2021 Volume 23 Issue 6 Published: 28 June 2021
  

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  • Pay attention to euglycemic diabetic ketoacidosis caused by sodium-glucose transporter 2 inhibitor
    Ji Liwei
    2021, 23(6): 281-284. https://doi.org/10.3760/cma.j.cn114015-20210515-00575
    Abstract ( ) PDF ( )
    Sodium-glucose transporter 2 inhibitors (SGLT2i) are novel oral hypoglycemic agents, which reduces blood glucose by inhibiting the reabsorption of glucose in the proximal convoluted tubule of the kidney and increasing the excretion of glucose to the urine. SGLT2i is effective in the treatment for diabetes mellitus, but there are also some safety problems. Diabetic ketoacidosis (DKA) is a serious adverse reaction of SGLT2i. SGLT2i could cause at least a 7-fold increase in developing DKA, approximately 70% of which are euglycemic DKA (euDKA). The risk factors for euDKA include insufficient insulin secretion cell reserve, type 1 diabetes mellitus, insulin reduction or discontinuation, hypovolemia, perioperative period, weight loss, and restricted feeding, etc. Because the increase of blood glucose in patients with euDKA is not obvious, the diagnosis is often delayed, so close attention should be paid to it. Safety medication training for SGLT2i should be strengthened to improve clinicians′ understanding of SGLT2i-related euDKA, so that they can strictly grasp the indications of medication and avoid the inducement of euDKA. Once euDKA occurs, clinicians can make early diagnosis and treatment. Pharmacists should be involved in the safety management of patients using SGLT2i to improve the safety in treatment.
  • Expert consensus of anti-tumor drugs prescription review: kidney cancer
    Liu Min, Miao Wei, Zhang Chao, et al
    2021, 23(6): 285-292. https://doi.org/10.3760/cma.j.cn114015-20210302-00248
    Abstract ( ) PDF ( )
    Kidney cancer usually requires multidisciplinary individualized treatments. No matter what kind of treatment, drugs are essential. According to the "six-step process" (prescription legitimacy review, patient basic information evaluation review, treatment protocol review, organ function and laboratory index review, pretreatment review, and unconventional prescription review) in prescription review proposed by the anti-tumor drug prescription review expert group and referring to domestic and foreign kidney cancer guidelines and drug instructions in recent years, this consensus selects 9 targeted drugs and 4 immunotherapeutic drugs that are currently commonly used in China and elaborates the key review points in patient basic information evaluation review, treatment protocol review, and organ function and laboratory index review of kidney cancer drug treatment, in order to provide reference for clinical front-line pharmacists to review prescriptions of kidney cancer patients and promote rational drug use in clinic.
  • Analysis on the occurrence of adverse reactions of empagliflozin in hospitalized patients with type 2 diabetes mellitus
    Gao Wenjuan, Li Pengmei, Zhao Li
    2021, 23(6): 293-297. https://doi.org/10.3760/cma.j.cn114015-20210207-00162
    Abstract ( ) PDF ( )
    Objective To explore the occurrence of adverse reactions of empagliflozin in hospitalized patients with type 2 diabetes mellitus.　Methods Medical records of all patients who were treated with empagliflozin during hospitalization in China-Japan Friendship Hospital from May 1 to December 31, 2020 were collected through the hospital information system. According to the main adverse reactions indicated in the label of empagliflozin, the occurrence of urinary tract infection, hypoglycemia, and hypotension after the application of empagliflozin was retrospectively analyzed. According to the Handbook of Adverse Drug Reaction Reporting and Monitoring in China, the causality between drugs and adverse reactions was evaluated, and those adverse events that were certainly, probably, and possibly related to empagliflozin were judged as empagliflozin-related adverse reactions.　Results A total of 718 inpatients received empagliflozin treatment during the study period, including 517 males and 201 females, with age of (59±12) years. The doses of empagliflozin were all 10-mg orally once daily. The treatment time was (7±3) days and the length of hospital stay was (8±4) days. Among 718 patients, 17 (2.4%) experienced adverse reactions possibly related to empagliflozin, including 11 (1.5%) with urinary tract infection (all showing asympto-　matic bacteriuria), 4 (0.6%) with hypoglycemia, and 2 (0.3%) with hypotension. There were 8 males and 9 females among the 17 patients with adverse reactions, and the incidence of adverse reactions in females was significantly higher than that in males ［4.5% (9/201) vs. 1.5% (8/517), χ2=5.376, P=0.020］. Among the 11 patients with urinary tract infection, 4 were male, 7 were female, and the incidence of urinary tract infection in females was significantly higher than that in males ［3.5% (7/201) vs. 0.8% (4/517), χ2=7.040, P=0.008］. In the medical records of the 17 patients, the above-mentioned adverse reactions were all not documented as related to empagliflozin, and were all not reported as adverse drug reactions. Conclusions The adverse reactions related to empagliflozin in hospitalized patients with type 2 diabetes mellitus were urinary tract infection, hypoglycemia, and hypotension. The prevention of urinary tract infection should be strengthened, especially in female patients. The awareness of clinical medical staff on the adverse reactions of empagliflozin needs to be improved.
  • Effect of telephone follow-up-based pharmaceutical care on medication compliance and safety in discharged patients with type 2 diabetes mellitus
    Fu Yuechen, Song Zhihui, Dong Rui, Zhang Chao
    2021, 23(6): 298-303. https://doi.org/10.3760/cma.j.cn114015-20200721-00798
    Abstract ( ) PDF ( )
    Objective To investigate the effect of telephone follow-up-based pharmaceutical care on medication compliance and safety in discharged patients with type 2 diabetes mellitus.　Methods Type 2 diabetes mellitus patients, who were discharged from Beijing Tongren Hospital, Capital Medical University from January 2019 to December 2019 and with hemoglobin A1c (HbA1c) <9% during hospitalization were enrolled. Patients were divided into routine follow-up group and telephone follow-up group according to the post-discharge follow-up method. Patients in the routine follow-up group received routine pharmaceutical care and were followed up for 6 months after discharge, including outpatient follow-up once every 3 months and HbA1c test at the 6th month. On this basis, patients in the telephone follow-up group received pharmaceutical care by clinical pharmacists using telephone follow-up method, which was performed once every 2 weeks for the first 3 months after discharge and once a month for the next 3 months. The clinical pharmacists established follow-up registration files for patients in the 2 groups to record the condition of the patients on discharge and results of each follow-up. Scores of the "Diabetes Self-Management Scale (Chinese version)" score (DSMQ score, with a total score of 48 points, the higher the score, the better the self-management ability of the patient), "Chinese Version Morisky Medication Adherence Scale-8" score (Morisky score, with a total score of 8 points, regarding 6 to 8 points as good compliance), and blood glucose control results (evaluation index is HbA1c level, HbA1c <7.0% was used as the standard to calculate the compliance rate) 6 months after discharge and the incidences of adverse drug events during the follow-up period in patients between the 2 groups were compared.　Results A total of 95 patients were enrolled in the analysis, including 48 in the telephone follow-up group and 47 in the routine follow-up group. Differences in gender and age distribution, body mass index, DSMQ score, and HbA1c level and compliance rate on discharge in patients in the 2 groups were not statistically significant (all P>0.05). Six months after discharge, both the DSMQ score and Morishy score in the telephone follow-up group were higher than those in the routine follow-up group ［（38.1±4.4） vs.（34.3±4.1） points， P<0.001； （6.5±1.2） vs.（5.7±1.0） points， P<0.001］; the proportion of patients with good medication compliance in the telephone follow-up group were higher than those in the routine follow-up group ［81.3%（39/48） vs. 40.4%（19/47）， P=0.031］； the HbA1c level was lower and the HbA1c compliance rate was higher in the telephone follow-up group than those in the routine follow-up group［(6.2±1.2)% vs. (6.7±1.4)%, P=0.042; 72.9% vs. 51.1%, P=0.028］; the incidence of adverse drug events in the telephone follow-up group was lower than that in the routine follow-up group ［6.2% (3/48) vs. 25.5% (12/47), P=0.010］. Adverse drug events occurred in patients mainly included hypoglycemia, fatty induration or infection at the insulin injection site, and gastrointestinal reactions.　Conclusion Telephone follow-up-based pharmaceutical care can effectively improve the self-management ability of patients with type 2 diabetes after discharge, help patients maintain good medication compliance, thereby improving the blood glucose control effects and to a certain extent reducing the occurrence of adverse drug events.
  • Correlation between the risk of malignancy and dapagliflozin: a meta-analysis
    Huang Wenhui, Chen Qiuhong, Xue Honglin, Zhang Yunchen
    2021, 23(6): 304-311. https://doi.org/10.3760/cma.j.cn114015-20210315-00304
    Abstract ( ) PDF ( )
    Objective To systematically evaluate correlation between the risk of malignancy and dapagliflozin in type 2 diabetes mellitus.　Methods The databases such as PubMed, the Cochrane Library, American Clinical Trial Registry, Embase, JAMA, Wiley-Blackwell, Springer Link, Elsevier, Ovid, Taylor & Francis Online, CNKI, Wanfang, and VIP (up to March 2021) were searched. The randomized controlled trials (RCTs) on dapagliflozin with outcome indicators including malignancy occurrence were collected. Data extraction and quality analysis were performed for the enrolled literature, and meta-analysis was conducted using RevMan 5.3-software.　Results A total of 22-studies were enrolled in the analysis, all of which were multicenter RCTs, and the quality evaluation results were all grade A. Thirty-one thousand four hundred and fifty-one patients were involved in the 22-studies, of which 16-267 were in the experimental group (dapagliflozin 5 or 10-mg daily) and 15-184 in the control group (placebo or other hypoglycemic drugs). The course of treatment in the 22-studies ranged from 24 weeks to 5.2 years and it was 24 weeks in 15-studies (68.2%). A total of 1-302 patients developed malignancy during the trials, including 661 in the experimental group and 641 in the control group. The results of the meta-analysis showed that, regardless in the overall study of different dapagliflozin doses or in studies of dapagliflozin 5 or 10-mg/d, the differences in the risk of malignancy between the experimental group and the control group were not statistically significant ［overall study: 4.2% (661/15-911) vs. 4.1% (648/15-884), RR=1.02, 95%CI: 0.92-1.13, P=0.72; dapagliflozin 5-mg/d: 0.8% (10/1-181) vs. 0.6% (7/1-172), RR=1.35, 95%CI: 0.57-3.17, P=0.49; dapagliflozin 10-mg/d: 4.4% (651/14-730) vs. 4.4% (641/14-712), RR=1.01, 95%CI: 0.91-1.13, P=0.78］; the differences in the risk of breast cancer were not statistically significant ［overall study: 0.2% (25/12-216) vs. 0.2% (25/12-215), RR=1.00, 95%CI: 0.59-1.69, P=1.00; dapagliflozin 5-mg/d: 0.6% (2/348) vs. 0 (0/347), RR=3.00, 95%CI: 0.31-28.65, P=0.34; dapagliflozin 10-mg/d: 0.2% (23/11-868) vs. 0.2% (25/11-868), RR=0.93, 95%CI: 0.54-1.59, P=0.78］; the differences in the risk of bladder cancer were not significantly significant ［overall study: 0.1% (16/12-021) vs. 0.2% (28/12-019), RR=0.59, 95%CI: 0.33-1.07), P=0.08; dapagliflozin 5-mg/d: 0.7% (1/137) vs. 0 (0/137), RR=3.00, 95%CI: 0.12-73.00, P=0.50; dapagliflozin 10-mg/d: 0.1% (15/11-884) vs. 0.2 % (28/11-882), RR=0.55, 95%CI: 0.30-1.02, P=0.06］.　Conclusion Dapagliflozin may not increase the risk of malignancy in patients with type 2 diabetes mellitus, but its long-term safety needs further study.
  • Research progress on ocular adverse reactions related to paclitaxels and their prevention and treatment
    Ye Yating, Dou Guorui, Chang Tianfang, Chu Zhaojie
    2021, 23(6): 312-316. https://doi.org/10.3760/cma.j.cn114015-20200901-00922
    Abstract ( ) PDF ( )
    The ocular adverse reactions of paclitaxels can involve the ocular surface, ocular appendages and intraocular tissue, with various clinical manifestations, such as dry eye, lacrimal duct obstruction, conjunctivitis, keratitis, macular edema, retinal injury, optic nerve injury, etc., which can lead to irreversible visual impairment. The mechanism of ocular adverse reactions is still unclear. In these adverse reactions, macular edema may be related to the dysfunction of retinal pigment epithelial cells and Müller cells caused by paclitaxel, and others may be related to the cytotoxicity of paclitaxels. Baseline eye examination should be performed prior to the use of paclitaxels, and new ocular symptoms should be closely monitored during the treatment. Ocular adverse reactions can be diagnosed definitively through routine ophthalmic examination. The main treatments are timely adjustment of drugs and symptomatic treatments.
  • Severe liver injury and acute renal failure induced by ibuprofen
    Li Qin, Zhuo Ga, Jin Meiling, Ye Xiaofen
    2021, 23(6): 317-318. https://doi.org/10.3760/cma.j.cn114015-20201111-01126
    Abstract ( ) PDF ( )
    A 40-year-old female patient took ibuprofen dispersible tablets twice (0.4 g, 3-4 hours interval) by herself due to fever. One hour after the second medication, the patient developed nausea, vomiting, and small bleeding spots on skin. One day later, she developed yellowish skin and sclera. Three days later, her urine output decreased to 300-400-ml daily. Five days later, laboratory tests showed alanine aminotransferase (ALT) 3-531-U/L, aspartate aminotransferase (AST) 811-U/L, total bilirubin (TBil) 149.7-μmol/L, creatinine (Scr) 753-μmol/L, and uric acid (UA) 800-μmol/L. She was diagnosis as having severe liver injury and acute renal failure, which was considered to be associated with ibuprofen. After 6 days of treatments such as liver protection, continuous renal replacement therapy (CRRT), and fresh frozen plasma infusion, the patient′s yellowish skin and sclera were relieved and small bleeding points reduced. Laboratory tests showed ALT 513-U/L, AST 36-U/L, TBil 31.5-μmol/L, Scr 281-μmol/L, and UA 241-μmol/L. Her urine volume was 2-500-ml per day. After CRRT was stopped and liver-protective treatment was continued for 14 days, the yellowish skin subsided and the bleeding points disappeared. Laboratory tests showed ALT 55-U/L, AST 39-U/L, TBil 15.6-μmol/L, Scr 101-μmol/L, and UA 237-μmol/L, and her urine volume was 4-000-ml per day.
  • Submaxillary gland enlargement caused by reduced glutathione
    Yan Jingjing, Han Yi, Fan Manli
    2021, 23(6): 319-321. https://doi.org/10.3760/cma.j.cn114015-20201202-01196
    Abstract ( ) PDF ( )
    A 44-year-old male patient was hospitalized twice for chronic hepatitis B and alcoholic cirrhosis with hepatic encephalopathy. During the 2 times of hospitalization, the patient was treated with reduced glutathione and ornithine aspartate and developed bilateral submandibular gland enlargement on the 2nd day after the first medication in each hospitalization. Physical examination showed no abnormal skin color and temperature, no obvious tenderness, intact oral mucosa, and no redness and swelling of submandibular gland duct orifice. Ultrasonic examination showed diffuse enlargement of bilateral submandibular gland and visible peripheral lymph nodes and bilateral cervical lymph nodes. It was never aware to be drug-related in the first occurrence of submandibular gland enlargement, therefore the drug was not stopped and no special treatment was given. The patient′s submandibular gland enlargement subsided spontaneously 2 days later. During the 2nd hospitalization, the patient developed bilateral submandibular gland enlargement again, which was considered to be related to reduced glutathione because no submandibular gland enlargement appeared in the patient during the repeated use of ornithine aspartate in the past. Then the reduced glutathione was stopped and ornithine aspartate was continued. The patient′s submandibular gland enlargement subsided completely 1 day later.
  • Skin vitiligo-like depigmentation due to immune checkpoint inhibitors: report of 2 cases
    Wang Yuting, Chen Min, Zeng Minghui
    2021, 23(6): 321-323. https://doi.org/10.3760/cma.j.cn114015-20201120-01160
    Abstract ( ) PDF ( )
    Two patients (patient 1, a 72-year-old female; patient 2, a 52-year-old female) received immune checkpoint inhibitors for adenocarcinoma of right lung and melanoma, respectively. Patient 1 received an IV infusion of navacizumab 100-mg on the first day and 2 weeks was a cycle. In the 7th cycle of immunotherapy, Patient 1 developed vitiligo-like skin depigmentation around her lip and on the hairline, which was not treated because of no symptoms of pain or itching. In the 23rd cycle of immunotherapy, the area of vitiligo-like depigmentation reduced. In the 26th cycle of immunotherapy, reexamination showed progression of tumor. Patient 2 received an IV infusion of pablizumab 100-mg on the first day and 3 weeks was a cycle. In the 9th cycle of immunotherapy, she developed vitiligo-like depigmentation around the lip and on the hairline, which was not treated because of no symptoms of pain or itching. In the 15th cycle of immunotherapy, the area of vitiligo-like depigmentation increased and asymmetric round vitiligo mass appeared on the back and waist. Reexamination showed no tumor progression. Both the 2 patients did not use other drugs that might cause vitiligo-like skin depigmentation during immunotherapy. It was considered that the skin vitiligo-like depigmentation was probably related to immune checkpoint inhibitors.
  • Death due to severe hypoglycemia caused by diclofenac sodium and lidocaine injection
    Tang Jinyan, Lu Peipei, Yang Hui, Qian Hui, Xi Junzuan, Shen Jinhua
    2021, 23(6): 324-325. https://doi.org/10.3760/cma.j.cn114015-20201120-01163
    Abstract ( ) PDF ( )
    A 53-year-old male patient received intramuscular injection of diclofenac sodium and lidocaine injection 2-ml for abdominal pain. After one hour of medication, the patient developed upper abdominal discomfort, chest tightness, shortness of breath, sweating, and slight cyanosis of lips. Oxygen inhalation was given immediately. Electrocardiogram monitoring showed blood pressure 105/60-mmHg, heart rate 125 beats/min, and blood oxygen saturation 0.75. His peripheral blood glucose could not be detected. Glucose supplement and hormone therapy were given immediately. About 30-minutes later, the patient developed unconsciousness, no pulsation of the main artery, and cardiac and respiratory arrest. Cardiopulmonary resuscitation and other treatment measures were given immediately. However, the patient did not return to spontaneous heartbeat and breathing and was declared dead. It was considered that the patient′s severe hypoglycemia might be related to diclofenac sodium and lidocaine.
  • Liver injury induced by Rupixiao capsules (乳癖消胶囊)
    Niu Xiaoqiang
    2021, 23(6): 326-327. https://doi.org/10.3760/cma.j.cn114015-20201202-01202
    Abstract ( ) PDF ( )
    A 41-year-old female patient received Rupixiao capsules 1.6 g thrice daily for hyperplasia of mammary glands. About 30 days later, the patient developed nausea, dark urine, and yellowish skin and sclera. After 20 days of continued treatment, her symptoms worsened, so she stopped using Rupixiao capsules by herself. After 10 days of drug withdrawal, her symptoms were not improved. The laboratory tests showed alanine aminotransferase (ALT) 1-234-U/L, aspartate aminotransferase (AST) 778-U/L, gamma-glutamyltransferase (γ-GT) 174-U/L, alkaline phosphatase (ALP) 156-U/L, total bilirubin (TBil) 78.7-μmol/L, and total bile acid (TBA) 45.4-μmol/L. After excluding liver injury caused by other reasons through laboratory and auxiliary examination, drug-induced liver injury was diagnosed, which was considered to be related to Rupixiao capsules. Drugs such as reduced glutathione, polyene phosphatidylcholine, compound glycyrrhizin, ademetionine 1,4-butanedisulfonate, and bicyclol were given. The patient′s symptoms of nausea, yellow urine, and jaundice gradually subsided. After 35 days of treatments, laboratory tests showed ALT 39-U/L, AST 43-U/L, γ-GT 57-U/L, ALP 85-U/L, TBil 17.3-μmol/L, and TBA 14.3-μmol/L.
  • Rhabdomyolysis caused by gabapentin
    Wang Dongxue, Hou Jiqiu, Xu Feng
    2021, 23(6): 328-329. https://doi.org/10.3760/cma.j.cn114015-20201202-01198
    Abstract ( ) PDF ( )
    A 66-year-old female patient received gabapentin 0.3 g once daily for restless legs syndrome. After 3 days of medication, she developed muscle soreness, weakness of both legs, and dark brown urine. Laboratory tests showed myoglobin 2-855.0-μg/L, creatine kinase (CK) 3-009-U/L, CK-MB 61-U/L, serum creatinine (Scr) 542-μmol/L, urine protein (+++), and urine occult blood (+). Her lower limb muscle strength was grade 1. Rhabdomyolysis caused by gabapentin was considered. Then the drug was stopped, and the symptomatic treatments including rehydration, alkalized urine, diuresis, etc. were given. After 5 days of treatments, the patient′s dark brown urine and muscle soreness disappeared, weakness of both lower limbs was improved, and lower limb muscle strength returned to grade 3. Laboratory tests showed ALT 35-U/L, AST 55-U/L, myoglobin 929.0-μg/L, CK 325-U/L, Scr 557-μmol/L, urine protein (+), and urine occult blood (-). At a 1-month follow-up, the symptoms above-mentioned did not recur. Laboratory tests showed ALT 30-U/L, AST 38-U/L, myoglobin 135.0-μg/L, and CK 187-U/L.
  • Acute urinary retention with secondary acute kidney injury caused by paracetamol, pseudoepherine hydrochloride, dextromethorphan hydrobromide and chlorphenamine maleate in a patient with prostatic calculus
    Zhu Danyan
    2021, 23(6): 330-332. https://doi.org/10.3760/cma.j.cn114015-20201008-01006
    Abstract ( ) PDF ( )
    A 54-year-old male patient received furosemide, sacubitril and valsartan, trimebutine, and live combined bifidobacterium, lactobacillus and enterococcus capsules for heart failure, atrial fibrillation, abdominal distension, and diarrhea. The patient′s renal function was normal before medication and the serum creatinine (Scr) was 93-μmol/L. On day 2, due to the patient′s cough and sputum, paracetamol, pseudoepherine hydrochloride, dextromethorphan hydrobromide and chlorphenamine maleate (containing 325-mg paracetamol, 30-mg pseudoephedrine hydrochloride, 15-mg dextromethorphan hydrobromide and 2-mg chlorphenamine maleate in each tablet) 325-mg orally were added once every 6 hours. On day 3, the patient developed dysuria and lower abdominal pain. Laboratory tests showed Scr 215-μmol/L and B-type natriuretic peptide 0.091-μmol/L; emergency ultrasonography of urinary system showed prostatic calculus, normal prostate size, and full bladder. Considering that paracetamol, pseudoepherine hydrochloride, dextromethorphan hydrobromide and chlorphenamine maleate caused acute urinary retention and then acute kidney injury, the drug was stopped on that day and the other drugs were continued. On the 2nd day of drug withdrawal, the patient′s dysuria was relieved and Scr was 162-μmol/L; on the 3rd day of drug withdrawal, the patient′s symptoms disappeared and Scr was 134-μmol/L.
  • Levofloxacin-induced anaphylactic shock and rhabdomyolysis
    Sun Lirui, Zhou Wei, Tian Xu, Zhang Hongmei, Guo Qiushi
    2021, 23(6): 332-334. https://doi.org/10.3760/cma.j.cn114015-20201204-01210
    Abstract ( ) PDF ( )
    A 42-year-old male patient, who suffered serious wound pollution due to falling after drinking, received an intravenous infusion of levofloxacin hydrochloride injection 0.2 g dissolved in 0.9% sodium chloride injection 250-ml to prevent infection. When the first dose of levofloxacin was infused intravenously for about 2-minutes (about 4-ml), the patient suddenly developed dyspnea, restlessness, and agitation. His heart rate was 120 beats per minute, breath rate was 26 times per minute, blood pressure was undetectable, and blood oxygen saturation was 0.80. Levofloxacin was immediately discontinued and antiallergic therapy such as epinephrine and dexamethasone was given. Two minutes later, the patient′s heart rate dropped to 50 beats per minute, breathing decreased to 8 times per minute, and cyanotic appeared on the skin. Anaphylactic shock and type 2 respiratory failure were diagnosed and cardiopulmonary resuscitation, tracheal intubation, balloon assisted ventilation, and norepinephrine etc. were given immediately. Three hours later, the patient developed dark urine and elevated creatine kinase (CK), myoglobin, alanine aminotransferase, aspartate aminotransferase, and serum creatinine (Scr). His peak value of CK was 17-160-U/L, myoglobin was >3-000-μg/L, and peak value of Scr was 492-μmol/L. Rhabdomyolysis with acute kidney injury was considered. The symptomatic and supportive treatments such as hemofiltration, plasma infusion, correction of acidosis, and fluid replacement were given. Ten hours later, the patient′s blood pressure returned to normal, ventilator assisted breathing was continued, and the patient′s condition was gradually improved. Thirty-four days later, the levels of myoglobin, CK and Scr returned to within the normal range. Thirty-eight days later, the patient returned to spontaneous breathing and the ventilator was withdrawn.
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