Colistin
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Acquired Bartter-like syndrome: case report A 65-year-old man developed acquired Bartter-like syndrome during treatment with colistin for Acinetobacter baumanii ventilator-associated pneumonia. The man, who had a history of chronic obstructive pulmonary disease (COPD), hypertension and Parkinson’s disease, presented with 1-week history of progressive worsening of respiratory distress and productive cough. On examination, an infective exacerbation of COPD was suspected. He was intubated and required invasive mechanical ventilation. On day 9, he developed ventilator-associated pneumonia with Acinetobacter baumanii isolated from endotracheal aspirate. Therefore, he started receiving colistin 2 million units/8 hours [route not stated], along with cefoperazone/sulbactam. A significant fall in procalcitonin levels was observed. He failed spontaneous breath trial after 30 minutes with worsening respiratory acidosis, hypotension and desaturation. Evaluation revealed hypovolaemic hypotension which was responsive to fluid, despite persistent polyuria. Laboratory investigations showed hypokalaemia, hypocalcaemia, hypomagnesaemia and hyponatraemia. Excess renal loss of the electrolytes was noted with transtubular potassium gradient and high fractional excretion of sodium. He received parenteral correction of the electrolytes but, recurrence was observed and weaning was difficult. On day 9, the man’s colistin therapy was discontinued. After 3 days of colistin discontinuation, laboratory paramaters started to reverse and on day 4, he was extubated. However, he developed bed sores, which were infected and cultured as Klebsiella spp. His general parameters worsened secondary to sepsis. A rise in procalcitonin levels was observed, and colistin was restarted on day 27 of hospitalisation. A recurrence of electrolyte abnormalities and polyuria with hypovolaemic hypotension was observed, which persisted until discontinuation of colistin. Despite receiving repeated corrections, an episode of supraventricular tachycardia was noted, which was reverted with adenosine. During this episode, very low levels of serum magnesium was noticed. He received magnesium replacement therapy and no recurrence was observed. He then received a 10-day course of colistin with repeated electrolyte corrections and volume replacements. Resolution of abnormalities was noted and he was discharged on day 42. Based on the findings and evidence, a diagnosis of hypokalaemia due to colistin-induced Bartter-like syndrome leading to difficult weaning was made. Mahendran AJ, et al. Colistin-induced acquired bartter-like syndrome: A rare cause of difficult weaning. Indian Journal of Critical Care Medicine 24: 739-740, No. 8, Aug 803517367 2020. Available from: URL: http://doi.org/10.5005/jp-journals-10071-23551
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Reactions 28 Nov 2020 No. 1832
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