CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 41 A computed tomography (CT) scan of the abdomen showed mildly thickened caecal and ascending colonwalls. The radiologist suggested that ischaemic colitis be considered since mural calcifications were noted in multiple abdominal blood vessels, suggesting the presence of extensive atherosclerotic disease. A review was performed by the surgeon, who subsequently planned for an exploratory laparotomy, but the patient’s family refused consent for surgery. A point-of-care ultrasound (POCUS) assessment showed that the inferior vena cava was collapsed and there was no free fluid in the abdomen. The cardiac chambers appeared normal with good contractility and there was no pericardial effusion. Initial measures included volume replacement. Despite adequate fluid resuscitation with plasmalyte B (a repeat POCUS examination showed that the inferior vena cava was no longer collapsible), the patient remained hypotensive with persistent acidosis six hours after the initial assessment and had begun to show signs of Table 1. The metabolic response to thiamine Hours after commencing thiamine Variables 7 h 10 h 17 h 27 h Case 1 pH 6.94 7.06 7.39 7.45 Lactate (mmol/l) 23 19 10.2 1.7 Base excess –28.2 –24.9 –9.9 1.3 HCO3 (mmol/l) 6.0 7.8 15.1 25.3 1 h 1.5 h 3 h 5 h Case 2 pH 7.015 7.205 7.24 7.23 Lactate (mmol/l) 14 7.1 5.3 3.5 Base excess (mmol/l) –23 –13.1 –8.5 –7.3 HCO3 (mmol/l) 8.9 14.7 17.3 18.3 Case 1: There was early haemodynamic improvement but the improvement in acidosis and fall in lactate levels occurred 17 hours after the commencement of thiamine. Case 2: A dramatic improvement in acidosis and fall in lactate levels occurred within 1.5 hours of commencing thiamine. Fig. 1. Abdominal radiograph of index patient showing distended loops of bowel on the left, interpreted as a sigmoid volvulus. Fig. 2. Case 1: A. Baseline ECG recorded at the same time as the troponin I estimation (1 358 ng/l). showed no evidence of myocardial infarction. B. ECG done one hour after commencement of adrenaline infusion shows ST-segment elevation in V3–6. C. Recording two days after intravenous thiamine shows ST-segment resolution with T-wave inversion in precordial leads V1–4. A B C
RkJQdWJsaXNoZXIy NDIzNzc=