Despite variations in sodium and water concentrations, our body relies on several mechanisms to maintain the plasmatic osmolality within the normal range of 275-290 mOsm/L 1 . Hyponatremia is defined as a reduction in plasma sodium concentration below 136 mmol/L 2 . It occurs in 12% of the hospitalized patients and in 30% of the patients in the intensive care unit (ICU) 3 . Hyponatremia installed progressively usually causes no symptoms. If installed acutely, severe symptoms such as vomiting, progressive somnolence and confusion, coma and seizures often occur 2,4 . Hyponatremia related to the ingestion of free water is uncommon in healthy subjects that are neither athlete nor have psychiatric disorders [2][3][4][5] . Thus, after approval of the Hospital Ethics Committee and signed informed consent obtained from a patient representative.We report a case of hyponatremia associated with fast ingestion of large amounts of potable water causing severe neurological impairment. CaSeA 34-year-old male, previously healthy, was admitted in ICU of the Hospital da Cidade (Salvador BA, Brazil). The patient was transferred from the emergency department with a history of ingestion of 40 glasses of potable water, equivalent to approximately 8 liters, during a period of a few hours. The patient was playing domino and the players bet that one who loses a game should drink a full glass of water. The unlucky patient lost one game after the other and started to become sleepy, culminating with a generalized tonic-clonic seizure. Taken to the hospital, he developed new episode of seizure, lingered, requiring intubation and mechanical ventilation. The admission tests revealed plasma sodium of 123 mmol/L and mild cerebral edema at CT scan. The diagnosis of hypovolemic hyposmolar hyponatremia with low urinary osmolality ("the marathon runner's hyponatremia") was made based on plasmatic osmolality (262 mmol/L), urinary osmolality, urinary sodium (undetectable) and the volemic status was estimated by pre-load pressures. Since the installation of hyponatremia was rapid with severe symptoms, 3% saline solution was started with infusion rate of 0.5 mL/kg/h. Plasma sodium was measured hourly, aiming for an elevation of sodium level by 0.5 mEq/L/hour. After discontinuing sedation he gradually recovered, being disconnected from mechanical ventilation in the third day of hospitalization. He was discharged from ICU after five days without any neurological deficit. diSCuSSionThe initial approach to hyponatremia requires determination of plasmatic osmolality , in order to classify the hyponatremia in hypertonic, isotonic or hypotonic. The determination of osmolar gap -difference between measured and calculated osmolality, normal <10 mOsm/kg -helps with the interpretation and suggests which solutions should be utilized in the treatment 6 . Hypertonic hyponatremia is typically observed during hyperglycemia or after mannitol use and is also known as translocational hyponatremia. Isotonic hyponatremia is diagnosed in settings of severe hypertriglyceri...
Snakebites are common and lead to potential complications like neuromyopathies and strokes, these last associated with disturbances of blood coagulation. We report on a 65 years old woman of cerebral intraparenchymal hemorrhage associated with snakebite by a Bothrops jararaca that occurred in the Reconcavo of Bahia, BA, Brazil. The patient was submitted to a surgical evacuation of the hematoma, with a good result. This report is accompanied by a revision about the association among snakebite and neurological complications, emphasizing strokes. Statistics reveal a high incidence of snakebite in the world, mainly in tropical countries and gets attention for his socioeconomic impact. The clinical and laboratory characteristics to identify the victims that present a high risk of presenting strokes are discussed in order to identify early those patients, so that they may be treated in a more precocious and effective way.
During the Coronavirus-19, or COVID-19, pandemic there was an early shortage of available ventilators. Domestic production was limited by dependence on overseas sources of raw materials despite partnering with automotive manufacturers. Our group has developed a 3D printed alternative called the CRISIS ventilator. Its design is similar to existing resuscitator devices on the market and uses a modified Pressure-Control ventilation. Here we compare the performance of the device on a simulated ARDS lung and handling of different clinical scenarios included tension pneumothorax and bronchospasm.
The coronavirus disease of 2019 (COVID-19) has altered medical practice around the globe and revealed critical deficiencies in hospital supply chains ranging from adequate personal protective equipment to life-sustaining ventilators for critically ill hospitalized patients. We developed the CRISIS ventilator, a gas-powered resuscitator that functions without electricity, and which can be manufactured using hobby-level three-dimensional (3D) printers and standard off-the-shelf equipment available at the local hardware store. CRISIS ventilators were printed and used to ventilate sedated female Yorkshire pigs over 24-h. Pulmonary and hemodynamic values were recorded throughout the 24-h run, and serial arterial blood samples were obtained to assess ventilation and oxygenation. Lung tissue was obtained from each pig to evaluate for signs of inflammatory stress. All five female Yorkshire pigs survived the 24-h study period without suffering from hypoxemia, hypercarbia, or severe hypotension requiring intervention. One animal required rescue at the beginning of the experiment with a traditional ventilator due to leakage around a defective tracheostomy balloon. The wet/dry ratio was 6.74 ± 0.19 compared to historical controls of 7.1 ± 4.2 (not significantly different). This proof-of-concept study demonstrates that our 3D-printed CRISIS ventilator can ventilate and oxygenate a porcine model over the course of 24-h with stable pulmonary and hemodynamic function with similar levels of ventilation-related inflammation when compared with a previous control porcine model. Our work suggests that virtual stockpiling with just-in-time 3D-printed equipment, like the CRISIS ventilator, can temporize shortages of critical infrastructure needed to sustain life for hospitalized patients.
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