Severe Lactic Acidosis and Diastolic Hypotension after Salbutamol in an Italian Boy: A Rare Case

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salbutamol

This case study describes an adverse drug reaction to salbutamol, which led to prolonged hospitalization despite his asthma exacerbation showing improvement.

Case Study

A twelve-year-old Italian boy weighing 34kg was referred to PED with intermittent chest pain, wheezing, cough, and mild fever. The symptoms had been going on for 24 hours. Before his arrival at the PED, he was taking 0.2mg of inhaled salbutamol every 3 hours. It was initiated a day before without any medical advice. Moreover, his last administration was 1 hour ago. However, there was no report of inciting exercise. But his room was reported to have hypoallergenic material. The salbutamol inhaler was a part of his asthma treatment regime by his pulmonologist. Nevertheless, it should be noted that the boy’s Montelukast treatment was discontinued by his pneumologist after being asthma-free for 3 months.

Medical History

His past medical history comprises intermittent asthma diagnosed a year ago, which was exacerbated by exercise and dust mites. However, only one mild exacerbation appeared 9 months after the diagnosis. It did not require hospitalization. Moreover, during that period, his bedroom had no hypoallergenic material.

Physical Examination

The boy’s physical examination showed substernal and intercostal retractions. Furthermore, reduction in end respiratory breathing and normal breath sound was also seen. In addition, there was no effect on his speaking ability and his pediatric asthma score was 9.

Diagnosis and Treatment

The doctors made a diagnosis of a moderate asthma attack and treated him with 40mg IV methylprednisolone and 3.75mg nebulized salbutamol with 0.5mg ipratropium bromide at 20-minute intervals.

Moreover, the doctors performed three-oxygen-driven nebulization because the patient had persistent wheezing, moderate hypoxia, and retraction.

When the nebulization ended, a presyncope episode was seen five minutes after it. Nevertheless, other than tachycardia, the vitals were normal at the onset. Moreover, a physical examination revealed hand tremors, a pale look, and eupneic with normal breath sounds and weak radial pulse. Doctors also obtained a 12-lead electrocardiogram with blood samples that showed normal troponin-T serum levels. Hence a normal saline infusion started.

Clinical Conditions

The patient’s clinical conditions started worsening slowly in 30 minutes. He suffered extreme pallor, faintness, and cold extremities. The doctors conducted a blood gas test, which showed metabolic acidosis with elevated lactate levels, hypercalcemia, and hypokalemia. Furthermore, since the findings were consistent with β2 receptor agonist side effects, doctors discontinued the salbutamol. Moreover, therefore, two boluses of Ringer’s acetate were administered every twenty minutes because of persistent hypotension. Other than that, hypokalemia was treated with normal saline and potassium chloride. The oxygen supplementation was started with a Venturi mask with a maximum of 0.3 FiO2.

The patient had been admitted to the intensive observation unit. When he was observed, he was eupneic without any expiratory wheezing. His hypokalemia reverted quickly. However, lactic acidosis and lower DBP persisted for a while. Doctors administered ipratropium every four hours as a bronchodilator treatment.

After 24 hours, another 12-lead ECG was done. Moreover, based on the pediatric oncology consultation, any evidence of compromised left ventricular function and cardiac output suggested that the previous ECGs done may have had a multifactorial origin. For example, mild fever, β2-agonist toxicity, and hypokalemia. Eventually, the patient was discharged and had a good clinical condition upon discharge. He was prescribed oral betamethasone and nebulized ipratropium bromide every day, four times. Moreover, a drug challenge using inhaled salbutamol with a spacer a week after did not show any adverse effects.

Conclusion

It has been reinforced multiple times that the use of intermittent nebulized salbutamol for acute moderate asthma can cause severe transient complications in children. Healthcare providers should be wary of any emergency settings for achieving prompt recognition. In addition to management of this adverse reaction. Moreover, careful reassessment can prevent any similar reactions.

Based on the best knowledge, this case was described as a severe drug reaction after a low dosage of intermittent nebulized salbutamol ever reported. It was given to a child with moderate asthma exacerbation and mild dehydration. Hence doctors need to do a careful assessment followed by each nebulization. Clinicians should pay attention to the unexplained lactic acidosis, persistent lower diastolic blood pressure when treating exacerbated asthma in children. Even when standard doses are used. This practice can prevent an adverse outcome or poor management.

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