Phar2 Assignment

8/22/2019 Phar2 Assignment

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Isotonic solution: A solution that has the same salt concentration as cells and blood. Isotonic

solutions are commonly used as intravenously infused fluids in hospitalized patients.

: A solution having the same osmotic pressure as blood

Osmotic Pressure: A hydrostatic pressure caused by a difference in the amountsofsolutesbetween solutions that are separated by a semi-permeable membrane.

: The pressure exerted by a solution necessary to prevent osmosis into that

solution when it is separated from the pure solvent by a semi permeable membrane

5 BRANDS

1. ELIN POTASSIUM CHLORIDE2. ORALITE3. KDUR4. HYDRITE5. GLUCOLYTE SOLUTION

2 CASES: ELECTROLYTE IMBALANCE

Case Reports

Texas.In February 2005, a girl aged 2 years who was tested for blood lead during routine health

surveillance had a capillary BLL of 47g/dL. A venous BLL of 48g/dL obtained 12 days later

confirmed the elevated BLL. A complete blood count and iron study conducted concurrentlyrevealed low serum iron levels and borderline anemia. On February 28, 2005, the girl was

admitted to a local medical center for combined oral and IV chelation therapy.

The patient's blood electrolytes at admission were within normal limits. Initial medication orders

included IV Na2EDTA and oral succimer (an agent primarily used for treatment of lead

poisoning). The medication order subsequently was corrected by the pediatric resident to IVCaEDTA. At 4:00 p.m. on the day of admission, the patient received her first dose of IV

CaEDTA (300 mg in 100 mL normal saline at 25 mL/hr). At 4:35 p.m., she was administered

200 mg of oral succimer. Her vital signs remained normal throughout the night. At 4:00 a.m. the

next day, a dose of IV Na2EDTA (instead of IV CaEDTA) was administered. An hour later, the

patient's serum calcium had decreased to 5.2 mg/dL (normal value for pediatric patients: 8.5--10.5 mg/dL). At 7:05 a.m., the child's mother noticed that the child was limp and not breathing.

Bedside procedures did not restore a normal cardiac rhythm, and a cardiac resuscitation code wascalled at 7:25 a.m. The child had no palpable pulse or audible heartbeat. Repeat laboratory values

for serum drawn at 7:55 a.m. indicated that the serum calcium level was


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An autopsy revealed no results of toxicologic significance. A postmortem radiologic bone survey

indicated areas of sclerosis at the metaphyses (growth arrest and recovery lines compatible with

lead exposure). The cause of death was recorded as sudden cardiac arrest resulting fromhypocalcemia associated with chelation therapy. The hospital's child mortality review board

findings indicated that a dose of IV Na2EDTA was unintentionally administered to the child.

Pennsylvania. In August 2005, a boy aged 5 years with autism died while receiving IV chelation

therapy with Na2EDTA in a physician's office.During the chelation procedure, the mother noted

that the child was limp. The physician initiated resuscitation, and an emergency services teamtransported the child to the hospital. At the emergency department (ED), further resuscitation

was attempted, including administration of at least 1 and possibly 2 doses of IV calcium

chloride. Subsequently, the boy's blood calcium level was recorded in the ED as 6.9 mg/dL. The

child did not regain consciousness. The coroner examination indicated cause of death as diffuse,acute cerebral hypoxic-ischemic injury, secondary to diffuse subendocardial necrosis. The

myocardial necrosis resulted from hypocalcemia associated with administration of Na2EDTA.

The case is under investigation by the Pennsylvania State Board of Medicine.

Oregon. In August 2003, a woman aged 53 years with no evidence of coronary artery disease,

intracranial disease, or injury was treated with 700 mg IV EDTA in a naturopathic practitioner'sclinic. The EDTA was provided by a compounding laboratory (Creative Compounding,

Wilsonville, Oregon) and was administered by the practitioner to remove heavy metals from the

body. The practitioner had provided a similar treatment to the patient on three previous

occasions, once in June 2003 and twice in July 2003. Approximately 10--15 minutes aftertreatment began, the patient became unconscious. Cardiopulmonary resuscitation was initiated,

and an emergency services team was contacted. Attempts to revive the patient en route to and in

the ED were unsuccessful. The medical examiner determined the cause of death to be cardiacarrhythmia resulting from hypocalcemia associated with EDTA infusion and vascuolar

cardiomyopathy. The patient's ionized calcium level during code was 3.8 mg/dL (normal value

for adult patients: 4.5--5.3 mg/dL) after one IV injection of calcium gluconate administered by

emergency medical technicians en route to the hospital and another IV injection of calciumchloride in the ED. The Oregon State Naturopath Licensing Board is conducting an investigation

to determine whether Na2EDTA or CaEDTA was administered to this patient.

The cases described in this report have been reported to FDA. FDA is performing a safety

assessment of Na2EDTA, including a review of the adverse event reporting system to determine

whether other deaths related to use of chelating agents have been reported.

Reported by: RA Beauchamp, MD, TM Willis, TG Betz, MD, J Villanacci, PhD, Texas Dept of

State Health Svcs. RD Leiker, Oregon Childhood Lead Poisoning Prevention Program. L Rozin,MD, Allegheny County, Pennsylvania Office of the Coroner. MJ Brown, ScD, DM Homa, PhD,

TA Dignam, MPH, T Morta, Div of Emergency and Environmental Health Svcs, National Center

for Environmental Health, CDC.

LINK:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5508a3.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5508a3.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5508a3.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5508a3.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5508a3.htm


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2 CASES: ELECTROLYTE ADMINISTRATION

The patient was a 20-day-old Spanish male infant with a body weight of 2.5 kg, transferred from

the neonatal unit on the ninth day after the surgical correction of Fallot's tetralogy and pulmonary

atresia. On admission to the pediatric intensive care unit, the infant required mechanicalventilation, an infusion of vasoactive drugs (dopamine 6 mcg/kg/minute, dobutamine 10

mcg/kg/minute and milrinone 0.5 mcg/kg/minute) and furosemide in a continuous infusion of 0.4

mg/kg/hour. The patient had received treatment with vancomycin and amikacin up to 2 days

earlier. On examination, there was marked generalized edema. The initial blood tests revealed acreatinine level of 0.5 mg/dL, urea 75 mg/dL, albumin 2.8 g/dL, sodium 132 mmol/L, potassium4.6 mmol/L and chloride 96 mmol/L. In order to decrease the doses of intravenous vasoactive

drugs, it was decided to administer digitalis to the patient, prescribing a dose of digoxin of 10mcg/kg enterally. Four hours after the administration of the drug, the child presented with

progressive oliguria, with a fall in diuresis from 4 to 1.5 mL/kg/hour, and with no change in the

hemodynamic situation (blood pressure 65/40 mmHg, lactate 1.1 mmol/L, heart rate 140 bpm).

Blood tests revealed a rise in creatinine to 0.7 mg/dL and in urea to 89 mg/dL and a fall insodium to 121 mmol/L. There were no neurological clinical symptoms or alterations in the

cerebral echography that suggested cerebral edema. The urinalysis was normal. Initially, to

exclude hypovolemia, volume expansion was performed with 5% albumin (20 mL/kg).

Intravenous sodium replacement was started according to the equation (135 - 121) 0.6 weight (kg) in 24 hours and the dose of dopamine was increased from 7.5 to 15 mcg/kg/minute

in order to raise the mean blood pressure and improve renal perfusion. Subsequently, on

persistence of the oliguria, the infusion of furosemide was increased from 0.4 to 1 mg/kg/hour,though no improvement in the diuresis was achieved. The medication chart was reviewed and the

error was detected. Instead of digoxin, indomethacin had been prescribed at a dose of 25 mg (10

mg/kg), which is 50 to 100 times higher than the therapeutic dose.

Initially, it was decided to maintain a conservative approach. The child remained

hemodynamically stable but presented with anuria and an increase in edema; continuousvenovenous hemofiltration was therefore started after 12 hours. This therapy was continued for

33 hours, with a negative balance of 25 mL/hour, after which diuresis and renal function

recovered (Table1). The subsequent course was favorable and the infant was discharged fromthe pediatric intensive care unit with a creatinine level of 0.2 mg/dL, urea 15 mg/dL and normal

diuresis. No alteration of renal function has been detected on subsequent follow-up.

LINK:http://www.jmedicalcasereports.com/content/3/1/47

Case 1

A 4-year-old child who weighed about 15 kg underwent tonsillectomy as day surgery. No

abnormalities were noted during a preadmission assessment the day before the surgery. The

tonsillectomy was performed under general anesthesia, and the child was mechanically ventilated

during the procedure. The child received a total of 250 mL of normal saline IV (0.9% sodium

chloride). After the procedure, an infusion of 3.3% dextrose and 0.3% sodium chloride solution

(referred to herein as 2/3 and 1/3)*was ordered for IV administration at 55 mL per hour. Oral
http://www.jmedicalcasereports.com/content/3/1/47/table/T1http://www.jmedicalcasereports.com/content/3/1/47/table/T1http://www.jmedicalcasereports.com/content/3/1/47/table/T1http://www.jmedicalcasereports.com/content/3/1/47http://www.jmedicalcasereports.com/content/3/1/47http://www.jmedicalcasereports.com/content/3/1/47http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/#fn1-cjhp-62-512http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/#fn1-cjhp-62-512http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/#fn1-cjhp-62-512http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/#fn1-cjhp-62-512http://www.jmedicalcasereports.com/content/3/1/47http://www.jmedicalcasereports.com/content/3/1/47/table/T1


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intake of fluids was also encouraged. The child was transferred to a patient care area with orders

to be discharged home when drinking well.

Shortly after arriving in the patient care area, the child experienced several episodes of vomiting.

Oral intake of clear fluids over the next several hours was about 200 mL. The child was kept in

hospital, and the IV administration of 2/3 and 1/3 was continued as originally ordered over therest of the day and night. The child voided several times, but the amount was unknown.

Overnight, the child became incontinent and was noted to be drowsy. Toward the next morning,

the child had several seizures, which were treated initially with lorazepam and later with

phenobarbital. Blood testing indicated a sodium level below 120 mmol/L. The IV solution was

changed to sodium chloride 3%, and the child was transferred to a regional pediatric centre. The

child died shortly thereafter. The cause of death was severe cerebral edema with brain herniation

due to acute hyponatremia.

Case 2

A previously healthy 3-year-old child was brought to an emergency department with a 1-day

history of vomiting and diarrhea. The childs pulse was more than 125 beats per minute; blood

pressure was 85/60 mm Hg. The childs mucosal membranes were dry and the eyes sunken.

Laboratory testing indicated normal serum electrolytes, elevated blood urea nitrogen (BUN), and

normal creatinine; a urine test was positive for ketones. In the emergency department, the child

received 2 boluses of normal saline by IV administration, totalling about 450 mL. Follow-up

blood work revealed that the sodium level was 138 mmol/L and BUN had decreased to within

normal limits. The child was admitted, and 2/3 and 1/3 was administered at 130 mL per hour

IV. Over the course of the next 12 hours (through the evening and overnight), the child voided

about 110 mL urine in total and received over 1.5 litres of 2/3 and 1/3. The childs nauseacontinued.

The next day, the child voided once, but the amount was not determined or recorded. Shortly

thereafter, the child experienced incontinence of urine and seemed to be sleepy. A few hours

later, the child appeared lethargic and rigid. The infusion was stopped, and blood tests revealed a

sodium level below 120 mmol/L and lower-than-normal levels of potassium, BUN, and

creatinine. The child experienced a seizure and was treated with lorazepam. Hypertonic saline

was ordered, but none was available, so mannitol was administered IV, followed by a bolus of

normal saline. Because of continued seizure activity and oxygen desaturation, the child was

intubated and ventilated. Shortly thereafter, the child experienced cardiac arrest and could not beresuscitated. The cause of death was cerebral edema due to acute hyponatremia.

LINK:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827014/


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Energy drinks are not considered as electrolyte replenisher because the amount of electrolytes in

it is lesser than that of the required amount or concentration of electrolyte in an electrolyte

replenisher.

Phar2 Assignment

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