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Nozawa H, Tsuboi N, Oi T, Takezawa Y, Osawa I, Nishimura N, Nakagawa S. Chloride Reduction Therapy with Furosemide: Short-Term Effects in Children with Acute Respiratory Failure. J Pediatr Intensive Care 2023; 12:296-302. [PMID: 37970141 PMCID: PMC10631838 DOI: 10.1055/s-0041-1733942] [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: 04/05/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022] Open
Abstract
From the perspective of the Stewart approach, it is known that expansion of the sodium chloride ion difference (SCD) induces alkalosis. We investigated the role of SCD expansion by furosemide-induced chloride reduction in pediatric patients with acute respiratory failure. We included patients admitted to our pediatric intensive care unit intubated for acute respiratory failure without underlying diseases, and excluded patients receiving extracorporeal circulation therapy (extracorporeal membrane oxygenation and/or renal replacement therapy). We classified eligible patients into the following two groups: case-those intubated who received furosemide within 24 hours, and control-those intubated who did not receive furosemide within 48 hours. Primary outcomes included SCD, partial pressure of carbon dioxide (PaCO 2 ), and pH results from arterial blood gas samples obtained over 48 hours following intubation. Multiple regression analysis was also performed to evaluate the effects of SCD and PaCO 2 changes on pH. Twenty-six patients were included of which 13 patients were assigned to each of the two groups. A total of 215 gas samples were analyzed. SCD (median [mEq/L] [interquartile range]) 48 hours after intubation significantly increased in the case group compared with the control group (37 [33-38] vs. 31 [30-34]; p = 0.005). Although hypercapnia persisted in the case group, the pH (median [interquartile range]) remained unchanged in both groups (7.454 [7.420-7.467] vs. 7.425 [7.421-7.436]; p = 0.089). SCD and PaCO 2 were independently associated with pH ( p < 0.001 for each regression coefficient). As a result, we provide evidence that SCD expansion with furosemide may be useful in maintaining pH within the normal range in pediatric patients with acute respiratory failure complicated by concurrent metabolic acidosis.
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Affiliation(s)
- Hisataka Nozawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Norihiko Tsuboi
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tadashi Oi
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiki Takezawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Osawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
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Altun HI, Altun G, Altas OF, Aran G. Prognostic Significance of the Strong Ion Gap in Patients in Medical and Surgical Intensive Care Units. Cureus 2023; 15:e47964. [PMID: 38034207 PMCID: PMC10685706 DOI: 10.7759/cureus.47964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Background This study aimed to analyze acid-base imbalance by assessing the arterial blood gas (ABG) samples of the medical and surgical intensive care unit (ICU) patients by the Stewart approach and demonstrate the advantages of this method in delineating the acid-base status in cases where Henderson-Hasselbalch, anion gap, and base excess cannot optimally depict the imbalance and create recognition in the clinicians in this regard. Methodology Adult (i.e., age > 18 years) patients admitted to the ICU of our institution during a one-year study period were included in this study. The patients were divided into two groups based on the indication of admission to the ICU as medical or surgical. The ABG, sodium, potassium, calcium, magnesium, phosphate, chloride, albumin, lactate, hemoglobin, hematocrit, leukocyte, blood urea nitrogen, and creatinine values determined during the first 24-hour period were used for calculating the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE II), strong ion difference apparent (SIDa), and SID effective (SIDe) scores, which were subsequently compared between the groups. Results Overall, 220 (110 medical and 110 surgical) patients were included. The mean patient age was 63.56 ± 18.08 years. The mean APACHE II scores were 21.99 and 19.63 in the medical and surgical groups, respectively. Overall, 110 patients died, while 110 were referred to the regular patient floor. The mean APACHE II score of the patients who died was 28.3, and the latter group had a mean APACHE II score of 13.57. There was a significant difference between the surgical and medical patient groups regarding mean values of APACHE II, SIDa, and SIDe scores. Also, the differences were significant between the patients who died and were discharged. There was a significant difference between the patients who died and were discharged regarding the strong ion gap (SIG); however, the medical and surgical patient groups were not different concerning the SIG values. Conclusions We conclude that SIDa, SIDe, and SIG can be used in medical and surgical ICU patients to predict prognosis.
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Affiliation(s)
- Halil Ibrahim Altun
- Anesthesiology and Reanimation, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, TUR
| | - Gozde Altun
- Anesthesiology and Reanimation, Institute of Cardiology, Istanbul University-Cerrahpasa, Istanbul, TUR
| | - Omer Faruk Altas
- Anesthesiology and Reanimation, Bakırcay University Cigli Training and Research Hospital, Izmir, TUR
| | - Gulcin Aran
- Anesthesiology and Reanimation, Katip Celebi University Ataturk Training and Research Hospital, Izmir, TUR
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Adrogué HJ, Tucker BM, Madias NE. Clinical Approach to Assessing Acid-Base Status: Physiological vs Stewart. Adv Chronic Kidney Dis 2022; 29:343-354. [PMID: 36175072 DOI: 10.1053/j.ackd.2022.04.008] [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: 01/03/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Evaluation of acid-base status depends on accurate measurement of acid-base variables and their appropriate assessment. Currently, 3 approaches are utilized for assessing acid-base variables. The physiological or traditional approach, pioneered by Henderson and Van Slyke in the early 1900s, considers acids as H+ donors and bases as H+ acceptors. The acid-base status is conceived as resulting from the interaction of net H+ balance with body buffers and relies on the H2CO3/HCO3- buffer pair for its assessment. A second approach, developed by Astrup and Siggaard-Andersen in the late 1950s, is known as the base excess approach. Base excess was introduced as a measure of the metabolic component replacing plasma [HCO3-]. In the late 1970s, Stewart proposed a third approach that bears his name and is also referred to as the physicochemical approach. It postulates that the [H+] of body fluids reflects changes in the dissociation of water induced by the interplay of 3 independent variables-strong ion difference, total concentration of weak acids, and PCO2. Here we focus on the physiological approach and Stewart's approach examining their conceptual framework, practical application, as well as attributes and drawbacks. We conclude with our view about the optimal approach to assessing acid-base status.
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Affiliation(s)
- Horacio J Adrogué
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston, TX; Department of Medicine, Division of Nephrology, Houston Methodist Hospital, Houston, TX
| | - Bryan M Tucker
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston, TX; Department of Medicine, Division of Nephrology, Houston Methodist Hospital, Houston, TX
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Department of Medicine, Division of Nephrology, St Elizabeth's Medical Center, Boston, MA.
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Caldwell HG, Carr JMJR, Minhas JS, Swenson ER, Ainslie PN. Acid-base balance and cerebrovascular regulation. J Physiol 2021; 599:5337-5359. [PMID: 34705265 DOI: 10.1113/jp281517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/19/2021] [Indexed: 12/22/2022] Open
Abstract
The regulation and defence of intracellular pH is essential for homeostasis. Indeed, alterations in cerebrovascular acid-base balance directly affect cerebral blood flow (CBF) which has implications for human health and disease. For example, changes in CBF regulation during acid-base disturbances are evident in conditions such as chronic obstructive pulmonary disease and diabetic ketoacidosis. The classic experimental studies from the past 75+ years are utilized to describe the integrative relationships between CBF, carbon dioxide tension (PCO2 ), bicarbonate (HCO3 - ) and pH. These factors interact to influence (1) the time course of acid-base compensatory changes and the respective cerebrovascular responses (due to rapid exchange kinetics between arterial blood, extracellular fluid and intracellular brain tissue). We propose that alterations in arterial [HCO3 - ] during acute respiratory acidosis/alkalosis contribute to cerebrovascular acid-base regulation; and (2) the regulation of CBF by direct changes in arterial vs. extravascular/interstitial PCO2 and pH - the latter recognized as the proximal compartment which alters vascular smooth muscle cell regulation of CBF. Taken together, these results substantiate two key ideas: first, that the regulation of CBF is affected by the severity of metabolic/respiratory disturbances, including the extent of partial/full acid-base compensation; and second, that the regulation of CBF is independent of arterial pH and that diffusion of CO2 across the blood-brain barrier is integral to altering perivascular extracellular pH. Overall, by realizing the integrative relationships between CBF, PCO2 , HCO3 - and pH, experimental studies may provide insights to improve CBF regulation in clinical practice with treatment of systemic acid-base disorders.
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Affiliation(s)
- Hannah G Caldwell
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan, Kelowna, Canada
| | - Jay M J R Carr
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan, Kelowna, Canada
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Erik R Swenson
- Pulmonary, Critical Care and Sleep Medicine Division, University of Washington, and VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan, Kelowna, Canada
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Khemani RG, Lee JT, Wu D, Schenck EJ, Hayes MM, Kritek PA, Mutlu GM, Gershengorn HB, Coudroy R. Update in Critical Care 2020. Am J Respir Crit Care Med 2021; 203:1088-1098. [PMID: 33734938 DOI: 10.1164/rccm.202102-0336up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jessica T Lee
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Wu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patricia A Kritek
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Washington Seattle, Washington
| | - Gökhan M Mutlu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rémi Coudroy
- Institut National de la Santé et de la Recherche Médicale, Poitiers, France; and.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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Rubin DM. Stewart’s approach to quantitative acid-base physiology should replace traditional bicarbonate-centered models. J Appl Physiol (1985) 2021; 130:2019-2021. [DOI: 10.1152/japplphysiol.00042.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- David M. Rubin
- Biomedical Engineering Research Group, University of the Witwatersrand, Johannesburg, South Africa
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Cove ME, Kellum JA. Reply by Cove and Kellum to Swenson. Am J Respir Crit Care Med 2020; 202:907-908. [PMID: 32459981 PMCID: PMC7491412 DOI: 10.1164/rccm.202005-1747le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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