Submitted on 5 December 2008
Dr CHAN King Chung, Kenny
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
History of Present Illness
F/76
Hx of CRHD with MVR on warfarin
Presented with haematuria
Cystoscopy -> Ca bladder
Persistent gross haematuria
TURBT + haemostasis under GA
Large amount of organized clot noted upon cystoscopy
Clot evacuation with Elik evacuator
Bladder perforated
Laparotomy + clot evacuation + repair done
BP/P stable
To ICU for post-op care
Unexpected Acidosis !!!
Na 124 pH 6.956
K 6.5 pCO2 4.71
Ur 12.1 pO2 28.59
Cr 200 HCO3 7.7
BE -23.7
Differential Diagnosis
-
Normochloraemic
-
Lactic acidosis
-
Ketoacidosis
-
Renal failure
-
Other organic acids
-
-
Hyperchloraemic
- Urine loss of bicarbonate
- Extra-renal loss
What is your diagnosis?
Working Diagnosis
Glycine toxicity
1.5% Glycine as irrigant (100L)
Lactate & Ammonia level not a/v
CRRT started for hyperkalemia & removal of organic acids
Condition continued to deteriorate
Died ~12 hours post-op
Glycine Toxicity
Non-essential amino acid
Inhibitory neurotransmitter
Metabolize to CO2 + NH4
Transaminated to glyoxylic acid
+ H2O + -NH
3
Glycine Toxicity
1.5% Glycine = 230 mmol/L
Toxicity with >1 to 3L absorption
Hypo-Na, Hypo-Ca, Acidosis, ↑ NH3
Nausea, Vomiting, Cerebral oedema
Visual disturbance, Confusion
Haemolysis, Thrombocytopenia
Hypotension, ECG changes
Estimation of absorption difficult
Na level depends on water clearance
Glycine Toxicity vs. Hypo-Na
NS / NS+1.5%Glycine / 1.5%Glycine
Br J Anaesth. 1999
82(2):250-4
Glycine Toxicity
Risk Factors
- Prolonged surgery, Extensive resection
- Un-noticed perforation
- Intraperitomeal perforation
- Treatment: Supportive
- Recovery in 24-48hrs
- Slow correction of Na, < 0.5 mmol/hr
- ? Role of dialysis
- ? Role of arginine -> removal of ammonia
Other Poisons Used in Surgery