Acetazolamide
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Metabolic acidosis and paradoxical critical hyperkalaemia: case report A 42-year-old man developed metabolic acidosis and paradoxical critical hyperkalemia following treatment with acetazolamide for cerebrovascular reactivity study preoperatively. The man was scheduled to undergo a right-sided craniotomy for a superficial temporal artery to middle cerebral artery bypass graft for severe moyamoya disease. One day prior to surgery an acetazolamide challenge test was performed. He was administered IV bolus acetazolamide 1000mg followed by MRI confirmed critical right-sided moyamoya disease. Prior to this test, in preparation for surgery, routine laboratory investigation was performed which revealed serum potassium level of 5.1 mmol/L. The next morning, he was admitted for surgery, and subjectively felt well. Anesthesia was induced with fentanyl, propofol and rocuronium bromide [rocuronium]. Thereafter, he was administered with cefazolin and dexamethasone. Maintenance of anesthesia consisted of a propofol, remifentanil and sevoflurane. Normosol (containing sodium, potassium, magnesium, chloride, acetate and gluconate) was administered. Then, a radial arterial line and a central venous line were placed. Before incision, laboratory investigation showed critically increased arterial potassium level of 6.7 mmol/L consistent with hyperkalemia. Arterial and venous blood gas analysis revealed decreased levels of pH, bicarbonate and base excess, and increased partial pressure of carbon dioxide (pCO2) and partial pressure of oxygen (pO2). These findings were consistent with metabolic acidosis. A repeat investigation was performed to rule out a hemolysed blood sample, which showed the same potassium level of 6.7 mmol/L. A third sample also showed the same potassium level. Then a new IV line was established, and a blood sample was gently withdrawn, thereby decreasing the risk of haemolysis from the aspiration of blood. This venous potassium sample was increased at 6.6 mmol/L. Due to this unexplained critical electrolyte derangement the procedure was abandoned. The man was treated with salbutamol [albuterol], calcium chloride, insulin, and glucose [dextrose]. A subsequent laboratory investigation revealed a potassium level of 5.3 mmol/L, and he was shifted to the ICU for observation. The potassium levels throughout the day and night were stable between 5.0–5.4 mmol/L range. On the next day, he had undergone surgery without complications and had an excellent recovery. He remains asymptomatic. Burbridge MA, et al. Paradoxical Critical Hyperkalemia After Acetazolamide for Cerebrovascular Reactivity Study: A Case Report. A and A Practice 14: 69-71, No. 3, Feb 803506872 2020. Available from: URL: http://doi.org/10.1213/XAA.0000000000001148
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Reactions 17 Oct 2020 No. 1826
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