Aims: This survey intended to find the prevalence of hypokalemia and its clinical correlatives in acute psychiatric unwellness among hypokalemic and normokalemic patients after acetaminophen overdose.
Methods: This is a retrospective cohort survey of infirmary admittances for ague Datril overdose conducted over a period of 5 old ages from January 1, 2004 to December 31, 2008. Demographic informations and different types of psychiatric unwellness were compared between hypokalemic and normokalemic patients. Hypokalemia was predefined by a serum concentration & A ; lt ; 3.5 mmol/ L. SPSS 15 was used for informations analysis.
Consequences: Two hundred and eighty patients out of 305 admittances were studied. Hypokalemia was found in 63.6 % of patients with a higher prevalence in the presence of psychiatric unwellness ( 67.7 % ) . Hypokalemic patients were significantly associated with the presence of major depression ( P = 0.04 ) , adjustment upset ( P & A ; lt ; 0.001 ) , anxiousness ( P = 0.01 ) , and self-destructive efforts ( P = 0.04 ) .
Decision: Hypokalemia was common among patients with psychiatric unwellness and ague Datril overdose.
Cardinal Wordss: Acetaminophen ; Hypokalemia ; Overdose ; Potassium ; Psychiatric unwellness.
Deliberate self-poisoning ( DSP ) is recognized as a major cause of self-destruction around the world.1 Acetaminophen ( Paracetamol ) is the most common drug employed in DSP in many states, 2, 3 including Malaysia.4 Despite first-class safety in curative doses of Datril ; it is besides one of the prima causes of terrible hepatic necrosis.5
Acetaminophen overdose may be accompanied by electrolyte perturbations including hypokalemia, and these appear to be independent of the hepatotoxic effects.6 These electrolyte alterations appear to be due to the addition in fractional nephritic elimination of K, but the implicit in cellular mechanisms by which Datril might change electrolyte conveyance are still unknown.6-9 In some instances, hypokalemia may be terrible, making a degree of 2.3 mmol/ L after reported consumption of 48 g of acetaminophen.8
Hypokalemia, an easy identifiable and clinically of import status in clinical scenes, has received small attending from research workers worldwide. Not merely is hypokalemia associated with frequent cardiac and neuromuscular complications, but its consequence on mental map may besides worsen psychiatric disturbances.10, 11 Both anxiety12 and intense exercise13 addition go arounding adrenaline, which induces a ?2 – receptor-mediated inflow of K into skeletal muscle.14 As this status may be similar to the acute psychotic province, it was hypothesized that the diminution in serum K concentration could be associated with the presence of psychiatric unwellness during Datril overdose.
To better our cognition of hypokalemia after acute Datril overdose, we carried out a five-year, hospital-based survey with the following aims: 1 ) to find the prevalence of hypokalemia in patients showing to infirmary after Datril overdose, and 2 ) to look into the clinical correlatives in acute psychiatric unwellness among hypokalemic and normokalemic patients after acetaminophen overdose.
Settings and Study Design
This is an experimental retrospective instance reappraisal of all patients with acute Datril overdose admitted to a 1200-bed infirmary located in the Northern part of Malaysia. The infirmary provides wellness attention and exigency intervention for all unwellnesss and accidents. All facets of the survey protocol, including entree to and usage of the patients ‘ clinical information, were authorized by the local wellness governments before induction of this survey.
Participants and Data Collection
Datas were collected from January 1, 2004 to December 31, 2008. A computing machine generated list was obtained from the Hospital Record Office. We identified our instances harmonizing to the T-codes of the International Classification of Diseases-Tenth alteration ( ICD-10 ) . All patients with diagnostic codifications T 39.1 ( acetaminophen overdose ) were included in the survey.
Specially designed data-collection signifiers were used to roll up informations refering age, gender, fortunes of overdose ( inadvertent or suicidal ) , stated day of the month and clip of poisoning to cipher the latency clip ( the clip of consumption to the clip the patient was presented at the infirmary ) , measure of Datril ingested, GI decontamination such as tummy wash, research lab trials including serum Datril concentration, and serum K concentrations during the first twenty-four hours of admittance and after a lower limit of 4 hours of consumption. Data on serum Datril concentration measurings were obtained from the infirmary ‘s curative drug supervising laboratory service. In add-on, informations related to the presence of psychiatric unwellness were obtained. psychiatric unwellness was defined as the presence of any perturbation of emotional equilibrium, as manifested in maladaptive behaviour and impaired operation, caused by familial, physical, chemical, biological, psychological, or societal and cultural factors such as depression, anxiousness, accommodation upsets, unprompted behaviours and emphasis reactions, either emotional or behavioural ; these causes were noted by the infirmary psychiatric specialist study.
Hypokalemia was defined as a serum K degree of less than 3.5 mmol/ L.11 Patients with hypokalemia were classified into three groups based on K degrees: ( 1 ) mild/ grade 1 ( 3.0 – 3.4 mmol/ L ) , ( 2 ) moderate/grade 2 ( 2.5 – 2.9 mmol/ L ) and, ( 3 ) severe/grade 3 ( & A ; lt ; 2.5 mmol/ L ) .15
The charts of all patients identified through the hunt were reviewed and the information collected. Charts were excluded from analysis for the undermentioned grounds: ( 1 ) baseline K concentrations were non measured, ( 2 ) if patients had taken acetaminophen but the cause of consumption was unknown or undetermined, ( 3 ) the clip of consumption was non known or ( 4 ) the patients were on regular prescribed drugs that lead to hypokalemia, such as Lasix, and ( 5 ) the patients were kids under 13 old ages of age. Charts of patients who had research lab trials at or more than 4 hours post-ingestion were extracted for farther analysis.
Datas were entered and analyzed utilizing the Statistical Package for Social Sciences plan version 15 ( SPSS ) . Data were expressed as average ± SD for uninterrupted variables and as frequence for categorical variables. The Chi square or Fischer ‘s exact trial, as appropriate, was used to prove the significance between categorical variables. The independent samples t-test was used to compare agencies of uninterrupted variables. Variables were tested for normalcy utilizing the Kolmogorov-Smirnov trial. Variables that were non usually distributed were expressed as a median ( lower – upper quartiles ) . Statistical significance was considered at P & A ; lt ; 0.05.
Three hundred and five instances of Datril overdose were identified. Of these, 25 patients ( 8.2 % ) were excluded. Baseline K concentrations were non measured in eight patients, one patient was given furosemide at admittance, five patients were less than 13 old ages old, the cause of consumption was unknown or undetermined in 11 patients, and hence, the survey population consisted of 280 patients ( 45 male and 235 female patients with a average age of 23.4 ± 7.1, giving a female: male ratio of 5.22: 1 ) .
The bulk ( 72.1 % ) of instances of acetaminophen consumption were presented within eight hours. The average ( interquartile scope ) measure of Datril ingested was 10 g ( 6 – 15 g ) . Initial direction included tummy wash, which was performed in 181 ( 64.6 % ) instances. Activated wood coal was given while patients were in the Accident and Emergency section ; it was given as individual or multiple doses in 173 instances ( 61.8 % ) . Intravenous N-acetylcysteine ( NAC ) was given to 140 patients ( 50 % ) after Datril degrees were estimated. The average ( interquartile scope ) serum acetaminophen concentration was 55.6 mg/ L ( 14 – 120 mg/ L ) .
During the survey period, 63.6 % ( 178 patients ; 33 males and 145 females ) had K degrees of less than 3.5 mmol/ L. For the hypokalemic patients, the average K degree was 3.1 ± 0.26 mmol/ L, while that for the normokalemic patients was 3.76 ± 0.35 mmol/ L. Most of the patients ( 129 ) were in mild phase hypokalemia and 45 patients were in moderate phase hypokalemia. Few patients ( 4 ) were in terrible phase hypokalemia. Psychiatrically sick topics were found to hold hypokalemia, and the prevalence was higher than that in non-psychiatrically sick topics ( 67.7 % versus 43.8 % ; severally, P = 0.002 ) ( Figure 1 ) .
The most common clinical diagnosing among medically treated self-destruction triers was adjustment upset ( 45.7 % ) followed by unprompted behaviour ( 24.3 % ) , major depression ( 10.7 % ) , and anxiousness ( 2.1 % ) . Hypokalemia was significantly associated with the presence of major depression ( P = 0.04 ) , adjustment upset ( P & A ; lt ; 0.001 ) , anxiousness ( P = 0.01 ) , and self-destructive efforts ( P = 0.04 ) . However, normokalemia was significantly associated with unprompted behaviour ( P & A ; lt ; 0.001 ) , the absence of psychiatric unwellness ( P = 0.002 ) , and the presence of inadvertent overdose ( P = 0.04 ) ( Table 1 ) .
One hundred and twelve patients with adjustment upset and six patients with anxiousness were found to hold hypokalemia, and the prevalence of hypokalemia among these patients was higher than that in the overall survey population and in patients with other psychiatric upsets ( 100 % and 87.5 % , severally ) . Similarly, their average K degree was lower than that of the overall survey population ( 3.16 ± 0.41 and 3.2 ± 0.21 mmol/ L, severally ) ( Table 2 ) .
Eight hypokalemic patients ( 4.5 % ) were supplemented with unwritten K medicine, and 85 hypokalemic patients ( 47.8 % ) were treated with endovenous K chloride, and their K degrees were normalized in the following blood trial. Additionally, most of the treated patients ( 59 ) were in mild phase hypokalemia and 32 patients were in moderate phase hypokalemia. Few patients ( 2 ) were in terrible phase hypokalemia.
This survey is the first of its sort in Malaysia and has been carried out to find the prevalence of hypokalemia in patients showing to infirmary after acute Datril overdose, and to look into the clinical correlatives in acute psychiatric unwellness among hypokalemic and normokalemic patients after acetaminophen overdose in 280 patients with acute Datril overdose collected retrospectively from a records register.
In this survey hypokalemia was identified in 178 patients, and the prevalence of hypokalemia among hospitalized patients with acetaminophen overdose was 63.6 % . A old survey found that hypokalemia was common in medical inmate settings.16 About 20 % of shot, 10 % of myocardial infarction patients,17 21.2 % of psychiatric disorders,18 and about one tierce of ague Datril overdose patients suffered from hypokalemia.9 The high prevalence of hypokalemia after Datril overdose might be due to multiple hazard factors. The etiology of hypokalemia is complex. The degree of serum K depends on the balance between unwritten consumption, nephritic and GI losingss every bit good as the balance and motion between excess and intra-cellular compartments.11 A old survey found that 7.6 % of psychiatric patients had nutritionary jobs ; 19 unequal dietetic K consumption was comparatively rare unless day-to-day K consumption was less than 25 mmol.20
This survey found that it was the psychiatrically sick patients, instead than those patients with no psychiatric unwellness, who were more likely to develop hypokalemia. This determination is consistent with other published surveies that showed that hypokalemia was common among acute psychiatric inpatients.18, 21, 22 Adjustment upsets are frequently precipitated by emphasis reactions.23 For most people, emphasis is associated with higher hydrocortisone levels.24, 25 Previous surveies have suggested that high hydrocortisone degrees may be the chief cause of hypokalemia.26-28
In this survey, patients with anxiousness were enduring from a low mean K concentration and a high prevalence of hypokalemia. The exact mechanism was unsure. This determination is in understanding with another published survey that has shown little lessenings in serum K among 200 pre-operative patients who had an addition in anxiety.12 The account of this determination is that anxiousness increases the circulating adrenaline, 12 which induces a ?2 – receptor-mediated inflow of K into skeletal muscle.14
In the present survey, patients with major depression were enduring from a high prevalence of hypokalemia. This determination is similar to a old work that has shown patients with major depression had lower average serum K values and a higher incidence of hypokalemia than other upsets such as dysthymic upset and schizophrenic psychosis.18 This determination may be due to alterations in sympathomimetic thrust or in sensitiveness or denseness of the ?2-receptor. 18
Expected findings in our survey were the low incidence of hypokalemia in the patients with unprompted behaviour. These patients differed significantly from the other types of psychiatric unwellness and considered as a portion of the normal behavior.29 This is supported by findings that impulsivity is a type of human behaviour characterized by the disposition of an person to move on impulse instead than thought.30 It has been concluded in old survey that the reduced peripheral adrenaline degrees may be involved in pathophysiology of unprompted and overactive behaviors.31 This mechanism consequences in a reduced consumption of K by cells.
In add-on, this survey found that it was the self-destructive patients, instead than those with inadvertent overdose, who were more likely to develop hypokalemia. Attempted self-destruction is assumed to be a hyper-adrenergic state.18 A retrospective survey carried out on patients with psychiatric upsets concluded that important differences existed among the attempted self-destruction group with respect to hypokalemia.18 ?-adrenergic receptor stimulation causes hypokalemia in experimental animate beings and humans.32 There is small uncertainty that one of the mechanisms of hypokalemia is a beta 2-receptor-mediated inflow of K into skeletal musculus, induced by go arounding epinephrine.18, 33, 34 It has been demonstrated that adrenaline causes inordinate activation of the sodium/potassium-ATPase pump as a consequence of ?2-adrenergic receptor stimulation.14, 33 This mechanism consequences in an increased consumption of K by cells, taking to a lessening in serum K degrees. As the influence of the sympathomimetic system on serum K is found in many psychiatric state of affairss, 18, 21, 22, 35 it may explicate why a high prevalence of the patients included in our survey were presented with hypokalemia.
A high per centum of patients ( 47.7 % ) were still non being treated for low K degrees, seting their wellness in hazard. The common happening of hypokalemia in patients with acute Datrils overdose should alarm all clinicians to the importance of rectifying K loss, since most of the patients with an Datril overdose might hold received endovenous fluids or N-acetylcysteine in serum dextrose 5 % . However, this may hold altered serum K concentrations through endogenous insulin production induced by 5 % dextroglucose, ensuing in motion of K into the intracellular compartment. However, the extended usage of dextroglucose may expose the patients to higher hazards.
This survey is the first one of its type in Malaysia to look into the clinical correlatives in acute psychiatric unwellness among hypokalemic and normokalemic patients after acetaminophen overdose. It is besides the first survey suggested that hypokalemia is related to psychiatric position after Datril overdose instead than the old studious that showed a dose-dependent relationship between autumn in serum K and serum Datril at presentation.6, 9 Our survey suffers from a few restrictions. First, farther hazard factors for hypokalemia were non taken into history in the analysis. A 2nd restriction is its retrospective nature and the deficiency of structured interview appraisal of the topics. Third, we can merely propose, instead than turn out, that the psychiatric province is responsible for the high happening of hypokalemia diagnosed in our population.
Decisions and recommendations
In decision, hypokalemia is extremely prevailing among psychiatrically sick patients and after acute Datril overdose. Therefore, monitoring of serum K concentration may be clinically of import on exigency admittance for all instances of ague Datril overdoses to forestall the effects of hypokalemia. Supplemental potassium disposal should be commenced every bit shortly as possible.
Recognitions: The writers would wish to thank the Universiti Sains Malaysia ( USM ) for the fiscal support provided for their research. The aid of the medical and record office staff is appreciatively acknowledged.
Conflict of involvements: We would wish to declare that there was no struggle of involvements in carry oning this research.