Letters to the Editor

Unusual presentation of pericardial effusion Sir, I read the article on “Unusual presentation of pericardial effusion” by Saseedharan et al., with interest.[1] I have to commend the authors for highlighting well certain salient features of pericardial effusion symptomatology and clinical aspects of cough syncope. But there are some unexplained factors that had been left unattended in the case report. The authors do mention that the predominant feature of this particular case presentation is cough syncope, and they also do mention that this is possibly related to raised intrathoracic pressure. But what is lacking is the clear association with a prominent right hilar shadowing, a cytology positive for metastatic non-small cell carcinoma, and moderate effusions at both pleural cavities along with this pericardial effusion. Even the right supraclavicular node showed a positive cytology for confirming a spreading disease, possibly from a focus in the lung. Any of these could also lead to elevation of intrathoracic pressure, however, transiently, and present with cough syncope. Also noteworthy are the findings on CT scan, showing features of concentric thickening of bronchial tree in the right lower lobe. Even if a metastatic lesion is found during a process of treatment of symptom-inciting condition, it is mandatory that one search for the primary disease to stage the lesion correctly, and ascertain the prognosis along with the treatment pathway. With the moderate effusion as shown by the imaging, it would be difficult to establish this as the actual cause of cough syncope rather than the whole complex of lung disease or pleural effusions. Absence of cardiac tamponade should also alert one to other explanations of the symptoms, and to work up the case in more detail than shown here.

Nagarajan Muthialu

Great Ormond Street Hospital, London, UK

Correspondence: Dr. Nagarajan Muthialu, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.

E-mail: [email protected]

Reference 1.

Saseedharan S, Kulkarni S, Pandit R, Karnad D. Unusual presentation of pericardial effusion. Indian J Crit Care Med 2012;16:219-21.

Access this article online Quick Response Code: Website: www.ijccm.org

DOI: 10.4103/0972-5229.125440

Are we infusing acids into our patient’s blood? Sir, Add sugar to water it turns into acid! Add salt to water to drink it also turns into acid! This may not be happening at home but this is what happens daily in a hospital. Five percent dextrose has a pH of 4.2 and normal saline has a pH of 5.5 when the molecules used in them are neutral. Lebowitz et al. pointed out the same concern a nearly half a century ago in their study to calculate titerable acidity of commonly used intravenous fluids.[1] The literature is silent about the cause of this, however, it reflects in clinical outcomes, as this acid we infuse is associated with increased incidence thrombophlebitis with decreasing pH of the infuscate. On analyzing it can be seen that dextrose based fluids are most associated with venous thrombophlebitis followed by normal saline and least by ringer lactate which is in coherence with te concept of decreasing pH-increasing thrombophlebitis. Gaudry and Duffy in their comments on pH of intravenous fluids attributed the probable cause of this acidity to their method of sterilization by heat.[2] The exact mechanism is yet not commented upon by any available literature. It is unlikely for the constituents of fluids to cause this acidosis as normal saline and hypertonic saline both have same pH of 5.5. So if Sodium chloride (a neutral salt) were to be linked to acidosis it would have caused hypertonic saline to be more acidic. 49

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Unusual presentation of pericardial effusion.

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