代谢性酸中毒及大量胸腔积液等,其危险因素可能为血液透析不充分、高血压控制不佳、贫血、代谢性酸中毒、感染等。     

Fatal xylenol self-poisoning

A case of fatal xylenol ingestion by a long-stay mental hospital patient is described. The clinical course was similar to that observed in other phenolic poisonings with active bowel sounds, nausea and vomiting, severe metabolic acidosis, hypotension and cardiac and renal failure. The formulation of xylenol ingested contains alcohol which would facilitate absorption; due to the dangers of such poisonings care must be exercised as to access and exposure to xylenol sterilising agents.     

肺心病人临终前酸碱失衡及死亡原因的探讨

本文分析了179例肺心病人临终前动脉血气、血电解质和死亡原因。结果表明:肺心病人在临终前的酸碱失衡是常见的。其中慢性呼吸性酸中毒最常见,其它依次为三重酸碱失衡、慢性呼吸性酸中毒并代谢性酸中毒和慢性呼吸性酸中毒并代谢性碱中毒。慢性呼吸性碱中毒、慢性呼吸性碱中毒并代谢性碱中毒和代谢性酸中毒是少见的。肺心病人死亡的主要原因是并发上消化道出血,其次为直接死于酸碱失衡,特别是三重酸碱失衡。     

Myocarditis complicating ethylene glycol poisoning in the absence of neurological features

The consequences of ethylene glycol intoxication are described in a 42 year old man who presented with a profound metabolic acidosis, cardiogenic shock and renal failure. The clinical and electrocardiographic findings suggested a myocarditis and this was confirmed by endomyocardial biopsy. The striking absence of neurological features in this patient delayed diagnosis, which was not suspected until calcium oxalate crystals were demonstrated at renal biopsy. Retrospective analysis of serum retained at his admission to hospital confirmed toxic levels of ethylene glycol. Following a period of intensive cardio-respiratory support and peritoneal dialysis he made a good recovery with cardiac and renal function returning to normal.     

急性脑卒中67例血气变化及酸碱平衡临床分析

为探讨急性脑卒中后血气及酸碱平衡变化.本文选择了经头颅CT证实的脑出血。蛛网膜下出血(SAH)及脑梗塞患者67侧,于发病后24—48小时进行血气分析.发现脑出血>30ml和出血破入脑室。SAH及大面积脑梗塞患者中60％为呼碱并代酸及呼碱型三重碱失衡(TADD),还发现混合性酸碱失衡死亡率比单纯性的和正常血气要高(P<0.05).生存组与死亡组PaCO_2和HCO_3值比较有显著性差异(P<0.05),提示酸碱失衡的严重程度同血管性病的性质和大小及预后有较大关系,PaCO_2降低程度与HCO_3值和死亡率呈正相关.     

An unusual cause of severe metabolic acidosis

A 50-year-old man was transferred to the intensive care unit with high anion gap metabolic acidosis. Investigations suggested a diagnosis of pyroglutamic acidaemia. Factors contributing to the acidosis were medications (paracetamol and flucloxacillin), sepsis and renal failure. The acidosis resolved with supportive therapy and withdrawal of the drugs. It is important to recognise this treatable aetiology of metabolic acidosis.     

Acetonitrile ingestion: delayed onset of cyanide poisoning due to concurrent ingestion of acetone

A fatal case of acetonitrile ingestion is reported. The patient presented having apparently taken an overdose but was well until around 24 hours after the supposed ingestion, when cardiovascular collapse and profound metabolic acidosis developed. Later investigation revealed that the patient had taken acetone and acetonitrile. Acetone is known to slow the metabolism of acetonitrile to cyanide, thereby delaying the appearance of toxicity.     

小儿烧伤并发惊厥的原因及防治

目的：探讨小儿烧伤并发惊厥的原因及防治。方法：回顾性分析42例发生惊厥的烧伤患儿临床资料。结果：1例死于惊厥,2例惊厥缓解后又因败血症导致多器官功能衰竭死亡,其余均治愈。结论：高热、休克、低钠血症、低钙血症、酸中毒等是小儿烧伤并发惊厥的主要原因,也是治疗的关键。     

Fatal renal haemorrhage following haemodialysis in a patient with obstructive uropathy.

A 22-year-old male with obstructive uropathy and renal failure was given pre-operative haemodialysis. He collapsed five hours later. Autopsy revealed massive intrarenal haemorrhage and rupture of a dilated superior calyx intraperitoneally. Anticoagulation employed during haemodialysis was probably responsible for this spontaneous renal haemorrhage and subsequent calyceal rupture.     

The mechanism of hypophosphatemia in acute heat stroke

Severe heat stroke may be associated with hypophosphatemia and hypocalcemia. Hypophosphatemia is generally observed within hours after onset, but hypocalcemia usually occurs on the second or third day, and after hypophosphatemia has undergone spontaneous correction. A young man displayed respiratory alkalosis during the course of severe heat stroke. The hypophosphatemia abated spontaneously as metabolic acidosis and acute renal failure supervened. Hypocalcemia became prominent and was more severe than that ascribable to uremia. Hypocalcemia was probably the result of calcium phosphate and calcium carbonate deposition in injured skeletal muscle.     

诱因及并存病对尿毒症酸碱失衡的影响

目的观察尿毒症患者的诱因及并存病对酸碱失衡的影响。方法同步检测153例住院尿毒症患者血气分析、电解质系列及肾功能。结果诱因及并存病在单纯代酸组、代酸呼酸组、代酸呼喊组、代酸代碱组四组中构成比为32．9％～100．0％。肺水肿、肺气肿及肺炎影响肺通气致呼酸，而心衰、急性支气管炎、发热等通气过度并呼碱，频繁呕吐或用速尿致低氯性代碱。结论有诱因及并存病者易致复合酸碱失衡。     

Delayed sudden death after ingestion of MCPP and ioxynil: an unusual presentation of hormonal weedkiller intoxication.

A patient who died in asystole less than 18 h after ingestion of ''Clovercide Extra'', a combination hormonal weedkiller containing ioxynil and 4-chloro-2-methyl phenoxypropionic acid, is described. Previous reports describe coma as an early event following ingestion of these herbicides. In contrast our patient, although showing other characteristic features, including metabolic acidosis, tachycardia, pupillary constriction and pyrexia, remained conscious until the terminal event. Absence of coma does not appear to be related to a more favourable outcome.