Furosemide/methylprednisolone/sodium chloride
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Various toxicities: case report A 72-year-old woman developed hypervolemic hypernatraemia, metabolic alkalosis and hypokalaemia during treatment with furosemide for treatment of hypertensive acute pulmonary oedema. Additionally, she also developed excessive generation of urea and osmotic diuresis during treatment with methylprednisolone (for laryngospasm) in addition with sodium chloride overload led to further worsening of hypervolemic hypernatraemia [time to reactions onset not stated]. The woman, who had a history of type 2 diabetes mellitus, hypertension and heart failure, was admitted to the emergency department due to hypertensive acute pulmonary oedema. She needed invasive mechanical ventilation. She had been receiving high-dose IV methylprednisolone 75mg 8/8 hours for laryngospasm. On day 4 of hospitalisation, she was started on treatment with IV furosemide 40 mg/day due to signs of congestion on chest radiography, oliguria and peripheral oedema. She was extubated, but she presented with severe laryngospasm refractory to methylprednisolone treatment requiring reintubation. Subsequently, she developed ventilator-related pneumonia and an increase in serum sodium level (reaching 165 mEq/L). Blood tests showed creatinine of 0.79 mg/dL, urea 61 mg/dL, sodium (PNa) of 141 mEq/L, chlorine of 101 mEq/L, potassium of 4.2 mEq/L, bicarbonate of 25.2 mEq/L and glucose of 139 mg/dL. Her urine volume (UVol) was 800mL. The woman was started on treatment with solution of sodium chloride 0.45% along with free water administered via nasoenteric feeding tube, but no improvement in natraemia was observed. During the weaning of ventilator, physical examination revealed right hemiparesis. Cranial CT showed haemorrhagic stroke in the left middle cerebral artery region. After extubation, dysphagia and aphasia persisted. Hence, she needed enternal hyperprotein diet. On day 12, furosemide was discontinued due to hypernatraemia and worsening renal function. On day 14 of hospitalisation, nephrology team performed additional investigations for hypernatraemia. She was found to be hypervolemic and hypertensive with positive fluid balance despite febrile condition and diarrhoea. Blood tests revealed creatinine of 1.53 mg/dL, urea 239 mg/dL, PNa of 165 mEq/L, chlorine of 117 mEq/L, potassium of 3.4 mEq/L, bicarbonate of 24 mEq/L, glucose of 270 mg/dL and osmolarity (POsm) of 345 mOsm/L. Her urine tests showed UVol of 2025mL, creatinine of 1.05g, urea of 48.9g, sodium (UNa) of 22 mEq/L, potassium (UK) of 62 mEq/L, osmolarity (UOsm) of 570 mOsm/L, free water clearance (CH2O) of -1320mL, electrolyte-free water clearance (CeH2O) of +957mL, total urine osmoles of 1154 mOsm, urine osmoles generated by urea of 814 mOsm and urine osmoles generated by Na + K of 340 mOsm. Based on the findings, she was diagnosed with hypervolemic hypernatraemia, metabolic alkalosis and hypokalaemia. She continued to receive high doses methylprednisolone. Hypervolemic hypernatraemia was thought to be due to osmotic diuresis secondary to methylprednisolone-relate
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