Life‐threatening pulmonary hypertension and right ventricular failure complicating calcium and phosphate replacement in the intensive care unit

Felton, Tim; McCormick, B. A.; Finfer, Simon; Fisher, M. McD.

doi:10.1111/j.1365-2044.2005.04381.x

Cited by 11 publications

(10 citation statements)

References 21 publications

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“…A pumpless "lung assist" device has been used in patients bridging to transplant [344]. Extracorporeal membrane oxygenation (ECMO) has been used in severe PH [345-348], as a bridge to transplant [349,350], and after endarterectomy [351] or massive PE [352-355]. Intraaortic balloon counterpulsation (IABP) has been used for RV failure after CPB [356] and transplantation [357], thought to improve CO by augmenting left coronary flow rather than by direct RV effects [358].…”

Section: Resultsmentioning

confidence: 99%

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

et al. 2010

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IntroductionPulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care.MethodsA systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method.ResultsClinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy.ConclusionsThis systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.

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Section: Resultsmentioning

confidence: 99%

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

et al. 2010

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“…Cases of acute phosphorus poisoning have been described secondary to phosphorus containing enemas and ingestion of cloth washing detergent. Calcium and phosphorus infusions have to be strictly separated because of the danger of precipitation which can trigger aggregate anaphylaxis similar to what has been described with the use of protamine to reverse heparin after cardiopulmonary bypass (51). Oral supplementation and prevention of severe hypophosphatemia is therefore more desirable than intravenous supplementation.…”

Section: Hypophosphatemiamentioning

confidence: 99%

CRITICAL CARE ISSUES FOR THE NEPHROLOGIST: Electrolyte Disturbances in the Intensive Care Unit

Sedlacek

Schoolwerth

Remillard

2006

Seminars in Dialysis

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The development of many electrolyte disturbances in the ICU can be prevented by attention to the use of intravenous fluids and nutrition. Hyponatremia is a relative contraindication to the use of hypotonic intravenous fluids and hypernatremia calls for the administration of water. Formulae have been devised to guide the therapy of severe hyponatremia and hypernatremia. All formulae regard the patient as a closed system, and none takes into account ongoing fluid losses that are highly variable between patients. Thus, therapy of severe hyponatremia and hypernatremia must be closely monitored with serial electrolyte measurements. The significance of hypocalcemia in the critically ill is controversial. Hypokalemia, hypophosphatemia, and hypomagnesemia should be corrected.

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“…Although rare an allergic reaction to calcium phosphate cement has been noted in skull reconstruction [15]. Even severe hypoxia with ventricular failure as a sign of possible aggregate anaphylaxis has been seen after formation of intravenous calcium phosphate precipitant [16]. Therefore, it seems more likely that Krügers’ observation and our case highlight the capacity of bone cement to trigger a disproportionate display of mast cell activity in mastocytosis patients with a BCIS response as a result.…”

Section: Discussionmentioning

confidence: 67%

Anaphylactic shock during cement implantation of a total hip arthroplasty in a patient with underlying mastocytosis: case report of a rare intraoperative complication

2016

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BackgroundCemented total hip arthroplasty (THA) is a safe and common procedure. In rare cases life threatening bone cement implantation syndrome (BCIS) may occur, which is commonly caused by pulmonary embolism (PE).Case presentationWe describe the rare case of a 70-year old patient who underwent an elective total hip replacement. Before surgery he was diagnosed with underlying systemic indolent mastocytosis, a rare pathological disorder that may result in anaphylaxis after massive systemic mast cell activation. Triggers may be IgE-mediated, direct mast cell activation, or unclear. Some patients may be at risk for severe non IgE-mediated reactions, such as those experienced with nonsteroidal anti-inflammatory drugs, or with perioperative muscle relaxants. During cementing of the acetabular component, our patient developed acute hypotension (blood pressure dropped from 90/50 to 60/40 mmHg, and saturation dropped from 95 to 80 %). The differential diagnosis of acute PE was excluded (no signs of breathing abnormalities during physical examination, normal arterial blood sample, and no electrocardiography or cardiac ultrasound abnormalities). The patient was diagnosed with acute anaphylactic shock, which was successfully managed by 100 % oxygen administration, rapid fluid induction, and vasoconstrictive drug therapy. He recovered hemodynamically within 15 min, did not lose consciousness, and did not develop angioedema or an urticarial rash. Forty-five minutes after onset of the symptoms, the surgical procedure was completed after inserting a press fitted uncemented femoral stem component. The patient was transported to the Intensive Care Unit (ICU) for optimal monitoring. Our patient had an uneventful recovery. Within six hours after surgery he started to ambulate following our standard fast-track rehabilitation regime. Post-operative day one he was discharged to the specialized Orthopedic Department, and after five hospital days discharged to his home. Twelve months after THA surgery our patient was satisfied with an optimal functional status of his hip joint replacement.ConclusionThe differential diagnosis of anaphylactic shock must be taken into consideration in patients with acute hypotension during cementing of total hip arthroplasty components. Patients with underlying mastocytosis are at particular risk of this potential life-threatening intra-operative complication. This rare entity should be taken into consideration during the pre-operative risk stratification and shared decision-making process for elective cemented joint replacement.

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Life‐threatening pulmonary hypertension and right ventricular failure complicating calcium and phosphate replacement in the intensive care unit

Cited by 11 publications

References 21 publications

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

CRITICAL CARE ISSUES FOR THE NEPHROLOGIST: Electrolyte Disturbances in the Intensive Care Unit

Anaphylactic shock during cement implantation of a total hip arthroplasty in a patient with underlying mastocytosis: case report of a rare intraoperative complication

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