DO NOT BE BRASH: OCTREOTIDE-INDUCED SYNDROME OF BRADYCARDIA, RENAL FAILURE, ATRIOVENTRICULAR NODAL BLOCKADE, SHOCK, AND HYPERKALEMIA

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: . CASE PRESENTATION: A 71-year-old with cirrhosis, presented for epistaxis and was admitted due to AKI (Cr 2.4 from baseline of 0.8). She started on treatment hepatorenal syndrome (HRS) midodrine, SQ octreotide, albumin. That same day, a rapid response called acute symptomatic bradycardia (HR 40s-50s), hypotension (SBP 60s) obtundation. Labs revealed pH 7.12, lactate 7.5, K 6.5. EKG showed sinus AV dissociation. Bedside echo demonstrated normal EF. The patient given IV atropine, sodium bicarb, insulin, pressors. intubated rapidly progressed 3-pressor shock requiring norepinephrine, vasopressin, epinephrine infusions maintain her MAP heart rate. CRRT initiated the patient's improved 4.8 without decrease in pressor requirement.Her medications were reviewed, octreotide determined as potential culprit agent, it can cause through nodal blockade, day decompensation, one hour prior decompensation. ultimately received 4 doses before discontinued. After discontinuation, requirement slowly downtrended; however, hemodialysis catheter clotted off. In interim while off dialysis, increased 5.5 she had abrupt worsening shock, which intracellular shifting K. resumed. approximately 18 hours normalization potassium, resolved, pressors extubated. DISCUSSION: Hyperkalemia blocking agents bradycardia. Together they synergistically produce more dramatic than would be expected either factor alone at mild levels expected. This vicious cycle hyperkalemia, bradycardia, renal dysfunction hypoperfusion, progressive hyperkalemia evolve into profound multiorgan (BRASH - Bradycardia, Renal failure, Shock, Hyperkalemia). CONCLUSIONS: most common error management BRASH is lack recognition. case demonstrates that not commonly recognized impacting cardiac conduction syndrome. Octreotide acts node incidence frequent bolus infusion route. this case, developed existing injury initiation octreotide. first report octreotide-induced It important know precipitate syndrome, used HRS (patients predisposed developing hyperkalemia). REFERENCE #1: Farkas, J. D., Long, B., Koyfman, A., & Menson, (2020). syndrome: av hyperkalemia. Journal emergency medicine, 59(2), 216-223. DISCLOSURES: no disclosure file William Fischer; No relevant relationships by Hitesh Patel, source=Web Response