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Bhandari R, Ekladious A, Javaid MM. Demystifying normal-anion-gap metabolic acidosis: pathophysiology, aetiology, evaluation and diagnosis. Intern Med J 2024; 54:1056-1065. [PMID: 38837536 DOI: 10.1111/imj.16418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
Normal-anion-gap metabolic acidosis (NAGMA) is a common but often under-recognised and poorly understood condition, especially by less-experienced clinicians. In adults, NAGMA might be an initial clue to a more significant underlying pathology, such as autoimmune diseases, hypergammaglobulinemia or drug toxicities. However, identifying the aetiology can be challenging due to the diverse processes involved in the development of acidosis. A better understanding of the pathophysiology of NAGMA can help treating physicians suspect and evaluate the condition early and reach the correct diagnosis. This article provides an overview of renal acid-base regulation, discusses the pathophysiological processes involved in developing NAGMA and provides a framework for evaluation to reach an accurate diagnosis.
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Affiliation(s)
- Ritesh Bhandari
- Department of General Medicine, North West Regional Hospital, Burnie, Tasmania, Australia
- Department of General Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Adel Ekladious
- Department of General Medicine and Acute Assessment Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Muhammad M Javaid
- Monash Rural Health Mildura, Monash University, Melbourne, Victoria, Australia
- Department of Renal Medicine, Woodlands Health, Singapore
- School of Medicine, Deakin University, Melbourne, Victoria, Australia
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Pan Q, Mu Z, Li Y, Gu C, Liu T, Wang B, Kang X. The association between serum anion gap and acute kidney injury after coronary artery bypass grafting in patients with acute coronary syndrome. BMC Cardiovasc Disord 2023; 23:542. [PMID: 37940847 PMCID: PMC10634147 DOI: 10.1186/s12872-023-03588-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The purpose of this study was to explore the association between serum anion gap (SAG) and acute kidney injury (AKI) after coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) in the Intensive Care Unit (ICU). METHODS We retrospectively analyzed the clinical data of 2,428 ACS patients who underwent CABG in the Medical Information Mart for Intensive Care IV (Mimic-IV) database. The endpoint of this study was AKI after CABG. The baseline data of the two groups (non-AKI group vs. AKI group) was compared, and the restricted cubic spline (RCS) plot, multivariable logistic regression model, and subgroup analysis were used to explore the relationship between SAG and the risk of AKI after CABG. RESULTS In the adjusted multivariate logistic regression model, SAG was an independent predictor of AKI after CABG (OR = 1.12, 95% CI: 1.02-1.23, P = 0.015). The RCS revealed that the relationship between SAG levels and risk of AKI was J-shaped. When the SAG was ≥ 11.58 mmol/L, the risk of AKI increased by 26% for each unit increase in SAG. Additionally, we further divided the SAG into quartiles. In the fully adjusted model, compared with the first quartile of SAG, the odds ratios (ORs) and 95% confidence intervals (CIs) for AKI risk across the SAG quartiles were 0.729 (0.311, 1.600), 1.308 (0.688-2.478), and 2.221 (1.072, 4.576). CONCLUSIONS The SAG level was associated with the risk of AKI after CABG in a J-shaped curve in the ICU. However, the underlying causes of the problem need to be investigated.
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Affiliation(s)
- Qinyuan Pan
- Department of Critical Care Medicine, The First People's Hospital of Lianyungang, Zhenhua East Road, Lianyungang, 222002, Jiangsu, China
| | - Zhifang Mu
- Department of Critical Care Medicine, The First People's Hospital of Lianyungang, Zhenhua East Road, Lianyungang, 222002, Jiangsu, China
| | - Yong Li
- Department of Critical Care Medicine, The First People's Hospital of Lianyungang, Zhenhua East Road, Lianyungang, 222002, Jiangsu, China
| | - Caihong Gu
- Department of Critical Care Medicine, The First People's Hospital of Lianyungang, Zhenhua East Road, Lianyungang, 222002, Jiangsu, China
| | - Tao Liu
- Department of Cardiology, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai, 201500, China
| | - Bing Wang
- Department of Cardiology, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai, 201500, China
| | - Xiuwen Kang
- Department of Critical Care Medicine, The First People's Hospital of Lianyungang, Zhenhua East Road, Lianyungang, 222002, Jiangsu, China.
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Liu Y, Atiq A, Peterson A, Moody M, Novin A, Deymier AC, Afzal J. Metabolic Acidosis Results in Sexually Dimorphic Response in the Heart Tissue. Metabolites 2023; 13:metabo13040549. [PMID: 37110207 PMCID: PMC10142987 DOI: 10.3390/metabo13040549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
Metabolic acidosis (MA) is a highly prevalent disorder in a significant proportion of the population, resulting from imbalance in blood pH homeostasis. The heart, being an organ with very low regenerative capacity and high metabolic activity, is vulnerable to chronic, although low-grade, MA. To systematically characterize the effect of low-grade MA on the heart, we treated male and female mice with NH4Cl supplementation for 2 weeks and analyzed their blood chemistry and transcriptomic signature of the heart tissue. The reduction of pH and plasma bicarbonate levels without an associated change in anion gap indicated a physiological manifestation of low-grade MA with minimal respiratory compensation. On transcriptomic analysis, we observed changes in cardiac-specific genes with significant gender-based differences due to MA. We found many genes contributing to dilated cardiomyopathy to be altered in males, more than in females, while cardiac contractility and Na/K/ATPase-Src signaling were affected in the opposite way. Our model presents a systems-level understanding of how the cardiovascular tissue is affected by MA. As low-grade MA is a common ailment with many dietary and pharmaceutical interventions, our work presents avenues to limit chronic cardiac damage and disease manifestation, as well as highlighting the sex differences in MA-induced cardiovascular damage.
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Affiliation(s)
- Yamin Liu
- Department of Biomedical Engineering, University of Connecticut Health, Farmington, CT 06032, USA
| | - Amina Atiq
- Department of Biomedical Engineering, University of Connecticut Health, Farmington, CT 06032, USA
| | - Anna Peterson
- Department of Biomedical Engineering, University of Connecticut Health, Farmington, CT 06032, USA
| | - Mikayla Moody
- Department of Biomedical Engineering, University of Connecticut Health, Farmington, CT 06032, USA
| | - Ashkan Novin
- Department of Biomedical Engineering, University of Connecticut Health, Farmington, CT 06032, USA
| | - Alix C Deymier
- Department of Biomedical Engineering, University of Connecticut Health, Farmington, CT 06032, USA
| | - Junaid Afzal
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA 94158, USA
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Zhou YH, Pang S, Miao GR, Zhao XY, Dong JZ. Combining the anion gap with the sequential organ failure assessment score to evaluate the short-term prognosis of patients in the cardiac intensive care unit. Int J Cardiol 2023; 370:381-387. [PMID: 36332753 DOI: 10.1016/j.ijcard.2022.10.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND We attempted to determine the predictive ability of the first-day Sequential Organ Failure Assessment (SOFA) score in the cardiac intensive care unit, as well as a new score combining the anion gap (AG) with the SOFA score (SOFA-AG). METHODS Information was obtained from the Medical Information Mart for Intensive Care III (MIMIC III 1.4) database. We plotted the relationship between the maximum first-day AG and 90-day mortality after admission to the care unit. Patients were divided into five groups based on the hazard ratio (HR) and assigned scores of 0, 1, 2, 3, or 4 points. We compared the area under the curve (AUC) for the receiver-operating characteristic curve of the SOFA and that of the SOFA-AG. RESULTS A total of 1316 patients were identified and divided into the following five groups: AG 8 to <16 mmol/L; AG 16 to <17 mmol/L; AG 17 to <19 mmol/L; AG 19 to <21 mmol/L; and AG ≥ 21 mmol/L. The SOFA-AG score had a greater AUC than the SOFA score at 7 days (0.770 vs. 0.711; P < 0.001), 14 days (0.751 vs. 0.692; P < 0.001), 28 days (0.741 vs. 0.684; P < 0.001), and 90 days (0.727 vs. 0.667; P < 0.001). CONCLUSIONS The SOFA score showed moderate predictive value only for 7-day mortality after admission to the cardiac intensive care unit, but the SOFA-AG score had improved predictive ability for up to 90 days after admission.
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Affiliation(s)
- Yuan-Hang Zhou
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Shuo Pang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Guang-Rui Miao
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Xiao-Yan Zhao
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China.
| | - Jian-Zeng Dong
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China; Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing 100029, China
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Yagi K, Fujii T. Management of acute metabolic acidosis in the ICU: sodium bicarbonate and renal replacement therapy. Crit Care 2021; 25:314. [PMID: 34461963 PMCID: PMC8406840 DOI: 10.1186/s13054-021-03677-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Kosuke Yagi
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan.
- ANZIC-RC, Monash University School of Public Health and Preventive Medicine, Melbourne, VIC, Australia.
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Respiratory Dialysis-A Novel Low Bicarbonate Dialysate to Provide Extracorporeal CO2 Removal. Crit Care Med 2021; 48:e592-e598. [PMID: 32304418 DOI: 10.1097/ccm.0000000000004351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We designed a novel respiratory dialysis system to remove CO2 from blood in the form of bicarbonate. We aimed to determine if our respiratory dialysis system removes CO2 at rates comparable to low-flow extracorporeal CO2 removal devices (blood flow < 500 mL/min) in a large animal model. DESIGN Experimental study. SETTING Animal research laboratory. SUBJECTS Female Yorkshire pigs. INTERVENTIONS Five bicarbonate dialysis experiments were performed. Hypercapnia (PCO2 90-100 mm Hg) was established in mechanically ventilated swine by adjusting the tidal volume. Dialysis was then performed with a novel low bicarbonate dialysate. MEASUREMENTS AND MAIN RESULTS We measured electrolytes, blood gases, and plasma-free hemoglobin in arterial blood, as well as blood entering and exiting the dialyzer. We used a physical-chemical acid-base model to understand the factors influencing blood pH after bicarbonate removal. During dialysis, we removed 101 (±13) mL/min of CO2 (59 mL/min when normalized to venous PCO2 of 45 mm Hg), corresponding to a 29% reduction in PaCO2 (104.0 ± 8.1 vs 74.2 ± 8.4 mm Hg; p < 0.001). Minute ventilation and body temperature were unchanged during dialysis (1.2 ± 0.4 vs 1.1 ± 0.4 L/min; p = 1.0 and 35.3°C ± 0.9 vs 35.2°C ± 0.6; p = 1.0). Arterial pH increased after bicarbonate removal (7.13 ± 0.04 vs 7.21 ± 0.05; p < 0.001) despite no attempt to realkalinize the blood. Our modeling showed that dialysate electrolyte composition, plasma albumin, and plasma total CO2 accurately predict the measured pH of blood exiting the dialyser. However, the final effluent dose exceeded conventional doses, depleting plasma glucose and electrolytes, such as potassium and phosphate. CONCLUSIONS Bicarbonate dialysis results in CO2 removal at rates comparable with existing low-flow extracorporeal CO2 removal in a large animal model, but the final dialysis dose delivered needs to be reduced before the technique can be used for prolonged periods.
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Szymańska E, Jóźwiak-Dzięcielewska DA, Gronek J, Niewczas M, Czarny W, Rokicki D, Gronek P. Hepatic glycogen storage diseases: pathogenesis, clinical symptoms and therapeutic management. Arch Med Sci 2021; 17:304-313. [PMID: 33747265 PMCID: PMC7959092 DOI: 10.5114/aoms.2019.83063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/08/2017] [Indexed: 11/22/2022] Open
Abstract
Glycogen storage diseases (GSDs) are genetically determined metabolic diseases that cause disorders of glycogen metabolism in the body. Due to the enzymatic defect at some stage of glycogenolysis/glycogenesis, excess glycogen or its pathologic forms are stored in the body tissues. The first symptoms of the disease usually appear during the first months of life and are thus the domain of pediatricians. Due to the fairly wide access of the authors to unpublished materials and research, as well as direct contact with the GSD patients, the article addresses the problem of actual diagnostic procedures for patients with the suspected diseases. Knowledge and awareness of the problem among physicians seem insufficient, and research on the diagnosis and treatment of GSD is still ongoing, resulting in a heterogeneous GSD typology and a changing way of its diagnosis and treatment.
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Affiliation(s)
- Edyta Szymańska
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Joanna Gronek
- Laboratory of Genetics, Department of Gymnastics and Dance, University School of Physical Education, Poznan, Poland
| | - Marta Niewczas
- Department of Sport, Faculty of Physical Education, University of Rzeszow, Rzeszow, Poland
| | - Wojciech Czarny
- Department of Human Sciences, Faculty of Physical Education, University of Rzeszow, Rzeszow, Poland
| | - Dariusz Rokicki
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Gronek
- Laboratory of Genetics, Department of Gymnastics and Dance, University School of Physical Education, Poznan, Poland
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Umbilical Cord Unmeasured Anions and Tissue Acid Levels According to Stewart’s Method in Term Newborn Infants and the Impact of Delivery Mode on these parameters. JOURNAL OF CONTEMPORARY MEDICINE 2020. [DOI: 10.16899/jcm.763338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Sławuta P, Sikorska-Kopyłowicz A, Sapikowski G. Diagnostic utility of different models used to assess the acid-base balance in cats with chronic kidney disease. Acta Vet Hung 2020; 68:169-176. [PMID: 32857709 DOI: 10.1556/004.2020.00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/06/2020] [Indexed: 11/19/2022]
Abstract
Metabolic acidosis is diagnosed based on the concentration of bicarbonate ions and partial pressure of carbon dioxide in arterial blood, although acid-base balance (ABB) disorders may also be diagnosed based on the serum ion concentrations in order to determine the values of strong ion difference (SID), anion gap (AG), corrected anion gap (AGcorr) and chloride/sodium ratio (Cl-/Na+). The aim of this study was to assess and compare the classic model, the value of the AG, AGcorr, and Cl-/Na+ in the diagnosis of ABB disorders in cats with chronic kidney disease (CKD). The study group consisted of 80 cats with CKD, divided into four groups based on the guidelines of the International Renal Interest Society (IRIS). The control group (C) included 20 healthy cats. Metabolic acidosis - diagnosed based on the classic model (Hendersson-Hasselbalch equation) - was found in IRIS group IV. AG, AGcorr, SID calculated for IRIS groups II, III and IV were lower than in group C, while the value of AGdiff and Cl-/Na+ in those groups was higher than in group C. We can conclude that ABB analysis using the classic model enabled the detection of ABB disorders in cats in stage IV CKD. However, the analysis of the AG, AGcorr and Cl-/Na+ values enabled the diagnosis of acid-base balance disorders in cats with IRIS stage II, III and IV CKD.
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Affiliation(s)
- Piotr Sławuta
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Science, Norwida 32, 50-375, Wrocław, Poland
| | - Agnieszka Sikorska-Kopyłowicz
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Science, Norwida 32, 50-375, Wrocław, Poland
| | - Grzegorz Sapikowski
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Science, Norwida 32, 50-375, Wrocław, Poland
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Changes in the SID Actual and SID Effective Values in the Course of Respiratory Acidosis in Horses With Symptomatic Severe Equine Asthma-An Experimental Study. J Equine Vet Sci 2019; 78:107-111. [PMID: 31203972 DOI: 10.1016/j.jevs.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 04/20/2019] [Accepted: 05/01/2019] [Indexed: 11/20/2022]
Abstract
Equine asthma syndrome is an allergic, inflammatory airway disease that usually affects older horses. Respiratory acidosis is an acid-base imbalance caused by alveolar hypoventilation. The acid-base balance may be assessed using the Henderson-Hasselbalch equation as well as the Stewart model. The authors hypothesized that systemic respiratory acidosis changes the ionic concentrations affecting water dissociation. The study group included 16 Warmblood, mixed breed horses of both sexes with a history of severe equine asthma, and 10 healthy horses were used as controls. Arterial and venous blood were collected from all the horses. The pH, pO2, and pCO2 and HCO3- were assessed in the arterial blood. Na, K, Cl, albumin, and Pinorganic (Pi) were assessed in the venous blood. The obtained results were used to calculate the anion gap (AG), modified AG, actual strong ion difference (SIDa), weak non-volatile acids, and effective strong ion difference (SIDe) values for all the horses. A systemic, compensatory respiratory acidosis was diagnosed in the study group. The concentration of Na in the blood serum in the study group was significantly higher, whereas the concentration of Cl was significantly lower than the values in the control group. The SIDa and SIDe values calculated in the horses from the study group were significantly higher than those in the control group. Significantly higher SIDa and SIDe values confirm the presence of ionic changes that affect water dissociation in the course of respiratory acidosis in horses. The SIDa and SIDe values may be useful in the diagnosis and treatment of respiratory acidosis in horses, which warrant further investigation.
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Sánchez-Díaz JS, Monares-Zepeda E, Martínez-Rodríguez EA, Cortés-Román JS, Torres-Aguilar O, Peniche-Moguel KG, Díaz-Gutiérrez SP, Pin-Gutiérrez E, Rivera-Solís G, García-Méndez RC, Huanca-Pacaje JM, Calyeca-Sánchez MV. Acidosis láctica por metformina: reporte de caso. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Metformin-related lactic acidosis: Case report☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201710000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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13
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Sánchez-Díaz JS, Monares-Zepeda E, Martínez-Rodríguez EA, Cortés-Román JS, Torres-Aguilar O, Peniche-Moguel KG, Díaz-Gutiérrez SP, Pin-Gutiérrez E, Rivera-Solís G, García-Méndez RC, Huanca-Pacaje JM, Calyeca-Sánchez MV. Metformin-related lactic acidosis: Case report. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Berbee JK, Lammers LA, Krediet CTP, Fischer JC, Kemper EM. Metabolic acidosis caused by concomitant use of paracetamol (acetaminophen) and flucloxacillin? A case report and a retrospective study. Eur J Clin Pharmacol 2017; 73:1459-1465. [PMID: 28782093 PMCID: PMC5662679 DOI: 10.1007/s00228-017-2311-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/24/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE A patient was identified with severe metabolic acidosis, a high anion gap and 5-oxoproline accumulation, probably caused by the simultaneous use of paracetamol (acetaminophen) and flucloxacillin. We wanted to investigate the necessity to control the interaction between both drugs with an automatic alert system. METHODS To investigate the relevance of the interaction of paracetamol and flucloxacillin, a retrospective study was conducted. Data on paracetamol and flucloxacillin prescriptions and laboratory data (pH, Na+, HCO3-, Cl-, albumin and 5-oxoproline levels) were combined to assess the prevalence of acidosis, calculate the anion gap and analyse 5-oxoproline levels in clinically admitted patients using both drugs simultaneously. RESULTS In the 2-year study period, approximately 53,000 admissions took place in our hospital. One thousand and fifty-seven patients used paracetamol and flucloxacillin simultaneously, of which 51 patients (4.8%) had a serum pH ≤ 7.35. One patient, the same patient as presented in the case report, had a high anion gap and a toxic level of 5-oxoproline. CONCLUSION The prevalence of metabolic acidosis is very low and the only patient identified with the interaction was recognised during normal clinical care. We conclude that automatic alerts based on simultaneous use of paracetamol and flucloxacillin will generate too many signals. To recognise patients earlier and prevent severe outcomes, a warning system (clinical rule) based on paracetamol, flucloxacillin and pH measurement may be helpful. Early calculation of the anion gap can narrow the differential diagnosis of patients with metabolic acidosis and measurement of 5-oxoproline can explain acidosis due the interaction of paracetamol and flucloxacillin.
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Affiliation(s)
- J K Berbee
- Department of Hospital Pharmacy, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - L A Lammers
- Department of Hospital Pharmacy, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - C T P Krediet
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - J C Fischer
- Department of Clinical Chemistry, Academic Medical Centre, Amsterdam, the Netherlands
| | - E M Kemper
- Department of Hospital Pharmacy, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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Kim MJ, Kim YH, Sol IS, Kim SY, Kim JD, Kim HY, Kim KW, Sohn MH, Kim KE. Serum anion gap at admission as a predictor of mortality in the pediatric intensive care unit. Sci Rep 2017; 7:1456. [PMID: 28469150 PMCID: PMC5431089 DOI: 10.1038/s41598-017-01681-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/31/2017] [Indexed: 01/27/2023] Open
Abstract
An accurate method to predict the mortality in the intensive care unit (ICU) patients has been required, especially in children. The aim of this study is to evaluate the value of serum anion gap (AG) for predicting mortality in pediatric ICU (PICU). We reviewed a data of 461 pediatric patients were collected on PICU admission. Corrected anion gap (cAG), the AG compensated for abnormal albumin levels, was significantly lower in survivors compared with nonsurvivors (p < 0.001). Multivariable logistic regression analysis identified the following variables as independent predictors of mortality; cAG (OR 1.110, 95% CI 1.06–1.17; p < 0.001), PIM3 [OR 7.583, 95% CI 1.81–31.78; p = 0.006], and PRISM III [OR 1.076, 95% CI 1.02–1.14; p = 0.008]. Comparing AUCs for mortality prediction, there were no statistically significant differences between cAG and other mortality prediction models; cAG 0.728, PIM2 0.779, PIM3 0.822, and PRISM III 0.808. The corporation of cAG to pre-existing mortality prediction models was significantly more accurate at predicting mortality than using any of these models alone. We concluded that cAG at ICU admission may be used to predict mortality in children, regardless of underlying etiology. And the incorporation of cAG to pre-existing mortality prediction models might improve predictability.
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Affiliation(s)
- Min Jung Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - In Suk Sol
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Deok Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.
| | - Myung Hyun Sohn
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Earn Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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Ghatak I, Dhat V, Tilak MA, Roy I. Analysis of Arterial Blood Gas Report in Chronic Kidney Diseases - Comparison between Bedside and Multistep Systematic Method. J Clin Diagn Res 2016; 10:BC01-5. [PMID: 27656429 DOI: 10.7860/jcdr/2016/19830.8252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 05/24/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Acid Base Disorders (ABDs) are commonly encountered in critically ill Chronic Kidney Disease (CKD) patients. Timely and correct analysis of Arterial Blood Gases (ABG) is critical for the diagnosis, treatment and prediction of outcome of the patients. AIM The aim was to explore type and prevalence of ABDs in 31 critically ill CKD patients from a tertiary care hospital in Maharashtra, to compare two methods of analysis- bedside and systematic approaches and to clinically correlate the nature of ABDs in these patients. MATERIALS AND METHODS The initial ABG reports of 31 consecutive CKD patients were analysed by two methods. Medica Easy stat analyser was the equipment for analysis with Principle of potentiometry and ion selective electrode for pH and pCO2 and amperometry for pO2. Serum albumin was also measured by Bromocresol green dye binding method using liquixx albumin kit in Erba XL 300 autoanalyser. STATISTICAL ANALYSIS Chi-square test was used for statistical analysis using Epi Info version 3.5.4 and SPSS 14.0 softwares. RESULTS The systematic method showed a significantly higher prevalence of mixed disorders (50%) compared to bedside method (12.9%). Most prevalent disorder by bedside method was metabolic acidosis in 15 cases (48.39%). By the systematic method, 3 reports were invalid. As a single category, most prevalent type was both simple respiratory alkalosis and mixed metabolic acidosis with respiratory alkalosis- 6 of 31 cases in each type (19.36% each). As a whole, metabolic acidosis (including both High Anion Gap Metabolic Acidosis or HAGMA and Non Anion Gap Metabolic Acidosis or NAGMA with 4 in each type) was most prevalent- 8 of 31(25.8%). CONCLUSION Systematic approach was more effective in diagnosing mixed acid base disorders. By systematic method the findings of analysis in most cases could be correlated with the clinical condition and provisional diagnosis. Thus interpretation of ABDs by using stepwise approach could be useful to the clinicians in early diagnosis and management of the patients.
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Affiliation(s)
- Ishita Ghatak
- Resident, Department of Biochemistry, Dr D Y Patil Medical College , Pimpri, Pune, Maharashtra, India
| | - Vaishali Dhat
- Professor, Department of Biochemistry, Dr D Y Patil Medical College , Pune, Maharashtra, India
| | - Mona A Tilak
- Professor and Head, Department of Biochemistry, Dr D Y Patil Medical College , Pune, Maharashtra, India
| | - Indranath Roy
- Medical Officer in Charge-Government Blood Bank, Chandannagar SD Hospital , Government of West Bengal, India
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Abstract
Undifferentiated patients in respiratory distress require immediate attention in the emergency department. Using a thorough history and clinical examination, clinicians can determine the most likely causes of dyspnea. Understanding the pathophysiology of the most common diseases contributing to dyspnea guides rational testing and informed, expedited treatment decisions.
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Affiliation(s)
- Elizabeth DeVos
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Lisa Jacobson
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.
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Locatelli F, La Milia V, Violo L, Del Vecchio L, Di Filippo S. Optimizing haemodialysate composition. Clin Kidney J 2015; 8:580-9. [PMID: 26413285 PMCID: PMC4581377 DOI: 10.1093/ckj/sfv057] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022] Open
Abstract
Survival and quality of life of dialysis patients are strictly dependent on the quality of the haemodialysis (HD) treatment. In this respect, dialysate composition, including water purity, plays a crucial role. A major aim of HD is to normalize predialysis plasma electrolyte and mineral concentrations, while minimizing wide swings in the patient's intradialytic plasma concentrations. Adequate sodium (Na) and water removal is critical for preventing intra- and interdialytic hypotension and pulmonary edema. Avoiding both hyper- and hypokalaemia prevents life-threatening cardiac arrhythmias. Optimal calcium (Ca) and magnesium (Mg) dialysate concentrations may protect the cardiovascular system and the bones, preventing extraskeletal calcifications, severe secondary hyperparathyroidism and adynamic bone disease. Adequate bicarbonate concentration [HCO3−] maintains a stable pH in the body fluids for appropriate protein and membrane functioning and also protects the bones. An adequate dialysate glucose concentration prevents severe hyperglycaemia and life-threating hypoglycaemia, which can lead to severe cardiovascular complications and a worsening of diabetic comorbidities.
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Affiliation(s)
- Francesco Locatelli
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Vincenzo La Milia
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Leano Violo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Lucia Del Vecchio
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Salvatore Di Filippo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
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Kimmoun A, Novy E, Auchet T, Ducrocq N, Levy B. Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:175. [PMID: 25887061 PMCID: PMC4391479 DOI: 10.1186/s13054-015-0896-7] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Lactic acidosis is a very common biological issue for shock patients. Experimental data clearly demonstrate that metabolic acidosis, including lactic acidosis, participates in the reduction of cardiac contractility and in the vascular hyporesponsiveness to vasopressors through various mechanisms. However, the contributions of each mechanism responsible for these deleterious effects have not been fully determined and their respective consequences on organ failure are still poorly defined, particularly in humans. Despite some convincing experimental data, no clinical trial has established the level at which pH becomes deleterious for hemodynamics. Consequently, the essential treatment for lactic acidosis in shock patients is to correct the cause. It is unknown, however, whether symptomatic pH correction is beneficial in shock patients. The latest Surviving Sepsis Campaign guidelines recommend against the use of buffer therapy with pH ≥7.15 and issue no recommendation for pH levels <7.15. Furthermore, based on strong experimental and clinical evidence, sodium bicarbonate infusion alone is not recommended for restoring pH. Indeed, bicarbonate induces carbon dioxide generation and hypocalcemia, both cardiovascular depressant factors. This review addresses the principal hemodynamic consequences of shock-associated lactic acidosis. Despite the lack of formal evidence, this review also highlights the various adapted supportive therapy options that could be putatively added to causal treatment in attempting to reverse the hemodynamic consequences of shock-associated lactic acidosis.
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Affiliation(s)
- Antoine Kimmoun
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France. .,Université de Lorraine, Nancy, 54000, France. .,INSERM U1116, Groupe Choc, Faculté de Médecine, Vandoeuvre-les-Nancy, 54511, France.
| | - Emmanuel Novy
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France. .,Université de Lorraine, Nancy, 54000, France.
| | - Thomas Auchet
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France.
| | - Nicolas Ducrocq
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France.
| | - Bruno Levy
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France. .,Université de Lorraine, Nancy, 54000, France. .,INSERM U1116, Groupe Choc, Faculté de Médecine, Vandoeuvre-les-Nancy, 54511, France.
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Cooper CM, Baron JM. Case records of the Massachusetts General Hospital. Case 4-2015. A 49-year-old man with obtundation followed by agitation and acidosis. N Engl J Med 2015; 372:465-73. [PMID: 25629745 DOI: 10.1056/nejmcpc1410940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Increased serum bicarbonate in critically ill patients: a retrospective analysis. Intensive Care Med 2015; 41:479-86. [PMID: 25600192 DOI: 10.1007/s00134-015-3649-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/08/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE Although metabolic alkalosis is a common occurrence, no study has evaluated its prevalence, associated factors or outcomes in critically ill patients. METHODS This is a retrospective study from the Multiparameter Intelligent Monitoring in Intensive Care II database. From 23,529 adult patient records, 18,982 patients met the inclusion criteria. RESULTS Serum bicarbonate levels demonstrated a U-shaped association with mortality with knots at 25 and 30 mEq/l. Of the total included patients, 5,565 (29.3 %) had at least one serum bicarbonate level measurement >30 mEq/l. The majority were exposed to multiple factors that are classically associated with metabolic alkalosis (mainly diuretic use, hypernatremia, hypokalemia and high gastric output). Patients with increased serum bicarbonate exhibited increased ICU LOS, more days on mechanical ventilation and higher hospital mortality. After multivariate adjustment, each 5-mEq/l increment in the serum bicarbonate level above 30 mEq/l was associated with an odds ratio of 1.21 for hospital mortality. The association between increased serum bicarbonate levels and mortality occurs independently of its possible etiologies. CONCLUSION An increased serum bicarbonate level is common in critically ill patients; this can be attributed to multiple factors in the majority of cases, and its presence and duration negatively influence patient outcomes.
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Hagiwara S, Oshima K, Furukawa K, Nakamura T, Ohyama Y, Tamura JI. The significance of albumin corrected anion gap in patients with cardiopulmonary arrest. Ann Thorac Cardiovasc Surg 2012; 19:283-8. [PMID: 23232266 DOI: 10.5761/atcs.oa.12.01942] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The reliable parameter, which can be obtained easily and quickly, is necessary to predict the return of spontaneous circulation (ROSC) of patients with cardiopulmonary arrest (CPA) in the emergency situation. In this study, we evaluated the significance of albumin corrected anion gap (ACAG) for the prediction of ROSC in patients with CPA. PATIENTS AND METHODS In 166 patients with CPA between January 2009 and December 2010, 132 patients could be analyzed retrospectively. We compared acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment(SOFA) score, anion gap (AG) and ACAG levels between patients with/without ROSC and evaluated the significance of AG and ACAG to predict ROSC in patients with CPA. RESULTS Both AG and ACAG were significantly lower in patients with ROSC than in patients without ROSC. Both AG and ACAG had the relation with APACHE II and SOFA scores, however, coefficients of correlation with APACHE II and SOFA score were higher in ACAG (r = 0.506) than in AG (r = 0.482). The sensitivity, specificity, positive predictive value, and negative predictive value of ACAG for the prediction of ROSC in patients with CPA were better than those of AG. CONCLUSION Our study shows that both AG and ACAG have the relation with ROSC and ACAG is better to predict the ROSC following CPR in patients with CPA compared with AG. ACAG can be easily obtained in the emergency situation, and ACAG is a useful parameter to predict ROSC in patients with CPA.
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Affiliation(s)
- Shuichi Hagiwara
- Department of Emergency Medicine, Gunma University Gradu ate School of Medicine, Maebashi, Gunma, Japan
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Mehta HJ, Bhanusheli G, Nietert PJ, Pastis NJ. WITHDRAWN: The association between initial anion gap and outcomes in medical intensive care unit patients. J Crit Care 2012:S0883-9441(12)00114-1. [PMID: 22699034 PMCID: PMC3530657 DOI: 10.1016/j.jcrc.2012.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 03/06/2012] [Accepted: 04/02/2012] [Indexed: 11/23/2022]
Abstract
Purpose Anion gap (AG) metabolic acidosis is common in critically ill patients. The relationship between initial AG at the time of admission to the medical intensive care unit (MICU) and mortality or length of stay (LOS) is unclear. This study was undertaken to evaluate this relationship. Materials and Method We prospectively examined the acid-base status of 100 consecutive patients at the time of MICU admission and recorded their mortality and LOS. The etiology of each AG was also recorded. Anion gap was corrected for albumin levels. The patients were divided into 4 stages based on severity of AG. Outcomes based on severity of AG were measured, and comparisons that adjusted for baseline characteristics were performed. Results This study showed that increased AG was associated with the higher mortality and that an AG more than 30 had the highest mortality. Mortality was significantly (P = .013) increased, even after accounting for AG etiology. Patients with highest AG also had the longest LOS in the MICU, and patients with normal acid-base status had the shortest MICU LOS (P < .01). Conclusion A high AG at the time of admission to the MICU was associated with higher mortality and LOS. Initial risk stratification based on AG and metabolic acidosis may help guide appropriate patient disposition (especially in patients without other definitive criteria for MICU admission) and assist with prognosis. Mixed AG metabolic acidosis with concomitant acid-base disorder was associated with increased MICU LOS.
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Affiliation(s)
- Hiren J. Mehta
- Medical University of South Carolina, Division of Pulmonary and Critical Care Medicine, Charleston, SC 29425, USA
| | - Gautam Bhanusheli
- John H. Stroger Jr. Hospital of Cook County, Department of Internal Medicine, Chicago, Ill, USA
| | - Paul J. Nietert
- Medical University of South Carolina, Department of Biostatistics and Epidemiology, Charleston, SC 29425, USA
| | - Nicholas J. Pastis
- Medical University of South Carolina, Division of Pulmonary and Critical Care Medicine, Charleston, SC 29425, USA
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Kurt A, Ecevit A, Ozkiraz S, Ince DA, Akcan AB, Tarcan A. The use of chloride-sodium ratio in the evaluation of metabolic acidosis in critically ill neonates. Eur J Pediatr 2012; 171:963-9. [PMID: 22215130 DOI: 10.1007/s00431-011-1666-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 12/19/2011] [Indexed: 11/27/2022]
Abstract
Acid-base disturbances have been usually evaluated with the traditional Henderson-Hasselbach method and Stewart's physiochemical approach by quantifying anions of tissue acids (TA). It is hypothesized that an increase in tissue acids during metabolic acidosis would cause a compensatory decrease in the plasma chloride (Cl) relative to sodium (Cl-Na ratio) in order to preserve electroneutral balance. Therefore, we aimed to investigate the use of Cl-Na ratio as a bedside tool to evaluate the identifying raised TA in neonates as an alternative to complex calculations of Stewart's physiochemical approach. This retrospective study was conducted between January 2008 and December 2009. Infants were included in the study when blood gas analysis reveals a metabolic acidosis; pH <7.25 and sHCO(3) concentration was <22 mEq/L. The Cl-Na ratio, sodium-chloride difference (Diff(NaCl)), anion gap (AG), albumin-corrected AG (AG(corr)), strong ion difference (SID), unmeasured anions (UMA), and TA were calculated at each episode of metabolic acidosis. A total of 105 metabolic acidosis episodes occurred in 59 infants during follow-up. Hypochloremic metabolic acidosis occurred in 17 (16%) of samples, and all had increased TA. The dominant component of TA was UMA rather than lactate. There was a negative correlation between the Cl-Na ratio and SID, AG(corr), UMA, and TA. Also, there was a positive correlation between Diff(NaCl) and SID, AG(corr), UMA, and TA. Base deficit and actual bicarbonate performed poorly in identifying the TA. In conclusion, our study suggested that Diff(NaCl) and Cl-Na ratio are simple and fast, and may be an alternative method to complex Stewart's physiochemical approach in identifying raised UMA and TA in critically ill neonates.
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Affiliation(s)
- Abdullah Kurt
- Department of Pediatrics, Division of Neonatology, Baskent University Faculty of Medicine, Ankara, Turkey
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Vilas Boas WW, Marques MB, Alves A. Hydroelectrolytic balance and cerebral relaxation with hypertonic isoncotic saline versus mannitol (20%) during elective neuroanesthesia. Rev Bras Anestesiol 2011; 61:456-68. [PMID: 21724008 DOI: 10.1016/s0034-7094(11)70053-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 01/04/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cerebral relaxation during intracranial surgery is necessary, and hiperosmolar therapy is one of the measures used to this end. Frequently, neurosurgical patients have sodium imbalances. The objective of the present study was to quantify and determine cerebral relaxation and duration of hydroelectrolytic changes secondary to the use of mannitol versus hypertonic isoncotic solution (HIS) during neurosurgery. METHODS Cerebral relaxation and hydroelectrolytic changes were evaluated in 29 adult patients before de beginning of infusion, and 30 and 120 minutes after the infusion of equiosmolar loads of approximately 20% mannitol (250 mL) or HIS (120 mL). The volume of intravenous fluids infused and diuresis were recorded. A p < 0.05 was considered significant. RESULTS A statistically significant difference in cerebral relaxation between both groups was not observed. Although several changes in electrolyte levels and acid-base balance with mannitol or HIS reached statistical significance only the reduction in plasma sodium 30 minutes after infusion of mannitol, mean of 6.42 ± 0.40 mEq.L(-1), and the increase in chloride, mean of 5.41 ± 0.96 mEq.L(-1) and 5.45 ± 1.45 mEq.L(-1) 30 and 120 minutes after infusion of HIS, caused a transitory dislocation of serum ion levels from normal range. The mannitol (20%) group had a significantly greater diuresis at both times studied compared with HIS group. CONCLUSIONS A single dose of hypertonic isoncotic saline solution [7.2% NaCl/6% HES (200/0.5)] and mannitol (20%) with equivalent osmolar loads were effective and safe in producing cerebral relaxation during elective neurosurgical procedures under general anesthesia.
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Vanzant AM, Schmelzer M. Detecting and Treating Sepsis in the Emergency Department. J Emerg Nurs 2011; 37:47-54. [DOI: 10.1016/j.jen.2010.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 05/09/2010] [Accepted: 06/28/2010] [Indexed: 10/19/2022]
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Evaluation of acid-base balance in ST-elevation myocardial infarction in the early phase: a prognostic tool? Coron Artery Dis 2010; 21:266-72. [PMID: 20617567 DOI: 10.1097/mca.0b013e32833b20c6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Metabolic acidosis has been described after myocardial infarction, but little data are available on the acid-base imbalance in ST-elevation myocardial infarction (STEMI) submitted to mechanical revascularization, and earlier studies on this topic differ with respect to patients' selection criteria, treatment and evaluated parameters. METHODS We assessed admission base excess, anion gap, and lactate in 445 consecutive patients with STEMI submitted to primary percutaneous coronary intervention and whether its evaluation could help in identifying patients at a higher risk for in-hospital mortality and complications (acute pulmonary edema and arrhythmias). RESULTS At backward stepwise logistic regression analysis, the following variables were independently associated with intra-ICCU mortality: age [odds ratio (OR) 1.05; 95% confidence interval (CI) 1.02-1.10; P = 0.006], estimated glumerular filtration rate (OR 0.98; 95% CI 0.96-0.99; P= 0.010), Tn I (OR 1.006; 95% CI 1.004-1.008; P <0.001), and base excess (OR 0.90; 95% CI 0.82-0.99; P = 0.038); Hosmer-Lemeshow v2: 5.69, P = 0.681. At backward stepwise logistic regression analysis, the following variables were independently associated with intra-ICCU complications: left ventricular ejection fraction (OR 0.95; 95% CI 0.91-0.98; P = 0.005) and lactic acid (OR 1.31; 95% CI 1.10-1.57; P =0.003); Hosmer-Lemeshow v2: 4.11, P = 0.847. CONCLUSION According to our findings, the evaluation of base excess and lactate in the early phase of STEMI provides the bedside clinicians with useful tools for early risk stratification. In fact, base excess proved to be an independent predictor for intra-ICCU mortality, whereas lactate represented an independent marker for intra-ICCU complications.
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Smith-Erichsen N, Kofstad J, Ingvaldsen B. [Acid-base disturbances in intensive-care patients]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:1471-4. [PMID: 20706308 DOI: 10.4045/tidsskr.09.0302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Acid-base disturbances may cause a variety of symptoms, multi-organ failure and compromised immune defense. The aim of this paper is to provide an overview of acid-base disturbances in intensive-care patients. MATERIAL AND METHOD The article is based on a non-systematic search in Pub Med, a textbook on intensive care and the authors' clinical experience. RESULTS The Henderson-Hasselbalch equation describes acid-base status by changes in pCO2 and bicarbonate. Changes in pCO2 reflect the respiratory and bicarbonate the metabolic status. Standard base excess describes the metabolic part more exactly. Anion gap is calculated as a supplement. The Stewart method, describes acid-base status through three independent variables (pCO2, weak acids and strong ion difference [SID]) that regulate the dependent variables pH and bicarbonate concentration. INTERPRETATION The Henderson-Hasselbalch equation and standard base excess do not consider which acids or bases that are involved, The anion gap may disclose unmeasured anions and distinguish hyperchloremic acidosis from other types of metabolic acidosis, but the calculation is associated with uncertainty. The Stewart method describes the involved ions, but complicated equations makes it unsuitable in clinical practice. A combination of standard base excess and anion gap corrected for albumin levels provide a good description of acid-base status.
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Lazzeri C, Valente S, Chiostri M, Picariello C, Gensini GF. Acid-base imbalance in uncomplicated ST-elevation myocardial infarction: the clinical role of tissue acidosis. Intern Emerg Med 2010; 5:61-6. [PMID: 19998062 DOI: 10.1007/s11739-009-0338-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 11/18/2009] [Indexed: 10/20/2022]
Abstract
Little information is available on acid-base imbalance in uncomplicated ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI). We therefore assessed acid-base imbalance in 257 consecutive uncomplicated STEMI patients submitted to PCI to determine whether its evaluation could help in identifying patients at higher risk for in-hospital complications (acute pulmonary edema and dysrhythmias). A basic metabolic profile was performed at hospital admission, that is before PCI. After PCI, we measured: creatinine, uric acid and NT-pro BNP and serum electrolytes. Peak troponin I was also considered. Acidemia was present in 11 patients (4.2%), HCO(3) < 22 in 62 (24.1%). Base excess < -3 was detectable in 70 patients (27.2%), anion gap > 12 in 13 (5.1%), Cl/Na < 0.79 in 93 patients (38.5%). Patients with a Cl/Na < 0.79 had a lower LVEF (p = 0.042) and higher values of NT-pro-BNP (p = 0.019) and of latency (p = 0.029) together with a higher length of stay (p = 0.017) and a higher incidence of in-hospital complications (p = 0.017). At backward stepwise regression analysis, the following variables resulted independent predictors of in-hospital complications: base excess OR 1.47 (95% CI 1.04-2.10) p = 0.031; Cl/Na ratio O.R. 1.85 (95% CI 1.05-3.27) p = 0.035. In STEMI patients submitted to mechanical revascularization the evaluation of acid-base status and, in particular the detection of even mild degrees of acidosis may help in risk stratification for in-hospital complications. A Cl/Na < 0.79 ratio and a base excess are independent predictors for in-hospital complications.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Cardiac Coronary Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Viale Morgagni 85, 50134, Florence, Italy.
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Plaat F. Anaesthetic issues related to postpartum haemorrhage (excluding antishock garments). Best Pract Res Clin Obstet Gynaecol 2008; 22:1043-56. [PMID: 18849197 DOI: 10.1016/j.bpobgyn.2008.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The obstetric anaesthetist is a key member of the multidisciplinary team required to manage postpartum haemorrhage, having been trained in resuscitation and being experienced in managing haemorrhage and in monitoring and caring for the critically ill patient. The diagnosis of shock, initial resuscitation controversies surrounding fluid replacement, cell salvage in obstetrics and monitoring are discussed.
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Affiliation(s)
- Felicity Plaat
- Queen Charlotte's & Chelsea Hospital, Department of Anaesthesia, Hammersmith House, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK.
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