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Refractory Hypoglycemia and Subsequent Cardiogenic Shock in Starvation and Refeeding: Report of Three Cases

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Refractory Hypoglycemia and Subsequent Cardiogenic Shock in Starvation and Refeeding: Report of Three Cases Nutrition 30 (2014) 1090–1092 Contents lists available at ScienceDirect Nutrition journal homepage: www.nutritionjrnl.com Case report Refractory hypoglycemia and subsequent cardiogenic shock in starvation and refeeding: Report of three cases Kentaro Shimizu M.D. a,*, Hiroshi Ogura M.D. a, Masafumi Wasa M.D. b, Tomoya Hirose M.D. a, Takeshi Shimazu M.D. a, Hironori Nagasaka M.D. c, Ken-ichi Hirano M.D. d a Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan b Medical Education Center, Osaka University Graduate School of Medicine, Osaka, Japan c Department of Pediatrics, Takarazuka City Hospital, Hyogo, Japan d Laboratory of Cardiovascular Disease, Novel, Non-invasive and Nutritional Therapeutics (CNT), Graduate School of Medicine, Osaka University, Osaka, Japan article info abstract Article history: Objective: Although starvation is associated with high in-hospital mortality, its related cardiac Received 8 September 2013 complications are not sufficiently understood. The aim of this study was to determine the clinical Accepted 10 January 2014 course and pathogenesis of cardiac complications in malnourished patients. Methods: We reviewed three cases of hypoglycemia and hypotriglyceridemia with cardiac com- Keywords: plications in starvation. Starvation Results: This report concerns three patients, respectively suffering from anorexia nervosa, esoph- Refeeding ageal carcinoma, and Parkinson’s disease. Their ages ranged from 18 to 70 y, body mass index was Hypoglycemia Æ 2 Æ Hypotriglyceridemia 11.5 1.5 kg/m (mean SD), and the main symptom was coma. The average blood glucose level Æ Hypophosphatemia was 15.7 7.8 mg/dL without any history of insulin use or diabetes mellitus. In all cases, hypo- Takotsubo cardiomyopathy glycemia was refractory and repetitive so that continuous glucose administration was required to maintain euglycemia. Serum triglyceride and non-esterified fatty acid levels were also very low (7 Æ 4 mg/dL and 10 Æ 9.1 mEq/L, respectively). Levels of serum potassium, phosphate, and magne- sium were almost normal at admission. The main cardiac complications included Takotsubo car- diomyopathy and cardiac arrest. All patients survived as a result of intensive treatment. Conclusions: Repetitive severe hypoglycemia without known background causes should be viewed as an important sign. Once this occurs, the administration of a much higher caloric input than usual accompanied by intensive monitoring will be required to maintain appropriate glucose levels. The early identification of such patients seems to be essential to reduce the high risk for cardiac complications during starvation and refeeding. Ó 2014 Elsevier Inc. All rights reserved. Introduction mortality [3]. However, starvation-related cardiac complications are not sufficiently recognized and only a few reports have Malnutrition in hospitals has been increasing despite pro- described the related metabolic profiles [4]. longed life span and progress in medical treatments [1] and Hypoglycemia represents an important metabolic emergency malnourished patients are associated with longer hospital in the critical care field and especially hypoglycemia without the lengths of stay and poorer survival rates [2]. Patients suffering use of insulin features higher mortality. Low body mass index from starvation, i.e., a severely malnourished state, show higher (BMI) is an important risk factor for hypoglycemia, the clinical course of which is still poorly understood [5,6]. KS, TH, and TS analyzed the data from the perspective of critical care. MW and In this study, we reviewed three hospitalized cases with sud- HN analyzed the data from the perspective of nutrition. KH analyzed the data den cardiac complications related to severe starvation. In all cases, from the perspective of cardiology. KS, HO, and KH organized and wrote the both hypoglycemic coma and hypotriglyceridemia preceded the manuscript. * Corresponding author. Tel.: þ81 6 6879 5707; fax: þ81 6 6879 5720 . onset of cardiac complications. We also discuss how such cases E-mail address: [email protected] (K. Shimizu). might be identified and cardiac complications prevented. 0899-9007/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nut.2014.01.007 K. Shimizu et al. / Nutrition 30 (2014) 1090–1092 1091 Case 1 IU/L, total protein 6.3 g/dL, phosphate 9.3 mg/dL, and TG 3 mg/ dL. He was in hypoglycemic coma accompanied by hypo- An ambulatory 18-y-old woman with anorexia nervosa pre- triglyceridemia with elevated liver enzymes. Acetate Ringer’s sented with appetite loss. Her BMI was 9.9 kg/m2. On the day of solution with 5% dextrose was administered at 100 mL/h, but admission, enteral nutrition was administered via nasal tube, his blood glucose had dropped to 39 mg/dL at 11 h after 250 mL (250 kcal) in 3 h. After administration, she became admission, when he suddenly became bradycardic followed by comatose and was transferred to the intensive care unit. Arterial cardiac arrest. He was resuscitated successfully 7 min after À1 blood gases were pH 7.43, PaCO2 40.3 mm Hg, PaO2 83.7 mm Hg, cardiac arrest and required dopamine 14 mg$min$kg for cir- À HCO3 26.5 mmol/L, and base excess 2.5 mmol/L. Blood tests culatory support. Acetated Ringer’s solution with 5% dextrose findings were sodium 141 mEq/L; potassium 4.4 mEq/L; glucose was administered at 100 mL/h to maintain euglycemia and at 21 mg/dL (normal range: 70–110 mg/dL); phosphate 6.2 mg/dL 480 kcal/d on day 2 without signs of hypoglycemia. His Glasgow (normal range: 2.9–4.8 mg/dL); triglyceride (TG) 11 mg/dL Coma Scale had recovered to E3 V-M4 on hospital day 3. (normal range: 30–150 mg/dL); aspartate aminotransferase Because the patient’s NEFA level was markedly low (3 mEq/L) on (AST) 3961 IU/L; and total protein 6.5 g/dL. She was in day 4, we began continuous enteral nutrition at 20 kcal/h (480 hypoglycemic coma accompanied by hypotriglyceridemia with kcal/d) on day 6. Cardiac function recovered gradually and À elevated liver enzymes. We administered intravenous (IV) dopamine was reduced to 3 mg$min$kg 1 on day 7 after which Ò glucose and a vitamin, Alinamin -F (fursultiamine 100 mg, a his condition became stable. He was then transferred to another thiamine derivative), but the blood glucose level took 1 h to rise hospital. to normal after repetitive infusion of 44 g glucose in total. Her consciousness became clear after she had recovered from re- Case 3 fractory hypoglycemia. Administration of acetated Ringer solu- tion with 5% dextrose was initiated and gradually increased to a A 58-y-old woman was admitted due to anemia. She had a total of 480 kcal/d. On day 2, her blood pressure suddenly began past history of postoperative laryngeal and esophageal tumor, for to decrease. Echocardiography revealed apical ballooning with which she was not taking medication. Her BMI was 11.8 kg/m2, relatively strong contraction in the basal left ventricle. She was blood pressure 98/65 mm Hg, and pulse rate 66/min. Her con- diagnosed with Takotsubo cardiomyopathy because, apart from sciousness was lucid. Prophylactic administration of a vitamin Ò malnutrition, she had no known previous abnormalities. The (Vitamedine ) was initiated with saline. On day 3, the patient patient’s non-esterified fatty acid (NEFA) level was markedly low became drowsy, and her blood glucose was 19 mg/dL. Because at 17 mEq/L (normal: 130–770 mEq/L). Enteral nutrition was hypoglycemia was refractory, 30 g IV glucose was needed for initiated at 10 kcal/h (240 kcal/d) on day 6 and by day 12, cardiac recovery to normal and infusion with 744 kcal/d to maintain wall motion had returned to normal. On day 18, the patient was euglycemia. White blood cell count was 9780/mm3, red blood transferred to the psychiatric ward. cell count 220 Â 104/mm3, hemoglobin 7.4 g/dL, hematocrit 21.7%, and platelet count 4.2 Â104/mm3. Biochemical findings Case 2 included sodium 129 mEq/L, potassium 3.7 mEq/L, glucose 68 mg/dL, AST 617 IU/L, total protein 5.2 g/dL, albumin 2.1 g/dL and A 70-y-old man with Parkinson’s disease was admitted as an TG 7 mg/dL. The patient was suffering from anemia, hypo- emergency patient because of loss of consciousness. His blood triglyceridemia with elevated liver enzymes, and severe malnu- pressure was 117/37 mm Hg, pulse rate 87/min, and BMI 12.8 trition. On day 4, the patient suffered congestive heart failure. kg/m2. Because his blood glucose level was 7 mg/dL, he required Echocardiography revealed apical ballooning with relatively Ò infusion of glucose 30 g and vitamin (Vitamedine :Thiamine strong contraction in the basal left ventricle, requiring 2 À disulfide phosphate 107.13 mg, pyridoxine hydrochloride 100 mg$min$kg 1 of dobutamine and furosemide. On day 6, total mg, and cyanocobalamin 1 mg) before the level returned to parenteral nutrition was initiated at 819 kcal/d. The patient’s normal. He was intubated because he did not recover con- blood pressure had recovered to normal gradually and dobut- sciousness due to refractory hypoglycemia. Initial blood test amine was stopped on day 17, after which she gradually recov- results were sodium 144 mEq/L, potassium 5.2 mEq/L, AST 2830 ered and was transferred to another hospital. Table 1 Patient characteristics and blood test results Case 1 Case 2 Case 3 Age 18 70 58 Sex (M/F) FM F Body weight (kg) 26.5 32.0 27.0 BMI (kg/m2) 9.9 12.8 11.8 Past history Anorexia nervosa Parkinson’s disease Esophageal carcinoma Glucose (mg/dL) 21 7 19 Calories administered to maintain euglycemia during hypoglycemia (kcal/d) 25.2 11.9 27.6 Maximum daily frequency of hypoglycemia 5 3 5 Non-esterified fatty acids (mEq/L) (normal: 130–770) 17 3 – Triglyceride (mg/dL) (normal: 30–150) 11 3 7 Potassium (mEq/L) (normal: 3.6–4.8) 4.7 5.3 3.4 Phosphate (mg/dL) (normal: 2.9–4.8) 6.2 9.3 2.9 Magnesium (mg/dL) (normal: 1.8–2.4) 1.8 2.9 1.6 Lactate (mg/dL) (normal: 3–17) 5 5 – Cardiac complications Takotsubo Cardiac arrest Takotsubo Time from coma to cardiac complications (d) 1 2 1 BMI, body mass index; Takotsubo, Takotsubo cardiomyopathy 1092 K.
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