Combined lactic acidosis and ketoacidosis in a female diabetic patient with severe heart failure

SGLT2i are now recommended in a wide spectrum of indications including type 2 diabetes (T2DM), heart failure, and chronic kidney disease. This medication class is now available in combination with metformin, which is still a fundamental treatment in patients with T2DM. Despite excellent proven safety profile for both drugs, the expanding use of these agents in clinical practice may lead to an increased incidence of rare side effects, like metformin-associated lactic acidosis (MALA) and euglycemic diabetic ketoacidosis (EDKA), which can be life-threatening. A 58-year-old woman with T2DM and severe heart failure treated by metformin and empagliflozin developed progressive EDKA triggered by fasting that was also complicated by severe acute renal failure and MALA. She was successfully treated with intermittent hemodialysis. This case report highlights the importance of the recognition of rare, but very serious adverse effects due to combined metformin and SGLT2i therapy.

294 Implementation of Colorectal Robotic Assisted Surgical Programme During a Global Pandemic: Collaboration Between Territorial and National Waiting Times Centre

Introduction

Golden Jubilee National Hospital (GJNH) established a thoracic Robotic Assisted Surgical (RAS) programme in 2018. In March 2021, GJNH invested in a new elective colorectal service and in response to the Scottish Government robotic investment established a collaboration with a territorial health board to host their robot and start a RAS colorectal programme. We provide an overview of barriers and facilitators leading to establishing this new collaboration.

Method

An observational review of RAS training timeline. Demographics, surgical operations, and hospital length of stay were documented. Surgeons, perioperative team, management, and industry (Intuitive) were interviewed to provide insights into implementation and training.

Results

Boards approved RAS business case in April 2021, robot on-site with GJNH governance approval in May. First cohort of colorectal surgeons completed proctored training July 2021. To date, 17 RAS resections performed (mean age 64, 9 males: 8 female). Mean length of stay 4.65 days. No anastomotic leaks and no mortality reported. Interviews revealed key facilitators: advantage of having an established RAS perioperative team and building on pre-existing industry links; developing and strengthening collaborative working between different health boards and surgeons. Barriers included: education of all team members to ensure patient safety for new specialty; multisite collaborative working.

Conclusions

This work provides a template model for future RAS collaborations between different sites and health boards. Collaborative working in a green-hospital setting may improve equity of access for patients whilst future-proofing surgery against further waves of the pandemic.

Palpitations Revealing a Primary Pulmonary Artery Sarcoma

Primary pulmonary artery sarcoma is an exceedingly rare and aggressive malignancy that carries poor prognosis. Clinical manifestations are nonspecific and include chest pain, dyspnea, syncope, palpitations, and asthenia, among others. Delay to diagnosis is common and compromises the prognosis. Here, we report an interesting case of primary pulmonary artery sarcoma presenting with frequent monomorphic premature ventricular contractions arising from the right/left ventricle outflow tract. Cardiac imaging is key in the evaluation of patients with frequent premature ventricular contractions to rule out rare pathologies such as tumour compression.

Heart Failure With Midrange Ejection Fraction-What Is It, If Anything?

The patient cohort with left ventricular ejection fractions (LVEFs) of 41%-49%, which has been defined as heart failure with midrange ejection fraction (HFmrEF), represent a significant proportion of the heart failure (HF) population. Despite the clear cutoffs established by different society guidelines, confusion remains regarding the exact significance of midrange LVEF within the HF syndrome. Patients with LVEF 41%-49% represent a heterogeneous group of patients sharing pathophysiologic mechanisms, biomarker profiles, comorbidities, and clinical characteristics with patients with preserved and reduced LVEF. In this clinical review, we discuss the underlying pathophysiologic mechanisms that culminate in the clinical syndrome of HF and contribute to the disparities observed between HFpEF, HFrEF, and HFmrEF. We highlight differences and similarities in clinical characteristics and imaging features between HFpEF and HFrEF in an effort to disentangle the heterogeneous group of patients with midrange LVEF, but ultimately we conclude that LVEF should be seen as simply one important element of a continuum throughout the HF syndrome, and that although is useful, it is an oversimplification, because HF syndrome is more of a continuum. The underlying pathophysiology, etiology, and comorbidities of patients presenting with HF is becoming ever more important as the limitations of a classification solely based on LVEF are being better recognised, and as patient-specific personalisation of care is becoming ever more important.

Left axis deviation. An electrocardiographic study with post-mortem correlation

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