Prolonged Hemodialysis for Severe Metformin Intoxication

Rifkin, Stephen I.; McFarren, Christopher; Juvvadi, R.; Weinstein, Stefanie

doi:10.3109/0886022x.2011.568132

Cited by 24 publications

(20 citation statements)

References 17 publications

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“…An acute overdose of metformin can cause a severe lactic acidosis [48][49][50][51]. In such cases, a depressed level of consciousness may occur following several hours of lucidity, although typically it is in the setting of cardiovascular instability [47,[52][53][54][55][56]. Hypothermia, as observed in our patient, has also been well described in acute metformin overdoses [47,54,[57][58][59][60].…”

Section: Could This Be Metformin-associated Lactic Acidosis?supporting

confidence: 57%

Case Files from the University of California San Diego Health System Fellowship Coma and Severe Acidosis: Remember to Consider Acetaminophen

Villano

O'Connell

et al. 2015

J. Med. Toxicol.

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A 28-year-old man was brought to the Emergency Department (ED) for evaluation of a depressed level of consciousness that developed while in jail. Sixteen hours previously, he had been arrested on charges of murder. The patient's mental status was reported as normal at the time of arrest, and it had remained so during several hours of interrogation and during the booking process at jail. Following interrogation, the patient was placed into a cell with no other inmates. During the jail intake process, the patient had not reported any history of medical problems nor was he prescribed with any medications. Paramedics arrived to find him unresponsive, but maintaining airway reflexes and hemodynamically stable. They measured a blood glucose of 300 mg/dL and noted one episode of blood-tinged emesis during transport to the ED. No seizure activity was witnessed.On arrival to the ED, vital signs were: heart rate 132/min, blood pressure 129/74 mmHg, temperature 35.3°C (95.5°F), respiratory rate 24/min, and 100 % oxygen saturation on 15 l/ min of oxygen delivered by non-rebreather face mask.Physical examination was notable for a depressed level of consciousness. His eyes remained closed to pain, he withdrew all extremities equally to pain, and he was non-verbal. He had no signs of trauma, and his pupils were normal in size and reactive. Rapid sequence tracheal intubation was performed for airway protection. An electrocardiogram was normal except for sinus tachycardia at a rate of 111/min. An initial peripherally drawn arterial blood gas obtained immediately after intubation revealed: pH 6.97, pCO 2 40 mmHg, pO 2 215 mmHg. A computed tomography scan of the brain was normal. Initial blood chemistry panel was significant for a serum bicarbonate of 7 mEq/L, glucose of 362 mg/dL, and a normal potassium, blood urea nitrogen (BUN), creatinine, and calcium. The initial serum anion gap was 34 mEq/L. Measured serum osmolality was 320 mOsm/kg, yielding an osmol gap of 9 mOsm/kg (using formula of [2(Na)+BUN/2.8+glu-cose/18] for calculated serum osmolarity). Initial lactate was 156.5 mg/dL (normal reference range 4.5-19.8 mg/dL) and beta-hydroxybutyrate (βHB) 2.9 mg/dL (normal reference range 0.0-2.8 mg/dL). Initial liver panel included an aspartate aminotransferase (AST) of 64 U/L, alanine aminotransferase (ALT) of 27 U/L, and bilirubin of 0.4 mg/dL. Prothrombin time was 13.1 s (reference range 9.7-12.5), and lipase was normal at 25 U/L. Initial creatinine phosphokinase (CK) was slightly elevated at 373 U/L (0-175). Urinalysis was positive for small ketones and crystals were not present. Measurements of acetone and acetoacetate were not performed. Serum ethanol and salicylate levels were undetectable, and a urine drug of abuse panel by immunoassay was negative for amphetamines as a class, barbiturates as a class, benzodiazepines as a class, benzoylecgonine (cocaine metabolite), methadone, opiates as class, oxycodone, phencyclidine, and tetrahydrocannabinoids. Iron concentration was normal at 87 mcg/dL.Over the first hour of management,...

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Section: Could This Be Metformin-associated Lactic Acidosis?supporting

confidence: 57%

Case Files from the University of California San Diego Health System Fellowship Coma and Severe Acidosis: Remember to Consider Acetaminophen

Villano

O'Connell

et al. 2015

J. Med. Toxicol.

View full text Add to dashboard Cite

show abstract

“…Fortunately, the [31]. Bicarbonate therapy alone may not be sufficient to restore the acid-base derangement from lactic acidosis and multi-organ compromise [32].…”

Section: How Does Metformin Lead To the Development Of Lactic Acidosimentioning

confidence: 99%

Metformin-Associated Lactic Acidosis (MALA): Case Files of the Einstein Medical Center Medical Toxicology Fellowship

Kopec

Kowalski

2012

J. Med. Toxicol.

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A 39-year-old man presented to the emergency department after intentionally ingesting 50 tablets of metformin 1,000 mg. The reported time of ingestion was 6 h prior to arrival. Vital signs were: temperature, 37.4°C; pulse, 94 beats per minute; blood pressure, 117/74 mmHg; respirations, 16/min; and oxygen saturation, 96 % on room air. Gastric lavage was performed, and a single dose of activated charcoal was given. His initial serum lactate was 4.3 mmol/L (normal00.67-1.8 mmol/L). The patient had a negative urine drug screen, and acetaminophen and salicylate levels were below detection limits. The patient was admitted for monitoring of lactic acidosis.Twenty hours after arrival, the patient became hypotensive with a blood pressure of 85/45 mmHg. Arterial blood gas analysis revealed a pH of 7.20, pCO 2 19 mmHg, and bicarbonate HCO 3 of 6 mmol/L. A repeat serum lactate at this time was 20 mmol/L, and a basic metabolic panel showed sodium of 134 mmol/L, potassium 3.8 mmol/L, chloride 98 mmol/L, bicarbonate 16 mmol/L, BUN 32 mg/ dL, and creatinine 1.3 mg/dL; the calculated anion gap was 20 mmol/L. A 1-L normal saline bolus was administered, and serum alkalinization was initiated with a sodium bicarbonate drip.

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“…La observación más dramática en este caso fue la presencia de una hiperpotasemia extrema de 15,4 mEq/L, acompañada de bradiarritmia severa que requirió del uso de una sonda marcapasos transitoria, administración de glucosa hipertónica y rápida corrección de la acidosis metabólica con bicarbonato intravenoso e inicio de HDFVVC 12,14,20,21 . La hiperpotasemia es una condición potencialmente fatal, definida por un nivel sérico de K > 5,5 mEq/L, mientras que niveles sobre 7 mEq/L representan hiperpotasemia severa 22 .…”

Section: Discussionunclassified

“…Por otra parte, aunque algunos estudios muestran que el uso de metformina no estaría asociada a la generación de acidosis láctica [9][10][11] , se ha demostrado que es una complicación de baja incidencia pero elevada mortalidad [12][13][14][15][16][17] . Los factores predisponentes incluyen la insuficiencia renal y hepática, el alcoholismo y las patologías asociadas con hipoxia (insuficiencia cardiaca, enfermedad pulmonar, cirugía), la edad .…”

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Hiperpotasemia extrema no fatal en un caso de acidosis láctica por sobreingesta de metformina

2015

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Prolonged Hemodialysis for Severe Metformin Intoxication

Cited by 24 publications

References 17 publications

Case Files from the University of California San Diego Health System Fellowship Coma and Severe Acidosis: Remember to Consider Acetaminophen

Case Files from the University of California San Diego Health System Fellowship Coma and Severe Acidosis: Remember to Consider Acetaminophen

Metformin-Associated Lactic Acidosis (MALA): Case Files of the Einstein Medical Center Medical Toxicology Fellowship

Hiperpotasemia extrema no fatal en un caso de acidosis láctica por sobreingesta de metformina

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