Being the patient (or not being the patient) Gerry Lee - PowerPoint PPT Presentation

Being the patient (or not being the patient…) Gerry Lee Gerry.lee@kcl.ac.uk

Figure 1: 12 lead ECG of Atrial Fibrillation (rate 96 bpm)

Table 1: Blood test results Electrolytes Value (normal range) Sodium 139 (133-146 mmol/L) Potassium 5.0 (3.5-5.3 mmol/L) Creatinine 69 (44-97 umol/L) Echo parameter: Value: Glucose 4.5 (3.5-8.0 mmol/L) Left atrium LAA 17.5cm 2 Lipid Profile Right atrium RAA 15.9cm 2 Cholesterol 4.5 mmol/L Ejection Fraction Biplane 66% HDL 1.74 PASP estimated 19 mmHg + 0-5 mmHg LDL 2.49 Triglycerides 0.60 (0.30-1.80 mmol/L) LVEDV MOD BP 92 ml Cholesterol/HDL ratio 2.6 LVESV MOD BP 35 ml Vitamin D Vitamin D2 <5 Vitamin D3 51.5 Thyroid function test Serum TSH level 2.37 (0.35-5.5 Mu/L) Serum free T4 level 13.8 (10.0-19.8 pmol/L)

Issues: • 11.30pm Put in resus bed (not needed) • Bloods done & MSU • No plan of care (wait for doctor…) • Moved around the dept to avoid 4 hour (resus, ESSU, monitored bed) • Finally see SpR at 4am (insists on CXR despite no indication!) • Suggest cardioversion (luckily I had suggested it & was NBM!!) • No explanation to NoK (left when ED docs descended) • All eyes on ECG monitor, no nursing care at this stage • All docs once sinus rhythm restored- no aftercare (is she alright?) • Did not note cause of AF as stated

Glutamine • Glutamine, or L-glutamine, is an abundant non-essential amino acid endogenously synthesized from glutamate and ammonia by glutamine synthase. • Glutamine plays a role in the health of the immune system, GI tract, and muscle cells. It is stored in muscles and then the lungs where it is made and it is a principal carrier of nitrogen and is an important energy source. • Glutamine is commonly used in young adults as a supplement. • Ciocca (2005) reported that there is evidence that glutamine may prevent upper respiratory infections in athletes who undertake prolonged exercise and also to reduce symptoms of overtraining syndrome.

In the databases: • A search for both glutamine and glutamic acid. • Glutamic acid is converted in the body to form glutamine and therefore any reported side effects with glutamic acid could be relevant to Glutamine. • Most side effects with supplements do not get reported. In addition many of the supplements tend to be part of a complex product that has many ingredients. • In order to ensure that no data sources were overlooked, various herbal and supplement references were accessed and the Adverse Drug Reactions (ADRs) Databases in UK, Canada, Australia and New Zealand were also reviewed.

Side effects reported: • Although causality cannot be established, the following adverse reactions were reported. • 37 ADRs were reported with a total of 81 reactions. • Of these; there were 4 fatal ADRs with five possible cardiac-related ADRs of which one was fatal. • Glutamic acid was part of multiple ingredients in the product. • In terms of arrhythmias, there was one report of Bradycardia, one report of Tachycardia and one report of AF.

Other ADRs reported via other sources: • The New Zealand, Australian and Canadian medicines adverse reporting databases show that there have been a total of eight ADRs reported from the three databases combined. • These cardiac side-effects reported include: • palpitations (1), • ventricular tachycardia (1), • AF (1), • tachycardia (x2), • and chest pain (x3). • However, in all but one of these reports glutamate or glutamic acid were one of a number of 'active ingredients'

Impact on hospitals: • A recent review of ED surveillance data in the United States from 63 hospitals noted 3,667 cases of adverse effects from herbal and complementary nutritional products and micronutrients (Geller et al., 2015). • The authors estimated that on the basis of these cases, there are 23,005 ED visits annually relating to these products in the U.S. • They estimated there were 2,154 hospitalizations annually and approximately 28% of these hospitalizations involved young people between 20 to 34 years. • An estimated 65.9% (95% CI; 63.2-68.5) of ED visits were for single- supplement related adverse events and of those, 71.8% adverse events were related to weight-loss/energy products. The main symptoms reported palpitations, chest pain or tachycardia with 58% involving people aged between 20-34 years.

Follow-up • Sunday morning acute admission ward review • 12 lead ECG (SR) • Suggest echocardiogram • Tilt test and tests for syncopy • Document cause as glutamine powder

What I learnt: • How do patients NOT know they • Cardioversion via ‘conscious have AF?? sedation’ HURTS!! • Lack of communication • BUT did feel much better when HR reverted to SR • Very few ED staff introduced • Pain on inspiration for 2/52 themselves (no my name is…) afterwards and pain in • More concern about breaching 4 intercostal muscles hour wait than treatment • Can completely understand why • Carried out unnecessary tests patients do not want it (CXR) despite clear chest & no recent chest infections etc

Reference Lee G, Khatib R. An unusual case of atrial fibrillation. International Emergency Nursing 2016; 27: 56-59

References: • • Agostini, F., Giolo, G., 2010. Effect of physical activity on Liu, J., Marchase, R.B., Chatham, J.C., 2007. Glutamine-induced protection glutamine metabolism. Current Opinion Clinical Nutrition and of isolated rat heart from ischemia/reperfusion injury is mediated via the Metabolic Care 13(1), 58-64. hexosamine biosynthesis pathway and increased protein O-GlcNAc levels. Journal of Molecular and Cellular Cardiology 42 (1), 177-185. • Ciocca, M., 2005. Medication and supplement use by athletes. • Clinics in Sports Medicine 24 (3), 719-738. National Institute of Health and Clinical Excellence, 2014. Atrial fibrillation: the management of atrial fibrillation. • Geller, A.L., Sharma, N., Weidle, N.J., Lovegrove, M.C., Wolpert, https://www.nice.org.uk/guidance/CG180. Accessed November 19th B.J., Timbo, B.B. et al., 2015. Emergency department visits for 2014. adverse events related to dietary supplements. New England • Journal of Medicine 373, 1531-1540. Neu, J., DeMarco, V., Li, N., 2002. Glutamine: clinical applications and mechanism of action. Current Opinion Clinical Nutrition and Metabolic • Khogali, S.E.O., Pringle, S.D., Weryk, B.V., Rennie, M.J., 2002. Is Care 5 (1), 69-75. glutamine beneficial in ischemic heart disease? Nutrition 18 (2), • 123-126. Parry-Billings, M., Budgett, R., Koutedakis, Y. 1992. Plasma amino acid concentrations in the overtraining syndrome: possible effects on the • Kreider, R.B., 1999. Dietary supplements and the promotion of immune system. Medicine and Science Sports Exercise 24 (12), 1353-138. muscle growth with resistance exercise. Sports Medicine 27 (2), • 97-110. Weijs, B., Crijns, H.J.G.M., 2014. Lone or idiopathic atrial fibrillation, • Lacey, J.M., Wilmore, D.W., 1990. Is glutamine a conditionally messenger of misery in sight. International Journal of Cardiology 177, essential amino acid? Nutrition Review 48 (8), 109-136. 734-735. • Lee, G.A., Stub, D., Lin, H., 2012. Atrial fibrillation in the elderly- • Weitzel, L., Wischmeyer, P., 2010. Glutamine in Critical Illness: The Time not a benign condition. International Emergency Nursing 20, 221- Has Come, The Time Is Now. Critical Care Clinics 26 (3). 227 • Tao, K., Li, X., Yang, L., Yu, W., Lu, Z., Sun, Y., Wu, F., 2014. Glutamine supplementation for critically ill adults. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD010050. DOI: 10.1002/14651858.CD010050.pub2