Hey Dr. Bernard here.
The recommendation for caffeine is no more than 400 milligrams per day.
So don’t drink more than 4 cups of regular coffee.
400 milligrams 😳
A Student Drank 2 Gallons Coffee In 3 Hours.
This Is What Happened To His Kidneys.
BB is a 21 year old man, presenting to the emergency room, unconscious.
His mother Karen, tells the admitting nurse that she heard loud noise in the bathroom,
before finding her son collapsed on the floor.
You see, BB was a college student, who was studying for final exams.
It was the end of the semester.
His grades were OK.
But he was borderline in chemistry.
If I don’t pass this one, there’s no way I’m ever gonna get into medical school,
he thought.
I’ll pull an all nighter just this one time, and it’ll be fine, he thought.
Someone in his class had offered him a little something extra to help him study, but he
said no.
And good call.
One of his friends had taken that something extra last semester.
Couple days later, she got a random urine test for her internship.
It came out positive, and she was kicked out of the program.
Not worth it.
BB was good, he was just gonna need some coffee to get through this.
He had built up a healthy caffeine tolerance over the semester, so he would need a lot
of it, but just one night.
Just one exam.
Immediately after drinking a whole pot of coffee, BB felt great.
He was awake, alert and refreshed.
But then he started crashing.
Time for another pot he thought.
Awake, alert, then crashed.
One more pot.
And another.
And after 2 gallons of coffee, BB started sweating.
He got the shakes.
He was wired.
He could feel his heart beating in his neck.
His heart beat was pushing his eyes out of his skull.
In the bathroom now, BB wanted to run 20 miles.
He felt like he could lift mountains, but his insides were all starting to knot up like
twine.
He felt a burning in his chest.
As the time went on, his thoughts started racing and were getting cloudy.
He was sweating, everywhere.
His hands were shaking.
Later in the night, his calf muscles started hurting.
As he goes into the bathroom, BB noticed that his urine was turning brown.
Haha I drank so much coffee that it’s just going right through me now, he thought.
He laid down on the floor for a few minutes.
He felt his heart beating in his eyes, before finally having his first seizure.
Loud noises wake up his mom.
She rushes in to find her son on the floor, sweaty and unresponsive, as she calls for
911, and hes brought to the emergency room where we are now.
Karen and the doctors had no idea what happened to BB.
He couldn’t tell them either, because he was confused, coming out of his seizure.
They couldn’t smell anything from him.
In a 20 year old college guy— alcohol could be a problem.
But alcohol is a depressant.
BB is agitated and confused, sweating and hyperventilating.
His heart rate was fast.
His pupils were big and bold.
All of these together, don’t usually happen from a depressant.
These are the signs of a stimulant, which is opposite a depressant, so, not alcohol,
so we can narrow it down a little.
Further exam finds that BB also has hyperthermia.
High body temperature.
This is dangerous, not only because it means bad things are happening inside his body causing
the hyperthermia, but that the hyperthermia itself can cause even more bad things to happen.
BB was shaking.
This could be the cause of hyperthermia.
When you move, your muscles burn energy.
That releases heat.
LOTS of heat in BB’s case and that’s why he’s sweating because his body is trying
to cool him off.
This brings us to the idea of “fight or flight.”
When you get scared, you jump.
Your heart rate immediately goes up.
Your mouth dries up and your tongue feels like sand is in your mouth.
Your muscles become really twitchy and you start shaking.
You start hyperventilating, because your muscles need that oxygen, because you’re either
gonna run, or you’re going to fight.
This response is controlled by your nervous system.
You see something, you hear something, and those will make you jump.
But if you’ve ever been really scared, you’ll notice your heart doesn’t just slow down
afterwards.
And that’s because fight or flight isn’t just from the nerves.
To keep up the response, the body releases adrenaline, which is a hormone that floats
around in the blood.
It lasts for a couple of minutes and it comes from these adrenal glands on top of the kidneys.
But BB hasn’t been scared.
He’s been sitting there, studying.
He has no reason to fight or flight.
Meaning something is causing his adrenal glands to release adrenaline.
But what could it be?
At this point BB, was still confused and still agitated.
When asked what happened, he was able to tell doctors “coffee, gallons of coffee” and
this gives them several clues as to what’s happening.
Coffee comes from the seeds of the Coffea plant.
These seeds get called beans, they’re roasted and then grounded up to make a brew.
Coffee is a natural product, and inside those seeds is the naturally occurring chemical
called caffeine.
It’s also naturally found in tea.
It’s a stimulant.
In modest amounts like 1 cup of coffee, it can help you stay awake.
It can help keep you alert and focused.
But, your body adapts to it, so that’s why you might find you’ve developed a tolerance
if you consume it daily.
If you get a headache because you didn’t drink your caffeine that day, then you’re
experiencing withdrawal, because your brain has some dependence on it.
Biological dependence as we see it today is kind of like an adaptation.
Chemicals can block things in the body, causing the body to make more what was blocked, to
maintain an equilibrium.
Caffeine appears to constrict the blood vessels in the brain, so when you don’t have it,
he blood vessels are dilated and that can cause the headache.
In huge amounts, like 2 gallons coffee in a couple hours, caffeine won’t JUST keep
you awake it’ll do many other things.
And in BB, that caffeine was doing other things.
When caffeine is in the blood, one place it goes to is the brain.
You see, the brain uses electricity to send signals.
So to stop those signals from going off uncontrollably, the brain has chemicals to help insulate things.
Caffeine blocks these insulators.
So it causes the brain to get excited.
For an amount like a cup of coffee worth of caffeine, this is where the wakefulness, and
focus come from.
But if there’s 2 gallons coffee worth of caffeine in the body, then most of the insulators
are blocked.
The brain doesn’t stop getting excited.
Everything discharges at once, which by definition is a seizure, bringing us back to BB.
Usually hospitals don’t do tests for caffeine.
BB has many of the features of caffeine toxicity but the medical team needs to make sure he
didn’t ingest anything else.
And results for others return negative.
But as the nurses read the results, BB suddenly falls unconscious again.
His heart isn’t actually beating anymore, it’s just shaking in place and blood can’t
get to his brain.
Doctors immediately rush in to do CPR.
He’s resuscitated.
But over the next 3 hours, these cardiac arrests happen 5 more times.
Medicines to try and stabilize his heart rhythm were given, but they didn’t work.
If high amounts of caffeine caused BB’s brain to discharge all at once, then how is
it affecting his heart?
Are they somehow connected?
Well, this bring us back to adrenaline.
Excess caffeine doesn’t just go to the brain, it’s floating everywhere in the body.
It goes to the adrenal glands and forces them to release adrenaline.
Lots of caffeine means lots of adrenaline.
This explains BB’s racing heart.
At some point, his heart is so excited, that it doesn’t pump blood anymore it just shakes
in place.
But this wasn’t BB’s only problem.
His urine was dark.
It was the color of coffee.
But no one urinates out coffee, no matter how much they drink.
BB had complained that his right calf was hurting.
Muscles can be damaged when someone has a seizure, because when someone convulses, their
muscles contract chaotically and breakdown.
Meaning, that that’s not coffee he’s urinating.
Those are parts his muscles that have sloughed off, and have started floating around in his
urine.
A blood test finds that BB has hypokalemia.
Hypo meaning low.
Kale referring to potassium or more formally Kalium as shown by its symbol on the periodic
table of elements.
And emia meaning presence in blood.
Low potassium presence in blood.
If KC drank 2 gallons of coffee, but coffee has potassium in it, then how does he have
Low potassium presence in blood?
Well, there’s a bit of basic biology to be known here.
Adrenaline acts on the muscles.
The muscles that move your arms and legs are called skeletal muscle.
In fight or flight mode, you want these to be active, otherwise you wouldn’t be fighting,
and you definitely couldn’t be flighting.
But there’s also heart muscle, which you want the heart to beat faster and harder so
that those skeletal muscles get more oxygen from blood so they can help you run away.
Or wrestle a bear.
But your muscles also need a way to be told, to contract.
Sodium helps start a muscle contraction.
Potassium promotes muscle relaxation.
Lots of potassium present, means the muscles relax for a long time.
Too little present means your muscles won’t stop contracting.
If BB has low potassium presence in blood, then it explains why his muscles are twitching
nonstop.
They can’t relax because adrenaline has shifted potassium INto BB’s cells to support
fight or flight mode.
As BB’s muscles can’t stop twitching, they release heat from energy they’re burning,
causing his body temperature to go up.
High temperatures deform proteins.
Human muscles are made of proteins.
Meaning for BB, those muscles starting to break down and dissolve away into his bloodstream
causing rhabdomyolysis.
Rhabdo meaning striated or in this case skeletal Myo meaning muscle
Lysis meaning breakdown
Skeletal muscle breakdown.
This is life threatening.
It’s a medical emergency, and it’s happening because BB drank 2 gallons of coffee, while
trying to cram for his final.
The last part of this problem, is that the caffeine still isn’t finished.
It takes anywhere from 3 to 10 hours for caffeine levels to halve in the blood.
When it does get broken down, that metabolite, is still active, causing more adrenaline release.
The thing about adrenaline is that it plays a game like a track relay race.
1 molecule of adrenaline, relays the message to 20 molecules of the messenger chemical
next in line, which sends to 10 of the next chemical, then to a hundred, to a thousand,
to ten thousand, amplifying the effect.
One adrenaline molecule, is a signal that releases ten thousand other molecules.
A massive caffeine dose, will cause massive amounts of adrenaline to be released.
And if just 1 molecule is amplified 10,000 times, this is a huge problem.
But it’s not done here.
Caffeine stops the breakdown of those in the relay, meaning 1 adrenaline, gets amplified
more than 10,000 times.
Signals keep getting sent.
Messengers in the chain, stick around and amplify themselves.
They don’t stop.
When this doesn’t stop, the liver doesn’t stop breaking down sugars.
The muscles don’t stop contracting.
The arms and legs and the rest of the body are twitching non stop.
They create heat, which builds up, breaking down the muscle, and letting the muscle proteins
float freely in the blood.
As these muscle proteins swim through BB’s body, they don’t accumulate in the heart.
They won’t gather in his brain.
The liver can break them down, but it takes a while to catch them.
So where collect, is in the kidneys.
The kidneys filter out your blood and they’re kind of like a net to catch toxins in your
blood, putting them into the urine.
Think of it like this strainer.
If proteins are large, they get caught in this strainer.
It gunks up the kidneys, and ruptures the membranes of the nephrons.
It’s like tearing this grid apart.
This is called acute Kidney Injury, is what’s happening to BB.
The reddish brown urine is because muscle protein contains heme, a compound that has
iron that’s responsible for making your blood red when exposed to oxygen.
The protein builds up in the nephron and spills into your urine once it starts to damage the
tubules.
BB’s rhabdomyolysis is severe and he might have permanent kidney damage.
We may be able to fix his muscle damage, but those kidneys aren’t gonna regenerate.
This can cause nutritional deficiencies, problems with water and electrolyte balance.
It can even cause something called uremic bone syndrome— a disorder that deforms the
bones and weakens them, causing them to fracture easily.
At this point, there’s a few different ways to treat him.
First is to block adrenaline.
These medicines are very popular and are well known, and they’re called beta-blockers.
Beta referring to a type of adrenaline receptor.
These medicines are used to treat heart failure and control blood pressure.
There have been other ways to successfully treat caffeine toxicity, most recently reported
in literature was really high dose insulin, that could only be done in a controlled setting
inside a hospital.
If you’d like to hear more, it’s on my Heme Review podcast, link in the description
below.
Because BB was low on potassium, he was given an IV for it.
Other medicines were given to stabilize his heart, and other medicines were given to let
his brain “insulate” the electrical discharge, to help stop any more seizures.
Kind of like how we wash something out when things get trapped in a net, BB was hydrated
to help prevent any more kidney damage.
He was started on peritoneal dialysis.
That is a cleaning solution was put into the lining of his abdomen called the peritoneum.
This cleaning solution is used to absorb waste and fluid from the blood, with the goal of
removing caffeine.
After monitoring and treatment, a lesson learned that cramming and pulling all nighters is
probably never really worth it, and a chance to retake a final after his classmates, BB
made a recovery.
Thank you so much for watching.
Take care of yourself, and be well.