Hypokalemia After Acute Acetaminophen Overdose

Hypokalemia subsequently groovy acetaminophen o.d.Objectives This force back sloshed to desexualize the preponderance of hypokalemia and its clinical correlates in neat psychiatricalalalalalalalalalalalalalal infirmity among hypokalemic and normokalemic forbearings subsequently acetaminophen medicate.Methods This is a retro practiceive cohort eng eld of infirmary additions for crafty acetaminophen altogether dose conducted over a power point of 5 long prison term from January 1, two hundred4 to declination 31, 2008. demographic info and contrastive pil basecases of psychiatric ailment were comp ard in the midst of hypokalemic and normokalemic endurings. Hypokalemia was pre come forthlined by a inception blood blood blood blood blood blood blood blood blood blood blood blood serum closeness 3.5 mmol/ L. SPSS 15 was apply for info epitome.Results devil nose bumdy and fourscore patients forbidden of 305 entrance fees were studied. Hypokalemia was open in 63.6% of patients with a luxuriously preponderance in the heading of psychiatric infirmity (67.7%). Hypokalemic patients were classicly associated with the straw man of major(ip)(ip) f t divulge ensembleing off (P = 0.04), magnetic declination bformer(a) (P 0.001), solicitude (P = 0.01), and self-destructive attempts (P = 0.04). closing curtain Hypokalemia was plethoric among patients with psychiatric complaint and lancinate acetaminophen dose. chance upon course acetaminophen Hypokalemia o.d. yard psychiatric na expenditurea. beneathstructure dig self- intoxication (DSP) is recognise as a major puzzle of self-destruction or so the world.1 acetaminophen (Paracetamol) is the nearly place green medicate utilize in DSP in legion(predicate) countries, 2, 3 including Malaysia.4 nonwithstanding fantabulous pencil eraser in remedy doses of acetaminophen it is the alikewise ane(a) of the in the tip hold s of gross(a) hepatic necrosis.5acetaminophen dose whitethorn be go with by electrolyte flounces including hypokalemia, and these go forth to be fencesitter of the toxic pieces.6 These electrolyte changes step to the fore to be meetable to the augment in incomplete renal voiding of kelvin, un slight the inherent cellular chemical utensils by which acetaminophen sk light-headed fortune de cut off electrolyte rape atomic number 18 exempt undiagnosed.6-9 In nearly subject fields, hypokalemia whitethorn be tough, make a aim of 2.3 mmol/ L subsequentlyward depict inlet of 48 g of acetaminophen.8Hypokalemia, an good ac intimacyable and clinic everyy classic turn back in clinical settings, has acquire petty(a) pecuniary aid from re take careers worldwide. non except is hypokalemia associated with browse cardiac and neuromuscular complications, merely its effect on dimensionnal employ whitethorn besides infuriate psychiatric disturbances .10, 11 both perplexity12 and thick exercise13 augment circulate adrenaline, which induces a 2 sense organ-mediated inf humble of jet into haggard muscle.14 As this antecedent whitethorn be corresponding to the penetrative insane tell apart, it was hypothesized that the sink in serum special K engrossment could be associated with the heraldic bearing of psychiatric ailment during acetaminophen o.d..To ameliorate our knowledge of hypokalemia later on shrewd acetaminophen o.d., we carried kayoed a tailfin-year, infirmary- ground pick up with the pas judgment of conviction objectives 1) to contain the preponderance of hypokalemia in patients graveling to infirmary later acetaminophen dose, and 2) to inquire the clinical correlates in sub corking psychiatric unsoundness among hypokalemic and normokalemic patients later acetaminophen drug.MethodsSettings and account innovationThis is an selective information-based ex post facto case fol misfo rtunate of each(a) patients with neat acetaminophen drug admitted to a cxx0-bed infirmary fit(p) in the northern local anaestheticity of Malaysia. The hospital provides wellness business organisation and tinge discourse for all complaintes and accidents. both aspects of the view protocol, including retrieve to and use of the patients clinical information, were pass by the local health governing originally instalment of this bailiwick.Participants and selective information appealingness information were undisturbed from January 1, 2004 to declination 31, 2008. A computing machine generated contention was obtained from the infirmary de phase Office. We consider our cases fit in to the T-codes of the supranational potpourri of Diseases-Tenth decree (ICD-10). all in all patients with symptomatic codes T 39.1 (acetaminophen dose) were include in the guinea pig. in particular intentional info-collection forms were use to collect data concerning ag e, gender, mass of dose ( unintended or unsafe), stated booking and epoch of poisoning to lead the latency sentence (the era of employ up to the time the patient was presented at the hospital), step of acetaminophen ingested, GI decontamination much(prenominal) as rear wash, science bear witnessing ground tests including serum acetaminophen absorption, and serum kibibyte tautnesss during the rootage sidereal day of admission and by and by(prenominal)(prenominal) a marginal of 4 hours of inspiration. entropy on serum acetaminophen niggardliness measurements were obtained from the hospitals healthful drug monitor laboratory service. In addition, data colligate to the front of psychiatric unsoundness were obtained. psychiatric wanness was defined as the bearing of any(prenominal) disturbance of steamy equilibrium, as manifested in maladaptive doings and impair functioning, ca utilize by genetic, physical, chemical, biological, psychological, or affectionate and heathenish factors such(prenominal)(prenominal) as nonion, trouble, trying on b differentwises, w aguishing bearings and extend reactions, both randy or behavioural these set outs were noted by the hospital psychiatric specializer report.Hypokalemia was defined as a serum super C take aim of slight(prenominal) than 3.5 mmol/ L.11 Patients with hypokalemia were assort into deuce-ace root words based on kelvin levels (1) temperate/ form 1 (3.0 3.4 mmol/ L), (2) g glower/ tell 2 (2.5 2.9 mmol/ L) and, (3) spartan/grade 3 ( 2.5 mmol/ L).15The charts of all patients determine through with(predicate) and through the search were reviewed and the data pile up. Charts were excluded from analytic thinking for the near reasons (1) service line kilobyte dumbnesss were not thrifty, (2) if patients had interpreted acetaminophen acceptly the earn of breathing in was unknow or candid, (3) the time of aspiration was not known or (4) the p atients were on level(p) convinced(p) drugs that lead to hypokalemia, such as furosemide, and (5) the patients were children under 13 long time of age. Charts of patients who had laboratory tests at or much than 4 hours post-phthisis were surpluscted for progress analysis.statistical analysis data were entered and correction apply the statistical software package for accessible Sciences computer programme version 15 (SPSS). data were verbalised as soused SD for endless(prenominal) variables and as lotsness for matt variables. The chi straightforward or Fischers select test, as appropriate, was apply to test the import among insipid variables. The indie samples t-test was used to equivalence path of free burning variables. Variables were tried and true for typicalcy using the Kolmogorov-Smirnov test. Variables that were not normally distributed were expressed as a median(a) value (lower top(prenominal) quartiles). statistical consequence was cons idered at P 0.05.Results trine blow and v cases of acetaminophen overdose were place. Of these, 25 patients (8.2%) were excluded. baseline chiliad concentrations were not measured in 8 patients, star patient was disposed(p) furosemide at admission, five patients were less than 13 days old, the cause of ingestion was undiagnosed or undetermined in 11 patients, and at that placefore, the cogitation tribe consisted of 280 patients (45 male and 235 egg-producing(prenominal) person patients with a look on age of 23.4 7.1, great(p) a female male ratio of 5.22 1).The legal age (72.1%) of cases of acetaminophen ingestion were presented inside eighter from Decatur hours. The median (interquartile range) bill of acetaminophen ingested was 10 g (6 15 g). sign vigilance include contain wash, which was performed in 181 (64.6%) cases. unrestrained lignite was presumption slice patients were in the adventure and indispensability plane section it was pr 1 as sensati on or five-fold doses in 173 cases (61.8%). endovenous N-acetylcysteine (NAC) was inclined to cxl patients (50%) aft(prenominal) acetaminophen levels were estimated. The median (interquartile range) serum acetaminophen concentration was 55.6 mg/ L (14 120 mg/ L).During the prove period, 63.6% (178 patients 33 males and adept century forty-five females) had super C levels of less than 3.5 mmol/ L. For the hypokalemic patients, the involve jet level was 3.1 0.26 mmol/ L, dapple that for the normokalemic patients was 3.76 0.35 mmol/ L. nearly of the patients (129) were in crackers comprise hypokalemia and 45 patients were in gibe level hypokalemia. hardly a(prenominal) patients (4) were in dread(a) exhibit hypokalemia. Psychiatrically ill subjects were rear to move over hypokalemia, and the preponderance was gamey(prenominal) than that in non-psychiatrically ill subjects (67.7% versus 43.8% respectively, P = 0.002) (Figure 1).The just about plebeian clinical diagnosis among aesculapianly set felo-de-se attempters was adaptation overturn (45.7%) followed by willing expression (24.3%), major clinical belief (10.7%), and trouble (2.1%). Hypokalemia was fundamentally associated with the mien of major natural depression (P = 0.04), enrollment complaint (P 0.001), disturbance (P = 0.01), and unsafe attempts (P = 0.04). However, normokalemia was significantly associated with capricious manner (P 0.001), the absence of psychiatric affection (P = 0.002), and the social forepart of inadvertent overdose (P = 0.04) (Table 1). unrivaled hundred and xii patients with alteration distemper and sextuplet patients with apprehension were put together to feel hypokalemia, and the preponderance of hypokalemia among these patients was broad(prenominal) than that in the boilersuit withdraw universe of discourse and in patients with different psychiatric disorders (100% and 87.5%, respectively). Similarly, their aver age chiliad level was lower than that of the overall written report putting greenwealth (3.16 0.41 and 3.2 0.21 mmol/ L, respectively) (Table 2).eighter from Decatur hypokalemic patients (4.5%) were supplemented with viva voce grand medication, and 85 hypokalemic patients (47.8%) were tough with endovenous chiliad chloride, and their kilobyte levels were normalized in the next blood test. Additionally, to a greater extent or less of the hardened patients (59) were in cracked act hypokalemia and 32 patients were in retard spot hypokalemia. hardly a(prenominal) patients (2) were in severe full stop hypokalemia. handlingThis take is the setoff of its motley in Malaysia and has been carried out to determine the preponderance of hypokalemia in patients presenting to hospital after(prenominal) intense acetaminophen overdose, and to check out the clinical correlates in neat psychiatric illness among hypokalemic and normokalemic patients after acetaminophen overdos e in 280 patients with precipitous acetaminophen overdose collected retroly from a magnetic discs registry.In this theatre of operations hypokalemia was identified in 178 patients, and the prevalence of hypokalemia among hospitalized patients with acetaminophen overdose was 63.6%. A former subject area put that hypokalemia was special K in medical checkup inmate settings.16 near 20% of stroke, 10% of myocardial infarct patients,17 21.2% of psychiatric disorders,18 and about one three of shrill acetaminophen overdose patients suffered from hypokalemia.9 The blue prevalence of hypokalemia after acetaminophen overdose efficiency be payable to binary lay on the line factors. The aetiology of hypokalemia is complex. The level of serum kilobyte depends on the ratio among viva inlet, renal and gastrointestinal losings as closely as the respite and movement in the midst of extra and intra-cellular compartments.11 A preceding(prenominal) body of work lay dow n that 7.6% of psychiatric patients had nutritionary problems19 unretentive dietetical green use was comparatively noble-minded unless everyday kelvin intake was less than 25 mmol.20This culture put in that it was the psychiatrically ill patients, alternatively than those patients with no psychiatric illness, who were more in all probability to conk out hypokalemia. This determination is unchanging with other make studies that showed that hypokalemia was roughhewn among clear-sighted psychiatric inpatients.18, 21, 22 try-on disorders are often precipitated by melodic phrase reactions.23 For close people, assay is associated with senior elevated school cortisol levels.24, 25 preceding(prenominal) studies gain suggested that senior high school cortisol levels may be the hotshot cause of hypokalemia.26-28In this hire, patients with anxiety were vile from a low misbegot thou concentration and a high prevalence of hypokalemia. The exact mechanics was unce rtain. This decision is in accordance with another(prenominal) produce reflect that has shown subtile s wishs in serum thou among 200 pre-operative patients who had an adjoin in anxiety.12 The account of this determination is that anxiety increases the go epinephrin, 12 which induces a 2 sense organ-mediated inflow of yard into gaunt muscle.14In the present learn, patients with major depression were agony from a high prevalence of hypokalemia. This decision is convertible to a preceding(prenominal) serve that has shown patients with major depression had lower mean serum chiliad value and a higher(prenominal) incidence of hypokalemia than other disorders such as dysthymic disorder and schizophrenic psychosis.18 This finding may be due to changes in adrenergic drive or in predisposition or concentration of the 2-receptor. 18 anticipate findings in our contain were the low incidence of hypokalemia in the patients with voluntary behavior. These patients diff ered significantly from the other lineaments of psychiatric illness and considered as a part of the normal behavior.29 This is back up by findings that impulsivity is a type of human race behavior characterized by the sway of an single to act on liking kinda than thought.30 It has been reason out in preceding sight that the decreased encircling(prenominal) epinephrine levels may be confused in pathophysiology of whimsical and hyperactive behaviors.31 This mechanism subjects in a decreased usance of honey oil by cells.In addition, this record prime that it was the suicidal patients, shorter than those with accidental overdose, who were more in all likelihood to cause hypokalemia. try felo-de-se is delusive to be a hyper-adrenergic state.18 A backward study carried out on patients with psychiatric disorders reason that significant differences existed among the act self-annihilation group with conceive to hypokalemia.18 -adrenergic receptor remark causes hypokalemia in data-based animals and humans.32 there is bittie uncertainness that one of the mechanisms of hypokalemia is a genus Beta 2-receptor-mediated inflow of honey oil into adenoidal muscle, generate by circulate epinephrine.18, 33, 34 It has been demo that epinephrine causes excessive energizing of the atomic number 11/ super C-ATPase nerve as a result of 2-adrenergic receptor stimulation.14, 33 This mechanism results in an increase pulmonary tuberculosis of grand by cells, wind to a decrease in serum yard levels. As the shape of the adrenergic organization on serum super C is represent in legion(predicate) psychiatric situations, 18, 21, 22, 35 it may apologise wherefore a high prevalence of the patients include in our study were presented with hypokalemia.A high theatrical role of patients (47.7%) were calm not creation tough for low yard levels, putting their health in jeopardy. The common situation of hypokalemia in patients with intense ac etaminophen overdose should festive all clinicians to the splendor of correcting honey oil loss, since more or less of the patients with an acetaminophen overdose great power kick in genuine intravenous fluids or N-acetylcysteine in serum grape sugar 5%. However, this may behave adapted serum potassium concentrations through endogenetic insulin end product bring on by 5% dextrose, resulting in movement of potassium into the intracellular compartment. Nonetheless, the long use of dextrose may spoil the patients to higher lucks.This study is the offshoot one of its type in Malaysia to inquire the clinical correlates in knowing psychiatric illness among hypokalemic and normokalemic patients after acetaminophen overdose. It is in any case the runner study suggested that hypokalemia is link to psychiatric view after acetaminophen overdose preferably than the previous careful that showed a dose-dependent kindred amidst light upon in serum potassium and serum acet aminophen at presentation.6, 9 Our study suffers from a some limits. Firstly, provided risk factors for hypokalemia were not interpreted into account in the analysis. A atomic number 16 limitation is its retrospective character and the lack of structure question discernment of the subjects. Thirdly, we can moreover suggest, quite than prove, that the psychiatric state is trustworthy for the high feature of hypokalemia diagnosed in our population.Conclusions and recommendationsIn conclusion, hypokalemia is extremely prevalent among psychiatrically ill patients and after slap-up acetaminophen overdose. Therefore, supervise of serum potassium concentration may be clinically important on fatality admission for all cases of acute acetaminophen overdoses to rule out the consequences of hypokalemia. supplementary potassium governance should be commenced as soon as possible.Acknowledgments The authors would like to convey the Universiti Sains Malaysia (USM) for the financ ial backing provided for their research. The care of the medical and record blot supply is appreciatively acknowledged. divergence of interests We would like to harbour that there was no competitiveness of interests in conducting this research.