We report the case of an 18-year-old male admitted to the Intensive Care Unit in Basingstoke and North Hampshire Hospital, who developed chronic kidney disease following the ingestion of smoke machine fluid. Smoke machine fluid may contain ethylene glycol, and a diagnosis of ethylene glycol toxicity with calcium oxalate nephropathy was made. This case resulted in a National Poisons Information Service internal review of the subject and a new TOXBASE entry for smoke machine fluid ingestion. KeywordsRenal failure, ethylene glycol, propylene glycol, smoke machine, haemofiltration CaseWe report the case of an 18-year-old male presenting to the Emergency Department with vomiting and anuria following reported ingestion of 3 l of a fluid used in a smoke machine 35 h previously. The patient had mild learning difficulties and reported ingesting the liquid due to intrigue with no self-harm intent. He complained of nausea, vomiting and mild abdominal and back pain. He had been anuric for over 24 h.Blood results taken on admission showed a raised urea (6.1 mmol/l) and creatinine (176 mmol/l) with a normal full blood count and liver function tests on a background of a normal renal function. A venous blood gas showed a metabolic acidosis with a pH of 7.21, HCO À 3 15.3 mmol/l, BE 11.7 mmol/l, lactate 1.8 mmol/ l. An anion gap was calculated at 17.3 mEq/l (normal range: 3-11 mEq/l) and an osmolar gap was calculated at 4 mOsm/kg (normal range: <10 mOsm/kg). A diagnosis was made of acute kidney injury, possibly consistent with the metabolism of glycol products.The case was discussed with a toxicology consultant at the National Poisons Information Service (NPIS) who advised intravenous hydration and hemofiltration if renal function deteriorated. Fomepizole was not recommended by the NPIS and ethylene glycol levels were not measured.The metabolic acidosis continued to be static; however, the patient remained anuric and renal function continued to worsen.The patient was admitted to the intensive care unit (ICU) and Continuous Veno-Veno Haemofiltration with heparin anticoagulation was commenced. Liver function tests showed raised transaminases (ALT 278 u/l) and a raised amylase (685 u/l); coagulation tests remained normal. Following normalisation of transaminases citrate anticoagulation was commenced. He also developed hypertension (170/90 mmHg) requiring amlodipine and bisoprolol.A total of eight days of renal replacement therapy were required on ICU during which time he remained anuric before he was transferred to the regional renal unit. He remained on the regional renal unit for 20 days. His urine output recovered but further haemodialysis was required via a tunnelled RIJ central line. On day 14, he developed abdominal pain, which was traced to a 3-mm right mid-pole renal calculus, with a raised urinary oxalate. An episode of abdominal sepsis was treated with meropenem and vancomycin and resolved with no positive microbiology.
BackgroundSimulation can provide safe, realistic learning environments for repeated practice, underpinned by feedback and objective metrics of performance.1 Technical skills are often the main focus of simulation sessions whilst non-technical skills e.g. communication with patients/relatives and other team members are often neglected. Non-technical skills are essential for providing good safe medical practice.2,3 The UK Foundation Programme Curriculum4 provides information and guidance for newly qualified doctors and those involved in their education: This combines traditional medical training elements with communication and consultation skills, patient safety and teamwork.Several pieces of research have shown the importance of training as part of a multi disciplinary team. Falcone et al . stated,6 “Training of a multidisciplinary team in the care of paediatric trauma patients can be enhanced and evaluated through the use of high-fidelity simulation. Improvements in team performance using innovative technology can translate into more efficient care with fewer errors.” Therefore we recognise the importance of inter professional multi disciplinary training in acute medicine.We propose to set up a realistic learning environment for multi disciplinary professionals including the use of multi-modal, hybrid simulation using both actors and mannequins. These simulation sessions will target technical and non-technical skills encompassing patients and other team members as well as traditional mannequin training.Methodology30 FY1 doctors, Nurses, Health Care Support Workers and Paramedics will attend a simulation session in July 2015. Eight sessions will be held in the Winchester Simulation Suite set up as Resuscitation Area of an Emergency Department (ED).To facilitate a realistic learning environment, these sessions will combine ‘multi-modal’ and ‘hybrid’ components. Initial assessment and management will be done on a ‘human’ patient played by an actor. At a given point in the scenario the patient will have a cardiac arrest at which a traditional mannequin will be used. The simulation scenario will be ‘hybrid’ combining the cardiac arrest medical management and non-technical skills including communication (during and post resuscitation) with “relatives” of the patient.ResultsResults will be taken from pre and post questionnaires and feedback sessions. Perceived confidence and skills levels will be recorded and analysed. Themes emerging from the feedback sessions and a free text box will be analysed.Potential impactWe are evaluating hybrid simulation for its potential as a training tool for junior doctors and non-medical professionals. We hope technical and non-technical skill levels will increase post sessions, thus improving medical practice, team working and patient safety.ReferencesKneebone R. Simulation in surgical training: Educational issues and practical implications. Med Educ 2003;37Stroud L, Cavalcanti B. Hybrid simulation in knee arthocentesis: improving fidelity in procedure training. J Gen Intern Med 2013;28R...
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