Journal of the Royal Society of Medicine Volume 83 March 1990
185
Case reports
Dangerous synergism between sedatives and a hyponatraemic state
F J Lichtigfeld BSc FFPsych
M A Gillman Msc Dsc
South African Brain Research Institute, 173 Louis Botha Avenue, Orange Grove, 2192 Johannesburg, South Africa Keywords: hyponatraemia; electrolyte disturbance; delirium; coma
Hyponatraemia can have deleterious effects on brain function which can be aggravated by various associated conditions'. Indeed it has been suggested that the delirium of electrolyte disturbance is a contraindication to the use of 'large doses of tranquilisers', since the correction of the electrolyte inbalance produces rapid recovery, where no organic damage has occurred2. We report on a case in which an hyponatraemic state may have been aggravated by a combination of low dose sedative medication given on a single occasion to counteract insomnia in a patient whose hyponatremia was only recognized the following day. Such synergism would add another factor not generally recognized1 that could aggravate underlying hyponatraemia to the point of coma and respiratory arrest. This possibly dangerous synergism may be a great deal more common than generally realized. Case report A Caucasian woman of 64 years was admitted to hospital after a gradual deterioration of mental state following the death of her husband some months previously. Since she had suffered insomnia for some weeks and had not responded to previous sedation given on an outpatient basis elsewhere, she was given a combination of promethazine 100 mg, trimipramine 75 mg and clonazepam 2 mg on the night of her admission. She was at the same time given an intramuscular injection of depot flupenthixol 20 mg.- The
Malignant change in rectal duplication
R G Springall ChM FRCS Institute of Child Health, 30 Guildford Street, London WC1N lEW J D Griffiths MS FRCS Royal Marsden Hospital, Fulham Road, London SW3 Keywords: rectum; abnormalities; carcinoma; fistula; colon embryology
Squamous cell carcinoma has been reported in the heterotopic lining of the blind end of a duplication of the
flupenthixol was added as an initial treatment for a suspected severe endogenous depression presenting as a pseudodementia. After this treatment she appeared to settle down well and went to sleep. However at approximately 0300 h next morning her breathing suddenly changed and became laboured. On investigation no apparent mechanical obstruction was found on suction, but she could not be aroused over the next 4 h. To eliminate the possibility of a silent cardiac infarct an ECG was performed, which did not reveal acute pathology. Electrolytes were then measured showing the presence of sodium at 120 meq/l. A consultant physician prescribed oral sodium and that night no further sedation was given; the patient sleeping without such medication. Twenty four hours later the serum sodium appeared normal (140 meq/l) and the patient was much improved in mental alertness. Discussion
This case highlights the importance of serum sodium levels in the diagnostic assessment of any acutely confused patient and further suggests the possibility that there could be a very deleterious synergism existing between an hyponatremic condition and sedative use. Hyponatraemia can often be mild and transient and can thus pass unnoticed or be ignored3. However the delirium of electrolyte disturbance is often associated with sudden changes of electrolyte concentration2, thereby highlighting the importance of the change in level rather than the actual value nieasured as being critical for clinically important sequelae. References 1 Ayus JC, Krothapalli RK, Arieff Al. Treatment of symptomatic hyponatremia and its relation to brain damage. N Engl J Med 1987;317:1190-5 2 Oakely HF. Psychiatric emergencies in endocrine and metabolic disease. In: Sonksen PH, Lowy C, eds. Clinics in endocrinology and metabolism, vol 9. London: WB Saunders 1980;615-24 3 Gill GV, Flear CTG. Hyponatraemia, In: Price CP, Alberti KGMM, eds Recent advances in clinical biochemistry no 3. London: Churchill Livingstone, 1985:149-76 (Accepted 10 January 1989)
0141-0768/90/ 030185-01/$02.00/0 © 1990 The Royal Society of Medicine
ascending and transverse colon'. Adenocarcinoma in a villous adenoma was recorded in a duplication arising from the ascending colon2. Reports of malignant change in a separate duplication cyst rather than a segment in continuity with the bowel have appeared in the literature3.
Case report A male aged 49 presented with acute retention of urine, following one year of lower back pain and 6 months of increasing stool frequency. A hard mass was palpable per rectum posteriorly, indenting but not invading the bowel. Intravenous urography demonstrated the 15 cm mass within the pelvis. The bladder was displaced upwards and anteriorly and evacuated poorly. Needle biopsy was inconclusive and the lesion needed decompression. Through a horizontal post-anal incision 500 ml of infected gelatinous fluid were evacuated. Histology was again
0141-0768/90/ 030185-03/$02.00/0 © 1990 The Royal Society of Medicine
185
Case reports
Dangerous synergism between sedatives and a hyponatraemic state
F J Lichtigfeld BSc FFPsych
M A Gillman Msc Dsc
South African Brain Research Institute, 173 Louis Botha Avenue, Orange Grove, 2192 Johannesburg, South Africa Keywords: hyponatraemia; electrolyte disturbance; delirium; coma
Hyponatraemia can have deleterious effects on brain function which can be aggravated by various associated conditions'. Indeed it has been suggested that the delirium of electrolyte disturbance is a contraindication to the use of 'large doses of tranquilisers', since the correction of the electrolyte inbalance produces rapid recovery, where no organic damage has occurred2. We report on a case in which an hyponatraemic state may have been aggravated by a combination of low dose sedative medication given on a single occasion to counteract insomnia in a patient whose hyponatremia was only recognized the following day. Such synergism would add another factor not generally recognized1 that could aggravate underlying hyponatraemia to the point of coma and respiratory arrest. This possibly dangerous synergism may be a great deal more common than generally realized. Case report A Caucasian woman of 64 years was admitted to hospital after a gradual deterioration of mental state following the death of her husband some months previously. Since she had suffered insomnia for some weeks and had not responded to previous sedation given on an outpatient basis elsewhere, she was given a combination of promethazine 100 mg, trimipramine 75 mg and clonazepam 2 mg on the night of her admission. She was at the same time given an intramuscular injection of depot flupenthixol 20 mg.- The
Malignant change in rectal duplication
R G Springall ChM FRCS Institute of Child Health, 30 Guildford Street, London WC1N lEW J D Griffiths MS FRCS Royal Marsden Hospital, Fulham Road, London SW3 Keywords: rectum; abnormalities; carcinoma; fistula; colon embryology
Squamous cell carcinoma has been reported in the heterotopic lining of the blind end of a duplication of the
flupenthixol was added as an initial treatment for a suspected severe endogenous depression presenting as a pseudodementia. After this treatment she appeared to settle down well and went to sleep. However at approximately 0300 h next morning her breathing suddenly changed and became laboured. On investigation no apparent mechanical obstruction was found on suction, but she could not be aroused over the next 4 h. To eliminate the possibility of a silent cardiac infarct an ECG was performed, which did not reveal acute pathology. Electrolytes were then measured showing the presence of sodium at 120 meq/l. A consultant physician prescribed oral sodium and that night no further sedation was given; the patient sleeping without such medication. Twenty four hours later the serum sodium appeared normal (140 meq/l) and the patient was much improved in mental alertness. Discussion
This case highlights the importance of serum sodium levels in the diagnostic assessment of any acutely confused patient and further suggests the possibility that there could be a very deleterious synergism existing between an hyponatremic condition and sedative use. Hyponatraemia can often be mild and transient and can thus pass unnoticed or be ignored3. However the delirium of electrolyte disturbance is often associated with sudden changes of electrolyte concentration2, thereby highlighting the importance of the change in level rather than the actual value nieasured as being critical for clinically important sequelae. References 1 Ayus JC, Krothapalli RK, Arieff Al. Treatment of symptomatic hyponatremia and its relation to brain damage. N Engl J Med 1987;317:1190-5 2 Oakely HF. Psychiatric emergencies in endocrine and metabolic disease. In: Sonksen PH, Lowy C, eds. Clinics in endocrinology and metabolism, vol 9. London: WB Saunders 1980;615-24 3 Gill GV, Flear CTG. Hyponatraemia, In: Price CP, Alberti KGMM, eds Recent advances in clinical biochemistry no 3. London: Churchill Livingstone, 1985:149-76 (Accepted 10 January 1989)
0141-0768/90/ 030185-01/$02.00/0 © 1990 The Royal Society of Medicine
ascending and transverse colon'. Adenocarcinoma in a villous adenoma was recorded in a duplication arising from the ascending colon2. Reports of malignant change in a separate duplication cyst rather than a segment in continuity with the bowel have appeared in the literature3.
Case report A male aged 49 presented with acute retention of urine, following one year of lower back pain and 6 months of increasing stool frequency. A hard mass was palpable per rectum posteriorly, indenting but not invading the bowel. Intravenous urography demonstrated the 15 cm mass within the pelvis. The bladder was displaced upwards and anteriorly and evacuated poorly. Needle biopsy was inconclusive and the lesion needed decompression. Through a horizontal post-anal incision 500 ml of infected gelatinous fluid were evacuated. Histology was again
0141-0768/90/ 030185-03/$02.00/0 © 1990 The Royal Society of Medicine
