Implication of AV node blockers in patients with end-stage renal disease undergoing head and neck surgery; BRASH syndrome: a case report

Park, Ju Ik; Jung, Moon Sik; Lee, Hyunho; Kim, Hochang; Oh, Jimi

doi:10.1016/j.bjane.2021.04.031

Cited by 4 publications

(11 citation statements)

References 6 publications

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“…Furthermore, we explored the need to escalate treatment to include three specific aggressive interventions for BRASH syndrome, including temporary transcutaneous or transvenous pacing due to persistent bradyarrhythmias, emergent dialysis for electrolyte imbalances or fluid overload status, and adrenergic medications to maintain systemic perfusion. After an extensive literature search of all case reports from 2020 to the present, we identified 17 cases of documented BRASH syndrome that fulfilled all five components of the diagnosis, including known exposure to an AV-nodal blocking agent [8][9][10][11][12][13][14][15][16][17][18][19][20][21].…”

Section: Discussionmentioning

confidence: 99%

BRASH Syndrome: A Case Report and Literature Review

Imburgio¹,

Johal²,

Udongwo³

et al. 2022

JICOA

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BRASH syndrome is a newly coined diagnosis consisting of the clinical pentad of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia. It is a rare syndrome with just under 50 reported cases. This case report and literature review present a case of BRASH syndrome, refractory to pharmaceutical measures, and subsequent literature review to assess treatment decisions and overall outcomes. The consensus from the literature supports the use of advanced interventions in most cases, including transcutaneous or transvenous pacing, hemodialysis, and adrenergic support. The early recognition and initiation of treatment in this patient demographic are paramount to reducing possible multi-system organ damage and mortality. This case report and literature review aim to improve patient outcomes and help further elucidate a protocol for treating BRASH syndrome.

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Section: Discussionmentioning

confidence: 99%

BRASH Syndrome: A Case Report and Literature Review

Imburgio¹,

Johal²,

Udongwo³

et al. 2022

JICOA

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“…The vicious cycle of certain medications, hyperkalemia, and renal failure is the leading cause of this syndrome [ 1 , 2 , 5 , 13 ]. Hyperkalemia is driven by renal failure and may culminate in the buildup of certain AV node blockers (e.g., atenolol and nadolol).…”

Section: Discussionmentioning

confidence: 99%

“…The phenomenon is now known as the "BRASH phenomenon" or "BRASH syndrome" [1]. This novel, under-recognized clinical entity is epitomized by a clinical quintet of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) [1][2][3][4][5][6][7]. Although the incidence of BRASH syndrome is unknown, it is feasible for this uncommon manifestation to present in the emergency department due to the widespread use of atrioventricular (AV) nodal blockers for hypertension, chronic renal disease, and ischemic heart disease [2].…”

Section: Introductionmentioning

confidence: 99%

“…The existing literature available on BRASH syndrome has a great deal of variation in terms of clinical presentations, contributing variables, and therapy [ 3 , 5 , 6 ]. Although the incidence of each symptom is not well reported, preliminary symptoms may include generalized weakness or nonspecific symptoms like syncope and can manifest in a variety of ways, from coincidental bradycardia to multiorgan failure [ 5 ]. The prevalence of BRASH syndrome is greater than what has been documented in the medical literature.…”

Section: Introductionmentioning

confidence: 99%

“…Because IV calcium is not used in the advanced cardiac life support (ACLS) bradycardia protocol, BRASH syndrome is not properly treated. Thus, excessive transvenous pacing may result from naively following the ACLS bradycardia protocol without appropriate knowledge of the BRASH syndrome [ 4 , 5 ]. According to one PRISMA study, which included 34 articles comprised of one observational study, 18 case reports and series, and 15 conference abstracts revealed that patients' symptoms could not be relieved by atropine or glucagon; 59.5% needed inotropes or chronotropes instead, and 7.1% of people died due to BRASH syndrome [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

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A Case Report on BRASH (Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalaemia) Syndrome: A Challenging Diagnosis

Roy¹,

Rafa²,

Agrawal³

et al. 2022

Cureus

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A relatively new yet critical phenomenon of bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia (BRASH) syndrome is hypothesized to happen in patients who take atrioventricular nodal blocking (AVNB) agents and have underlying renal insufficiency. In our case, a 67-year-old female with an extensive medical history presented to the emergency room with chief complaints of decreased appetite, nausea, vomiting, fatigue, and left-sided atypical chest pain for the past two weeks. The patient was taking losartan potassium 50 mg daily in addition to carvedilol 6.25 mg twice daily for her hypertension (HTN) and heart failure with reduced ejection fraction (HFrEF) with the addition of bumetanide 0.5 mg, which was added three weeks prior. On presentation, the patient had sinus bradycardia and hypotension along with the laboratory finding of acute kidney injury (AKI) in the setting of chronic kidney disease (CKD) and hyperkalemia. Cardiology and nephrology were consulted emergently; her clinical scenario raised suspicion of the BRASH syndrome. The patient was admitted to the intensive care unit (ICU), and all antihypertensive medications, including beta-blockers, were stopped. Intravenous (IV) fluid resuscitation and medical management of hyperkalemia were initiated, along with BiPAP for respiratory distress. She responded significantly, and her vitals remained stable. She was successfully discharged home with a cardiology and nephrology follow-up. We highlight the case to emphasize the consideration of BRASH in a patient on multiple cardiac medications who presented with deranged electrolytes and organ failure, and decompensated heart failure (HF) should not be fixed on as the principal diagnosis.

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2022

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Implication of AV node blockers in patients with end-stage renal disease undergoing head and neck surgery; BRASH syndrome: a case report

Cited by 4 publications

References 6 publications

BRASH Syndrome: A Case Report and Literature Review

BRASH Syndrome: A Case Report and Literature Review

A Case Report on BRASH (Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalaemia) Syndrome: A Challenging Diagnosis

Multiple drugs

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