Critical Care Management of Patients with Barium Poisoning: A Case Series

0
0
0

Critical Care Management of Patients with Barium Poisoning: A Case Series

Acute barium poisoning is a rare but potentially life-threatening condition that occurs primarily due to the ingestion of soluble barium compounds such as barium chloride (BaCl2). This condition can lead to severe gastrointestinal symptoms, hypokalemia, hypertension, cardiac arrhythmias, and skeletal muscle paralysis. This article presents a detailed account of a case series involving multiple patients who experienced barium poisoning due to food contamination, along with a comprehensive discussion of the clinical management strategies employed to treat these patients.

Background and Case Presentation

The incident occurred on March 13, 2018, in Ningde city, Fujian province, China, where several patients presented with symptoms of abdominal cramps, vomiting, diarrhea, and partial paralysis after consuming KomPyang, a traditional charcoal-baked scallion cake. The Fujian Provincial Center for Disease Control and Prevention (CDC) investigated the cases and identified barium chloride contamination in the meat filling of the KomPyang. The contaminated food contained 40 g/kg of BaCl2, and each KomPyang had approximately 10 g of meat filling, resulting in 0.4 g of BaCl2 per cake.

Over the following 24 hours, 48 patients with suspected food poisoning were admitted to hospitals at the county level and above, with 41 requiring hospitalization. Seven patients with mild gastrointestinal symptoms were treated in outpatient clinics and recovered quickly. The severity of barium poisoning was classified based on serum potassium levels: severe (<2.5 mmol/L), moderate (2.5 to 3.0 mmol/L), and mild (3.0 to 3.5 mmol/L). Among the 21 cases treated at Ningde Hospital, 57% were severe, 19% were moderate, and 24% were mild.

Clinical Features and Diagnostic Criteria

Barium poisoning manifests with a range of symptoms, including gastroenteritis (vomiting, diarrhea, and abdominal pain), hypokalemia, hypertension, cardiac arrhythmias, and skeletal muscle paralysis. Hypokalemia is a hallmark of barium poisoning and results from the inhibition of potassium channels and the sodium-potassium pump by barium ions. This leads to a shift of potassium from the extracellular to the intracellular space, causing severe muscle weakness and potentially life-threatening cardiac arrhythmias.

In the presented case series, all patients exhibited hypokalemia to some extent, with severe cases showing serum potassium levels as low as 1.4 mmol/L. Electrocardiographic changes, including T-wave morphology, ST-segment depression, and U waves, were observed in patients with moderate to severe poisoning. The diagnosis of barium poisoning was confirmed by the detection of excess BaCl2 in the consumed food, although urinary or blood barium concentrations were not measured due to limited equipment.

Management and Treatment Strategies

The management of barium poisoning involves a multifaceted approach aimed at rapidly correcting hypokalemia, precipitating barium ions, and providing supportive care to prevent complications. The key steps in the treatment of barium poisoning include:

  1. Potassium Supplementation: Intravenous potassium chloride (KCl) is the cornerstone of treatment for barium poisoning. In the representative case, a 38-year-old man who consumed four KomPyangs (1.6 g BaCl2) developed life-threatening hypokalemia (1.4 mmol/L) and required aggressive potassium supplementation. He received KCl at a rate of 15.0 mmol/h, with a total dose of 160 mmol (11.2 g) over 8 hours. Continuous monitoring of serum potassium levels and electrocardiographic changes is essential to prevent rebound hyperkalemia.

  2. Precipitation of Barium Ions: Oral administration of sodium sulfate, sodium thiosulfate, or magnesium sulfate can precipitate barium ions in the intestines, preventing their absorption. In the presented case, magnesium sulfate (25 g in 250 mL of 5% glucose saline) was administered intravenously to precipitate Ba2+ ions. Magnesium ions also help maintain normal intracellular potassium levels and promote potassium retention.

  3. Correction of Acidosis: Patients with severe poisoning may develop metabolic acidosis due to tissue hypoxia and lactic acidosis. Sodium bicarbonate (125 mL) was administered to correct acidosis in the representative case, leading to an improvement in the patient’s pH and bicarbonate levels.

  4. Respiratory Support: Muscle paralysis caused by barium poisoning can lead to respiratory failure. Emergency tracheal intubation and mechanical ventilation were required for the representative case due to respiratory muscle paralysis. The patient was successfully weaned off the ventilator after 8 hours of intensive care.

  5. Supportive Care: Comprehensive supportive care, including rehydration, monitoring of vital signs, and protection of the myocardium, is essential for the successful management of barium-poisoned patients. In the presented case series, all patients received continuous oxygen inhalation, IV rehydration, and close monitoring of blood biochemistry and vital signs.

Outcomes and Prognosis

The prognosis of barium poisoning depends on the promptness and adequacy of treatment. In the presented case series, all patients who received timely and appropriate management recovered without complications. The average duration of hospitalization was 5 days, with a significant positive correlation between the duration of hospitalization and the ingested dose of BaCl2. The patient who consumed four KomPyangs (1.6 g BaCl2) experienced the most severe poisoning but made a miraculous recovery after intensive treatment.

Special Considerations

Although barium crosses the placenta, it may not be toxic to the human fetus. In the presented case series, a pregnant patient who experienced acute barium poisoning delivered a healthy baby months after the incident. This suggests that barium poisoning during pregnancy may not have significant teratogenic effects, although further research is needed to confirm this observation.

Prevention and Public Health Implications

Inadvertent consumption of barium-contaminated food is the leading cause of barium poisoning. This can occur when BaCl2 is mistakenly used instead of salt, flour, or baking powder. In the presented case series, the chef unknowingly used BaCl2 instead of potato flour, leading to widespread contamination. Public health measures, including proper labeling and storage of chemicals, are essential to prevent such incidents.

Conclusion

The management of barium poisoning requires a comprehensive and multidisciplinary approach to rapidly correct hypokalemia, precipitate barium ions, and provide supportive care. The presented case series highlights the importance of timely and appropriate treatment in ensuring the successful recovery of barium-poisoned patients. Continuous monitoring of serum potassium levels, electrocardiographic changes, and vital signs is essential to prevent complications and achieve favorable outcomes. Public health measures should be implemented to prevent accidental barium poisoning and protect the population from this rare but potentially devastating condition.

doi.org/10.1097/CM9.0000000000000672

Was this helpful?

0 / 0