A 24-year-old male with no previous disease was admitted to the emergency department after ingestion of ibuprofen 85 g of metformin (100 1.2 tablets of metformin Pensa® 850 mg), plus amoxicillin 28/1.75 g
Upon arrival to the hospital he was conscious, hemodynamically stable, presenting mild acidosis (pH 7.35) with a lactate value of 24 mg/dl and renal function preserved with a creatinine of 1.33 mg/dl.
A few hours after admission, the patient presented psychomotor agitation and altered analytical parameters: glucose 35 mg/dl, creatinine 2.52 mg/dl, pH 6.96, lactate 180 mg/dl and oxygen saturation 60% mmol/l.
Cardiac enzymes are also increased: creatine kinase (CK) 319 U/l and myoglobin 408 ng/ml.
The determination of serum metformin level is 749.9 mcg/ml (toxic values: > 5 mcg/ml).
glucose levels in the patient's condition are determined to enter the intensive care unit (ICU) where 400 mEq of sodium bicarbonate, 250 ml of 0.9% sodium chloride, Gelafundin sodium hydroxide (geltin sodium hydroxide) is administered.
During the placement of a subclavian central line, she suddenly presents a cardiorespiratory arrest following cardiac massage and administration of vasoactive drugs (noradrenaline 4 mcg/kg).
Subsequently, the patient was intubated and connected to mechanical ventilation (SatO2 65%).
Creatinine level at this time is 3.3 mg/dl and the patient is in renal failure, due to what initiates a continuous venosus (HDFVC) 120 flow.
Despite successive bicarbonate loads performed, acidosis persists with pH 6.95, lactate >180 mg/dl, bicarbonate 8 mmol/L, and significant hypernatremia (sodium 168 mmol/L).
To try to correct the high levels of sodium, the Department of Hygiene was asked to prepare a dialysis fluid with lower sodium intake than those presented by the marketed preparations (Dialisan®).
The result of the intervention allows maintaining sodium levels within the normal range (143 mmol/l).
A routine temperature measurement detected hypothermia of 35oC.
From the second day of admission to the ICU, the patient showed progressive improvement of laboratory tests with correction of acidosis (pH 7.37, lactate 79 mg/dl, bicarbonate 25 mmol/L).
Treatment with CVVHDF and bicarbonate administration proved to be effective, although renal failure persists.
In addition, there was a significant worsening of cardiac enzymes (CK 22,236 U/l, myoglobin 16,908 ng/ml and troponin T 2,08 ng/ml), and pericardial and pleural effusion was observed in the echocardiogram.
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On the fourth day after ICU admission, during an extubation maneuver for endotracheal tube obstruction, the patient experienced abundant vomiting and an episode of bronchoaspiration.
As a consequence, the patient suffers bradycardia, therefore, 1 mg of atropine, 9 mg of bicarbonate, 100 mEq of bicarbonate, extreme glyconate, norepinephrine is administered at high doses and volume overload.
Cardiac massage was performed and pulse recovered 4 minutes later, with neurological, hemodynamic and respiratory impairment.
A few hours later the patient suddenly presented widening of the QRS segment without response to cardiopulmonary resuscitation, with exitus appearing.
