Propylene Glycol-Induced Lactic Acidosis in a Patient Receiving Continuous Infusion Pentobarbital

Miller, Melissa A.; Forni, Allison; Yogaratnam, Dinesh

doi:10.1345/aph.1l186

Cited by 39 publications

(31 citation statements)

References 19 publications

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“…These diluents are often alcohol derivatives, for instance, isopropanol, ethanol, and propylene glycol. Side effects of these additives include potentiation of the sedative-hypnotic effects of the barbiturate and metabolic derangements such as lactic acidosis documented from propylene glycol additives [13]. …”

Section: Discussionmentioning

confidence: 99%

Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication

Crellin

Katz

2016

Case Reports in Emergency Medicine

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Suicide attempt via sodium pentobarbital is uncommon. A 48-year-old woman with a history of depression and prior suicide attempt was found unresponsive by her veterinarian spouse near a syringe containing pink solution. Upon EMS' arrival, the patient was experiencing apnea, hypoxemia, and miotic pupils; her blood glucose level measured 73 mg/dL. She was bradycardic and administered atropine with transient improvement in heart rate and transported to an emergency department; 2 mg of intravenous naloxone was administered without effect. She was endotracheally intubated via rapid sequence intubation. Rapid urine drug screening detected both benzodiazepines and barbiturates. The patient was transferred to an intensive care unit where she demonstrated a nearly absent radial pulse. Emergent fasciotomy to the left forearm and carpal tunnel was performed for acute compartment syndrome; “Euthasol” had been self-administered into the antecubital fossa. Expanded toxicological analysis via liquid chromatography/mass spectroscopy detected caffeine, atropine, 7-aminoclonazepam, phenytoin, citalopram, and naproxen. The patient's coma resolved over 48 hours and she was successfully extubated without complication. Emergency physicians must closely monitor patients exposed to veterinary euthanasia agents who develop central nervous system and respiratory depression, hypothermia, bradycardia, hypotension, or skin injury. Consultation with a regional poison center and medical toxicologist is recommended.

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Section: Discussionmentioning

confidence: 99%

Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication

Crellin

Katz

2016

Case Reports in Emergency Medicine

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“…Methanol toxicity is associated with visual symptoms and treated in a similar fashion to ethylene glycol 13. Diethylene glycol and propylene glycol are pharmaceutical solvents; the former usually presents with neuropathies and the latter presents in intensive care unit settings with the overdose of benzodianzepines and barbiturates 14 15…”

Section: Discussionmentioning

confidence: 99%

A rare case of fatal stroke after ethylene glycol toxicity

2015

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SUMMARYA 58-year-old man presented to the emergency department with acute left-sided weakness and left visual field defect. His examination was significant for confusion, acetone odour, tachycardia and tachypnoea. Further blood tests revealed an anion gap of 31 mEq/L, serum osmolal gap of 34 mOsm/kg, and creatinine 3.6 mg/dL. Brain MRI revealed acute infarctions scattered throughout the brain along with generalised oedema. The patient deteriorated rapidly and soon thereafter it was reported that a bottle of antifreeze was found near him at home. Haemodialysis was initiated and the patient received fomepizole and bicarbonate. Three days later the patient did not show any neurological improvement and expired later that day. Ethylene glycol toxicity can rarely present with stroke which can be lifethreatening when not diagnosed and managed in a timely fashion. BACKGROUND

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“…Indeed, pentobarbital administration may have led to propylene glycol toxicity, which has been previously reported. 28 Earlier EVD placement may have provided benefit and avoided the need for barbiturates. Additionally, decompressive craniotomy could have been used, as this has been shown to assist with successful treatment of cerebral edema associated with OTC deficiency.…”

Section: Discussionmentioning

confidence: 99%

Late-Onset Ornithine Transcarbamylase Deficiency: Treatment and Outcome of Hyperammonemic Crisis

Bergmann¹,

McCabe²,

Smith³

et al. 2014

Pediatrics

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Hyperammonemic crises in ornithine transcarbamylase deficiency (OTC) can be associated with devastating cerebral edema resulting in severe long-term neurologic impairment and death. We present an 8-year-old boy who had late-onset OTC deficiency in which early and aggressive management of hyperammonemia and associated cerebral edema, including therapeutic hypothermia and barbiturateinduced coma, resulted in favorable neurologic outcome. Our patient presented with vomiting and altered mental status, and was found to have a significantly elevated serum ammonia level of 1561 mmol/L. Hyperammonemia was managed with hemodialysis, 10% sodium phenylacetate, 10% sodium benzoate, L-arginine, intravenous 10% dextrose, intralipids, and protein restriction. He developed significant cerebral edema with intracranial pressures .20 mm Hg, requiring treatment with 3% saline and mannitol. Despite this treatment our patient continued to have elevated intracranial pressures, which were treated aggressively with non-conventional modalities including therapeutic hypothermia, barbiturate-induced coma, and external ventricular drainage. This therapy resulted in stabilization of hyperammonemia and resolution of cerebral edema. Molecular testing later revealed a hemizygous mutation within the OTC gene. Neuropsychological testing 1 year after discharge showed normal intelligence with no visualmotor deficits, minor deficits in working memory and processing speed, and slightly below average processing speed and executive functioning. Pediatrics 2014;133:e1072-e1076 Dr Bergmann conceptualized the case report, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr McCabe coordinated data collection and critically reviewed and revised the manuscript; Dr Smith critically reviewed and revised the manuscript; Dr Guillaume provided expertise in neurosurgical management and critically reviewed and revised aspects of the manuscript pertaining to neurosurgical intervention; Dr Sarafoglou provided expertise in endocrine and metabolic management and critically reviewed and revised aspects of the manuscript pertaining to endocrine and metabolic intervention; Dr Gupta conceptualized the case report and critically reviewed and revised the manuscript with emphasis on aspects pertaining to critical care medicine; and all authors approved the final manuscript as submitted.www.pediatrics.org/cgi

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Propylene Glycol-Induced Lactic Acidosis in a Patient Receiving Continuous Infusion Pentobarbital

Abstract: PG toxicity is a potential complication associated with intravenous pentobarbital. Practitioners should be aware of the PG content of pentobarbital and should be familiar with the signs and symptoms associated with PG toxicity.

Cited by 39 publications

References 19 publications

Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication

Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication

A rare case of fatal stroke after ethylene glycol toxicity

Late-Onset Ornithine Transcarbamylase Deficiency: Treatment and Outcome of Hyperammonemic Crisis

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