Bicarbonate
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Lack of efficacy in hypoxaemia and acidosis: case report A 53-year-old man exhibited lack of effectiveness during treatment with bicarbonate for hypoxaemia and acidosis in COVID-19. The man, who had a history of hyperlipidaemia and obesity, presented with an acute type A aortic dissection with compression of the right sided renal artery. Angiogram of renal arteries were suspicious for fibromuscular dysplasia. The dissection was repaired by a median sternotomy with hemi-arch and ascending and aortic replacement. He was discharged to intensive care unit on mechanical ventilation. He had leukocytosis, and persistent elevated fraction of inspired oxygen was required. On the postoperative day (POD) 4, he was extubated and remained oxygen dependent on bilevel positive airway pressure and high-flow nasal cannula. He received furosemide and metolazone for diuresis on POD 4, but his eGFR further declined. On the POD 6, his hypoxaemia progressed. His renal function improved briefly and further deteriorated on POD 6 along with onset of acute respiratory distress. He required re-intubation and nitrous oxide inhalation. Laboratory findings confirmed COVID-19 with positive SARS-CoV-2. He received off-label use of hydroxychloroquine 600mg twice daily followed by 200mg three times daily for three days. Additionally, he was enrolled in a randomised controlled trial, but not specified if he had received active drug or placebo. Despite the therapy, he developed multi-organ dysfunction, with new onset of diabetes and mildly elevated liver enzymes. On POD 11, his renal and respiratory status worsened with acidosis and progressive hypoxaemia, which was refractory to IV bicarbonate [dosage not stated]. The man became oliguric during the clinical course suggestive of acute kidney injury (AKI) and required continuous renal replacement therapy. He died on POD 12 due to cardiac arrest and an autopsy was performed. The autopsy findings was strongly suggestive of direct renal infection resulting in concurrent AKI in COVID-19. Farkash EA, et al. Ultrastructural evidence for direct renal infection with sars-cov-2. Journal of the American Society of Nephrology 31: 1683-1687, No. 8, Aug 2020. 803501617 Available from: URL: http://doi.org/10.1681/ASN.2020040432
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Reactions 19 Sep 2020 No. 1822
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