A case of pseudohyperkalaemia secondary to thrombocytosis in a patient with grumbling abdominal sepsis

s / International Journal of Surgery 11 (2013) 589e685 616 ABSTRACTS Results: All five patients were attacked when in a vulnerable position and sustained severe soft tissue injury to the face due to the ripping action of the hyena jaws. Three patients sustained facial bone fractures, making these injuries more severe than the majority of animal bites witnessed in the UK. Reconstruction was tailored to each individual but was dictated by the replacement of soft tissue. The ulna pedicle flap proved particularly useful in the treatment of a severely injured boy. Conclusions: This study uniquely describes the predictable pattern of hyena attacks on humans and provides guidance for managing these patients when they present to a surgical team in a resource-limited setting. 0383: IJS CASE REPORT 2ND PRIZE: UNUSUAL PRESENTATION OF GLOMUS JUGULARE TUMOUR: A CASE REPORT AND LITERATURE REVIEW Neil Killick , Jayne Robinson , Yakubu Karagama , Susannah Penney . 1 ENT Department, Tameside General Hospital, Ashton-u-Lyne, UK; University of Manchester, Manchester, UK; 3 Edge Hill University, Ormskirk, UK. Introduction: We present the case of a 62 year old female with sudden onset left sided hearing loss, hoarseness and normal otoscopy. Flexible nasendoscopy revealed left vocal cord palsy, pure tone audiogram showed an ipsilateral dead ear. CT scan of the neck reported a left subglottic mass (Figure 1). No lesion was identified intra-operatively. Subsequent MRI of the skull base revealed a glomus jugulare tumour (Figure 2). Glomus jugulare tumours are neoplasms of the jugular bulb, classically associated with the rising sun sign. Method: Advanced literature search of NHS evidence databases using the MEsH terms glomus jugulare, paraganglioma, vocal cord palsy, dead ear and cerebellopontine was perfomed. Association between these tumours and cranial nerve pathology is well established with 37% manifesting cranial nerve involvement at presentation. 5% of patients will have vagus nerve involvement. Sensorineural deafness is present in 22% of cases. 40% of cases will be positive for the rising sun sign. Results & Conclusions: To our knowledge this case report is unique as the first description of a case of glomus jugulare tumour presenting with vocal cord palsy in combination with dead ear. It also demonstrates the limited usefulness of the rising sun sign. 0458: A CASE OF PSEUDOHYPERKALAEMIA SECONDARY TO THROMBOCYTOSIS IN A PATIENT WITH GRUMBLING ABDOMINAL SEPSIS Nick Baylem, Tanvir Sian. King's Mill Hospital, Mansfield, UK. Aim: To increase awareness of pseudohyperkalaemia in surgical patients to prevent mismanagement. Method: We report a case of pseudohyperkalaemia secondary to thrombocytosis in a patient with intra-abdominal sepsis. Results: A 25 year old male patient was admitted to the ICU following a road traffic collision in which he suffered a perforated colon. Following a right hemicolectomy, he struggled with a succession of intra-abdominal collections. After a fortnight his serum potassium level began rising. Despite the use of potassium-chelating resins orally, the serum potassium level continued to rise to dangerous levels (6.3mmol/L); he was treated with serial dextrose/insulin infusions and salbutamol nebulisers, but failed to respond (K+ 6.5mmol/L 48 hours later). It was noted that the patient's platelet count had risen to 1748 due to the chronic sepsis (reactive thrombocytosis). The diagnosis of pseudohyperkalaemia was suggested; measurement of plasma potassium using a green-topped lithium bottle confirmed that the true level was only 3.6mmol/L. The patient was commenced on aspirin as thrombo-prophylaxis, hyperkalaemia treatment was stopped, and plasma potassium level rather than serum level was used to monitor progress. Conclusion: Reactive thrombocytosis is common in surgical patients and may lead to pseudohyperkalaemia. Ignorance of this condition can lead to dangerous overtreatment. 0471: NICORANDIL ASSOCIATED COMPLICATIONS OF THE GASTRO-INTESTINAL TRACT: SIDE-EFFECTS REQUIRING SURGICAL INTERVENTION Iestyn Shapey, David Agbamu, Nick Newall, Liviu Titu. Arrowe Park Hospital, Wirral, UK. Aims: Nicorandil is increasingly identified, but under-reported, as a cause of anal ulceration, with an estimated incidence of around 4/1000 patients. Ulceration of the mouth, genitalia, skin, and gastro-intestinal tract has also been reported. The study aimed to report a mini-series of Nicorandil associated complications of the gastro-intestinal tract (NAC-GIT) requiring surgical intervention. Methods: All cases of NAC-GIT from one surgeon's practice (2007-2012) who required surgical intervention were reviewed retrospectively. Results: Three cases of NAC-GIT were identified within the study period. Case 1 terminal ileum perforation requiring emergency small bowel resection and double-barrelled ileostomy. Case 2 colonic ulceration masquerading as malignancy requiring laparoscopic left hemicolectomy and end colostomy. Case 3 complex fistula-in-ano requiring multiple procedures for abscess drainage, seton insertion and laying open of fistulous tracts. Conclusions: NAC-GIT remains an under-reported but increasingly identified side-effect, which can remain occult until significant complications ensue and necessitate surgical intervention in patients with significant operative risks. A standard approach for managing intraabdominal or peri-anal sepsis is advised with an emphasis on safety when considering primary bowel anastomosis versus stoma formation. Multi-disciplinary involvement is required when considering the perioperative risks versus those of unresolved sepsis in patients with multiple co-morbidities. 0505: MALIGNANT TRANSFORMATION OF PLEOMORPHIC ADENOMA OF THE SKULL BASE e A DIAGNOSTIC AND MANAGEMENT CHALLENGE Jayne Robinson , Anders Bilde , Rajiv Bhalla , Gillian Hall , Neil Killick . Department of Otolaryngology Head and Neck Surgery, Tameside Hospital NHS Foundation Trust, Manchester, UK; Department of Otolaryngology e Head & Neck Surgery, Copenhagen University Hospital, Copenhagen, Denmark; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK,; Department of Pathology, Central Manchester University Hospital NHS Trust, Manchester, UK; Department of Otolaryngology e Head and Neck Surgery, Tameside Hospital NHS Foundation Trust, Manchester, UK. Objective: To present a unique case of primary pleomorphic adenoma (PA) of the anterior skull base that was initially diagnosed andmanaged as a left nasal cavity plexiform ameloblastoma. Subsequent expert review of the pathological specimen showed foci of adenocarcinoma. Case demonstrates advancements in transnasal endoscopic surgery for the resection of skull base tumours. Case Report: Patient presented with left-sided nasal obstruction and blood-stained discharge. It was presumed disease recurrence following endoscopic resection of a plexiform ameloblastoma five years earlier. Subsequent repeat endoscopic biopsy suggested PA. Extensive transnasal endoscopic resection and further histopathological examination confirmed PA but foci of adenocarcinoma were also identified. Patient went on to have a transnasal endoscopic skull base resection. To our knowledge, this is the first reported primary PA of the skull base. Discussion: Primary PA should be distinguished from other nasal tumour types. Complete excision is recommended to avoid recurrence and the possibility of malignant transformation. Avoiding excessive trauma to excised tissue/specimen is vital to ensure accurate histopathological diagnosis. Conclusions: Primary PA of the skull base is exceptionally rare. Highquality specimen tissue is imperative for histopathological examination and consequent diagnostic purposes. Endoscopic management of skull base lesions is a safe, effective and preferable approach. 0506: THE USE OF PLEURX DRAINAGE IN RECURRENT SEROMAS Selina Lam, Stephanie Fraser, Thomas Routledge. Department of Thoracic Surgery, Guy's & St Thomas Hospital, London Division of Cancer Studies, King's College London, London, UK. Aim: To determine whether a PleurX drain could be successfully used in the management of a chest wall seroma. Method: A 61 year old male, with a background of poorly differentiated carcinoma of the left chest wall, underwent chest wall resection and reconstruction. He presented to clinic 3 months post-operatively with a large chest wall seroma, which was aspirated but quickly recurred. A 15.5Fr tunnelled PleurX drain was suggested and the patient was re-admitted for insertion under a general anaesthetic.