The changes in cerebral vascular resistance of man in experimental alkalosis and acidosis

Balanced crystalloid solutions versus normal saline in intensive care units: a systematic review and meta-analysis

BACKGROUND

Intravenous fluid therapy is important for pediatric and adult patients in intensive care units (ICUs). However, medical professionals continue to struggle to determine the most appropriate fluids to obtain the best possible outcomes for each patient.

OBJECTIVE

We conducted a meta-analysis involving cohort studies and randomized controlled trials (RCTs) to compare the influence of balanced crystalloid solutions and normal saline among patients in ICUs.

PATIENTS AND METHODS

Studies that compared balanced crystalloid solutions and saline in ICU patients from databases including PubMed, Embase, Web of Science, and Cochrane Library were systematically searched up to July 25, 2022. The primary outcomes were mortality and renal-related outcomes, which included major adverse kidney events within 30 days (MAKE30), acute kidney injury (AKI), new receipt of renal replacement therapy (RRT), maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline. Service utilization including length of hospital stay, ICU stay, ICU-free days and ventilator-free days were also reported.

RESULTS

A total of 13 studies (10 RCTs and 3 cohort studies) involving 38,798 patients in ICUs met the selection criteria. Our analysis revealed that each subgroup had no significant difference in mortality outcomes among ICU patients between balanced crystalloid solutions and normal saline. A significant difference was detected between the adult groups (odds ratio [OR], 0.92; 95% confidence interval [CI], [0.86, 1.00]; p = 0.04) indicating that the AKI in the balanced crystalloid solutions group was lower than that in the normal saline group. Other renal-related outcomes, such as MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline showed no significant difference between the two groups. Regarding secondary outcomes, the balanced crystalloid solution group had a longer ICU stay time (WMD, 0.02; 95% CI, [0.01, 0.03]; p = 0.0004 and I2 = 0%; p = 0.96) than the normal saline group among adult patients. Furthermore, children treated with balanced crystalloid solution had a shorter hospital stay time (WMD, - 1.10; 95% CI, [- 2.10, - 0.10]; p = 0.03 and I2 = 17%; p = 0.30) than those treated with saline.

CONCLUSIONS

Compared with saline, balanced crystalloid solutions could not reduce the risk of mortality and renal-related outcomes, including MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline, but the solutions may reduce total AKI incidence among adult patients in ICUs. For service utilization outcomes, balanced crystalloid solutions were associated with a longer length of ICU stay in the adult group and shorter length of hospital stay in the pediatric group.

Fluid resuscitation with balanced crystalloids versus normal saline in critically ill patients: a systematic review and meta-analysis

Background

Intravenous fluids are used commonly for almost all intensive care unit (ICU) patients, especially for patients in need of resuscitation. The selection and use of resuscitation fluids may affect the outcomes of patients; however, the optimal resuscitative fluid remains controversial.

Methods

We systematically searched PubMed, Embase, and CENTRAL. Studies comparing balanced crystalloids and normal saline in ICU patients were selected. We used the Cochrane Collaboration tool to assess the risk of bias in studies. The primary outcome was mortality at the longest follow-up. Secondary outcomes included the incidence of acute kidney injury (AKI) and new renal replacement therapy (RRT).

Results

A total of 35,456 patients from eight studies were included. There was no significant difference between balanced crystalloid solutions and saline in mortality (risk ratio [RR]: 0.96; 95% confidence interval [CI]:0.92–1.01). The subgroup analysis with traumatic brain injury (TBI) showed lower mortality in patients receiving normal saline (RR:1.25; 95% CI 1.02–1.54). However, in patients with non-TBI, balanced crystalloid solutions achieved lower mortality than normal saline (RR: 0.94; 95% CI 0.90–0.99). There was no significant difference in moderate to severe AKI (RR: 0.96; 95% CI 0.90–1.01) or new RRT (RR: 0.94; 95% CI 0.84–1.04).

Conclusions

Compared with normal saline, balanced crystalloids may not improve the outcomes of mortality, the incidence of AKI, and the use of RRT for critically ill patients. However, balanced crystalloids reduce the risk of death in patients with non-TBI but increase the risk of death in those with TBI. Large-scale rigorous randomized trials with better designs are needed, especially for specific patient populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01015-3.

Saline Compared to Balanced Crystalloid in Patients With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This systematic review and meta-analysis compared the use of saline to balanced crystalloid for fluid resuscitation in patients with diabetic ketoacidosis (DKA).

DATA SOURCES

We searched databases including Medline, Embase, and the Cochrane registry.

STUDY SELECTION

We included randomized controlled trials (RCTs) that compared saline to balanced crystalloid in patients with DKA.

DATA EXTRACTION

We pooled estimates of effect using relative risk for dichotomous outcomes and mean differences (MDs) for continuous outcomes, both with 95% CIs. We assessed risk of bias for included RCTs using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation methodology.

DATA SYNTHESIS

We included eight RCTs (n = 482 patients). Both time to DKA resolution (MD, 3.51 hr longer; 95% CI, 0.90 longer to 6.12 longer; moderate certainty) and length of hospital stay (MD, 0.89 d longer in saline group; 95% CI, 0.34 longer to 1.43 d longer; moderate certainty) are probably longer in the saline group compared with the balanced crystalloid group, although for the latter, the absolute difference (under 1 d) is small. Post-resuscitation serum chloride level may be higher (MD, 1.62 mmol/L higher; 95% CI, 0.40 lower to 3.64 higher; low certainty), and post-resuscitation serum bicarbonate is probably lower (MD, 1.50 mmol/L; 95% CI, 2.33 lower to 0.67 lower; moderate certainty) in those receiving saline.

CONCLUSIONS

In patients with DKA, the use of saline may be associated with longer time to DKA resolution, higher post-resuscitation serum chloride levels, lower post-resuscitation serum bicarbonate levels, and longer hospital stay compared with balanced crystalloids. Pending further data, low to moderate certainty data support using balanced crystalloid over saline for fluid resuscitation in patients with DKA.

Acid-base balance and cerebrovascular regulation

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.

Regulation of cerebral blood flow by arterial PCO2 independent of metabolic acidosis at 5050 m

KEY POINTS

We investigated the influence of arterial PCO₂ (PaCO₂ ) with and without experimentally altered pH on cerebral blood flow (CBF) regulation at sea level and with acclimatization to 5050 m. At sea level and high altitude, we assessed stepwise alterations in PaCO₂ following metabolic acidosis (via 2 days of oral acetazolamide; ACZ) with and without acute restoration of pH (via intravenous sodium bicarbonate; ACZ+HCO₃ ^- ). Total resting CBF was unchanged between trials at each altitude even though arterial pH and [HCO₃ ^- ] (i.e. buffering capacity) were effectively altered. The cerebrovascular responses to changes in arterial [H⁺ ]/pH were consistent with the altered relationship between PaCO₂ and [H⁺ ]/pH following ACZ at high altitude (i.e. leftward x-intercept shifts). Absolute cerebral blood velocity (CBV) and the sensitivity of CBV to PaCO₂ was unchanged between trials at high altitude, indicating that CBF is acutely regulated by PaCO₂ rather than arterial pH.

ABSTRACT

Alterations in acid-base balance with progressive acclimatization to high altitude have been well-established. However, how respiratory alkalosis and the resultant metabolic compensation interact to regulate cerebral blood flow (CBF) is uncertain. We addressed this via three separate experimental trials at sea level and following partial acclimatization (14 to 20 days) at 5050 m; involving: (1) resting acid-base balance (control); (2) following metabolic acidosis via 2 days of oral acetazolamide at 250 mg every 8 h (ACZ; pH: Δ -0.07 ± 0.04 and base excess: Δ -5.7 ± 1.9 mEq⋅l^-1 , trial effects: P < 0.001 and P < 0.001, respectively); and (3) after acute normalization of arterial acidosis via intravenous sodium bicarbonate (ACZ + HCO₃ ^- ; pH: Δ -0.01 ± 0.04 and base excess: Δ -1.5 ± 2.1 mEq⋅l^-1 , trial effects: P = 1.000 and P = 0.052, respectively). Within each trial, we utilized transcranial Doppler ultrasound to assess the cerebral blood velocity (CBV) response to stepwise alterations in arterial PCO₂ (PaCO₂ ), i.e. cerebrovascular CO₂ reactivity. Resting CBF (via Duplex ultrasound) was unaltered between trials within each altitude, indicating that respiratory compensation (i.e. Δ -3.4 ± 2.3 mmHg PaCO₂ , trial effect: P < 0.001) was sufficient to offset any elevations in CBF induced via the ACZ-mediated metabolic acidosis. Between trials at high altitude, we observed consistent leftward shifts in both the PaCO₂ -pH and CBV-pH responses across the CO₂ reactivity tests with experimentally reduced arterial pH via ACZ. When indexed against PaCO₂ - rather than pH - the absolute CBV and sensitivity of CBV-PaCO₂ was unchanged between trials at high altitude. Taken together, following acclimatization, CO₂ -mediated changes in cerebrovascular tone rather than arterial [H⁺ ]/pH is integral to CBF regulation at high altitude.

Balanced Crystalloid Solutions

Intravenous fluid therapy is the most common intervention received by acutely ill patients. Historically, saline (0.9% sodium chloride) has been the most frequently administered intravenous fluid, especially in North America. Balanced crystalloid solutions (e.g., lactated Ringer's, Plasma-Lyte) are an increasingly used alternative to saline. Balanced crystalloids have a sodium, potassium, and chloride content closer to that of extracellular fluid and, when given intravenously, have fewer adverse effects on acid-base balance. Preclinical research has demonstrated that saline may cause hyperchloremic metabolic acidosis, inflammation, hypotension, acute kidney injury, and death. Studies of patients and healthy human volunteers suggest that even relatively small volumes of saline may exert physiological effects. Randomized trials in the operating room have demonstrated that using balanced crystalloids rather than saline prevents the development of hyperchloremic metabolic acidosis and may reduce the need for vasopressors. Observational studies among critically ill adults have associated receipt of balanced crystalloids with lower rates of complications, including acute kidney injury and death. Most recently, large randomized trials among critically ill adults have examined whether balanced crystalloids result in less death or severe renal dysfunction than saline. Although some of these trials are still ongoing, a growing body of evidence raises fundamental concerns regarding saline as the primary intravenous crystalloid for critically ill adults and highlights fundamental unanswered questions for future research about fluid therapy in critical illness.

Sympathetic influence on cerebral blood flow and metabolism during exercise in humans

This review focuses on the possibility that autonomic activity influences cerebral blood flow (CBF) and metabolism during exercise in humans. Apart from cerebral autoregulation, the arterial carbon dioxide tension, and neuronal activation, it may be that the autonomic nervous system influences CBF as evidenced by pharmacological manipulation of adrenergic and cholinergic receptors. Cholinergic blockade by glycopyrrolate blocks the exercise-induced increase in the transcranial Doppler determined mean flow velocity (MCA Vmean). Conversely, alpha-adrenergic activation increases that expression of cerebral perfusion and reduces the near-infrared determined cerebral oxygenation at rest, but not during exercise associated with an increased cerebral metabolic rate for oxygen (CMRO(2)), suggesting competition between CMRO(2) and sympathetic control of CBF. CMRO(2) does not change during even intense handgrip, but increases during cycling exercise. The increase in CMRO(2) is unaffected by beta-adrenergic blockade even though CBF is reduced suggesting that cerebral oxygenation becomes critical and a limited cerebral mitochondrial oxygen tension may induce fatigue. Also, sympathetic activity may drive cerebral non-oxidative carbohydrate uptake during exercise. Adrenaline appears to accelerate cerebral glycolysis through a beta2-adrenergic receptor mechanism since noradrenaline is without such an effect. In addition, the exercise-induced cerebral non-oxidative carbohydrate uptake is blocked by combined beta 1/2-adrenergic blockade, but not by beta1-adrenergic blockade. Furthermore, endurance training appears to lower the cerebral non-oxidative carbohydrate uptake and preserve cerebral oxygenation during submaximal exercise. This is possibly related to an attenuated catecholamine response. Finally, exercise promotes brain health as evidenced by increased release of brain-derived neurotrophic factor (BDNF) from the brain.

The effect of sodium bicarbonate on CBF and intracellular pH in man: stable Xe-CT and 31P-MRS

The effects of sodium bicarbonate on cerebral blood flow (CBF) and intracellular pH were studied in five normal volunteers. CBF and intracellular pH were measured by stable xenon computed tomography and phosphorus-31 magnetic resonance spectroscopy (31P-MRS) respectively. Each patient received 7% sodium bicarbonate (3.5 ml/kg body weight) infused intravenously for 15 minutes. Before and after this injection, CBF intracellular pH and physiological parameters were measured. CBF and PaCO2 were significantly increased. On the other hand, hematocrit and intracellular pH were decreased. These result suggests that three factors are thought to contribute to increase CBF during administration of sodium bicarbonate in humans: 1) arterial dilatation in response to carbon dioxide 2) an decrease of hematocrit 3) intracellular acidosis.

Transcranial Doppler ultrasound assessment of intracranial hemodynamics in children with diabetic ketoacidosis

The pathophysiology of acute neurological complications of diabetic ketoacidosis (DKA) in children and adolescents is not completely understood. We sought to establish whether transcranial Doppler (TCD) was able to monitor the changes of cerebral blood flow regulatory mechanisms, as measured by cerebral blood velocities (CBF-V), Gosling's pulsatility index (PI), and cerebral vascular reactivity (VR), prior to and during treatment of DKA. The increased values of PI suggested an increase of intracranial pressure (ICP) due to the existence of cerebral vasoparalysis, based on the low values of VR prior to treatment and 6 hours after initiation of treatment. At 24 hours, the correction of hematocrit and pH was associated with a significant decrease of PI, suggesting a decrease of ICP, likely due to a return of vascular tone in response to the low PaCO2. This was further supported by an increase of VR in all patients. At 48 hours, when PaCO2 returned to normal, the PI remained low and the VR increased further, suggesting a complete reversal of vasoparalysis and a return of cerebral blood flow regulatory mechanisms.

Shy-Drager syndrome. Effect of fludrocortisone and L-threo-3,4-dihydroxyphenylserine on the blood pressure and regional cerebral blood flow

In nine cases of Shy-Drager syndrome, the changes in blood pressure and cerebral blood flow on sitting up from a supine position were studied. The influence of fludrocortisone, a synthetic mineralocorticoid, and L-threo-3,4-dihydroxyphenylserine (DOPS), a precursor of norepinephrine, on these changes was examined. On sitting up, the regional cerebral blood flow (rCBF) measured by Xe133 inhalation showed a tendency to decrease. Fludrocortisone reduced the fall of the mean blood pressure significantly. DOPS reduced the fall of both the diastolic blood pressure and rCBF significantly.

Changes in quantitative EEG and blood flow velocity due to standardized hyperventilation; a model of transient ischaemia in young human subjects

A standardized hyperventilation (HV) procedure has been developed in which the end-tidal pCO2 was decreased to 2 kpa. In 24 young male subjects blood flow velocity and qEEG were studied before, during and after HV. This standardized hyperventilation procedure gave rise to a decrease in blood flow velocity to 40% of baseline value and highly significant qEEG changes in 3 derivations. Both relative and absolute band power estimates showed an increase in slow activity and a decrease in alpha and beta activity. The use of subtraction spectra led to a more precise and detailed presentation of these changes than the use of classical qEEG parameters. These changes were reproducible after 1 week. The effects found in the presented model of HV-induced ischaemia appeared to be twice as large as those found in a model of hypobaric hypoxia. The present model might be used to test the efficacy of anti-ischaemic drugs in young human subjects.

Effects of lactic acid infusions and pH on cerebral blood flow and metabolism

To determine the effects of lactic acidemia versus lactate on CBF, we infused lactic acid, either buffered with NaOH (L + NaOH) or with added NaCl (L + NaCl), to attain similar osmolalities in 18 piglets. CBF (microsphere technique), pH, blood gases, plasma osmolality, and cerebral arteriovenous differences of O2 content and lactic acid concentrations were measured prior to, at 30 min of a lactic acid infusion, and 15 and 90 min after completion of the infusion. Control arterial pH was comparable between groups (7.50 +/- 0.02 vs. 7.49 +/- 0.02, X +/- SE); during and following L + NaCl and L + NaOH, values were (p less than 0.05) 7.09 +/- 0.03, 7.35 +/- 0.02, and 7.46 +/- 0.02 vs. 7.58 +/- 0.03, 7.61 +/- 0.01, and 7.57 +/- 0.03, respectively. PaCO2 remained unchanged and osmolality rose by 15% in both groups during infusions and persisted throughout the study period. For L + NaCl piglets, CBF (ml/min.100 g) rose from 136 +/- 15 to 198 +/- 26 (p less than 0.05) at 30 min of infusion and remained elevated at 201 +/- 25 and 207 +/- 28 at 15 and 90 min following the infusion, respectively. Similarly, for L + NaOH piglets, CBF rose from 130 +/- 25 to 196 +/- 31 (p less than 0.05) with the infusion and was 174 +/- 17 and 166 +/- 21 at 15 and 90 min afterward, respectively. Although lactic acid infusion increases CBF, the associated metabolic acidemia is not responsible for changes in CBF.

The effect of metabolic acidosis upon autoregulation of cerebral blood flow in newborn dogs

The radioactive microsphere technique was used in 13 newborn dogs to determine the effect of a metabolic (lactic)acidosis upon cardiac output (CO), cerebral blood flow (CBF), and autoregulation of cerebral blood flow. The animals were mechanically ventilated with supplemental oxygen to ensure normocarbia and hyperoxia throughout the experiments. Baseline cardiac output and cerebral blood flow measurements were made, followed by a lactic acid infusion to maintain pH less than 7.25. Metabolic acidosis produced a 27% fall in cardiac output and no change in cerebral blood flow (19 ml/100 g/min). Autoregulation was tested in 6 of the acidemic puppies by acute volume depletion to reduce blood pressure by 30% of baseline, followed by rapid volume re-expansion of the withdrawn blood. With volume depletion, CO decreased by 38%, and with volume re-expansion CO returned to baseline. The CBF remained at baseline levels with volume depletion but was slightly increased after rapid volume re-expansion. Five acidemic controls maintained CO and CBF constant with time. Thus cerebral autoregulation is preserved in the newborn dogs during metabolic acidosis, although cerebral blood flow was slightly increased following volume re-expansion.

Effect of H+ and elevated PCO2 on membrane electrical properties of rat cerebral arteries

Some membrane electrical properties of muscle cells from the middle cerebral artery of the rat were recorded with intracellular microelectrodes. The resting membrane potential (Em) of this preparation was -63 mV. Reduction of extracellular pH to 7.0 in the face of a constant PCO2 of 40 mm Hg had no significant effect on Em. Similarly the slope of the steady-state voltage/current curves was not different at pH 7.0 compared to control at pH 7.4. In marked contrast, when PCO2 was elevated to around 60 to 70 mm Hg there was a rapid hyperpolarization and reduction in the slope of the voltage current curve suggesting an increased conductance for one or more ionic species. In addition elevation of PCO2 increased the slope of the Em vs. log[K]0 curve from 46 mV/decade to 59 mV/decade which is in good agreement with a Nernstian potential for a K+ selective membrane. These data suggest that while the smooth muscle cells of rat cerebral arteries are relatively insensitive to a small reduction in extracellular pH; reduction of intracellular pH by elevating PCO2 induces hyperpolarization by increasing K+ conductance (gk). However, it is not clear from these experiments if the PCO2 effects are mediated entirely by changes in pH or if there is a direct membrane action of CO2.

Effects on cerebral blood flow of infusion of hyperosmolar saline during cerebral vasodilation in the dog

In six anaesthetized dogs, cerebrovascular reaction to experimental (plasma osmolality in the range of 350-400 mosm . kg water-1) induced by intravenous infusion of 0.6 M saline was studied. In order to provoke and reinforce any effects from saline passage over the blood-brain barrier, pre-experimental submaximal vasodilation was induced by means of hypercapnia and in some cases haemodilution. Cerebral blood flow (CBF) was measured by the radioactive gas elimination method. CBF was unaffected by progressive hyperosmolality during a 2-h observation period.

Positron imaging of cerebral blood flow during continuous inhalation of C15O2

This investigation tests the hypothesis that the normal cerebral image obtained non-invasively during continuous inhalation of C15O2 is related to cerebral blood flow. Trace amounts of CO2 labeled with the positron-emitting radionuclide 15O were administered to 4 normal subjects at normo- and hypocapnia and to 2 of these subjects at hypercapnia. Hypocapnia typically caused a marked decrease in cerebral 15O activity, and hypercapnia a small increase in activity. The relative difference in the change in count rate in response to hypo- and hypercapnia is what one would expect if the activity represented bloow flow, according to a mathematical model which assumes the 15O label enters the brain as water of perfusion. The findings in this study suggest that the normal cerebral image obtained during continuous inhalation of C15O2 is related to cerebral blood flow, but in a non-linear fashion, and that the technique would be more sensitive to ischemic events than to hyperemic phenomena.

Controlled hypotension in hip joint surgery. An assessment of surgical haemorrhage during sodium nitroprusside infusion

Controlled hypotension, combined with light balanced anaesthesia, was employed during total hip replacement operations on 25 patients. Sodium nitroprusside (Nipride, Roche), in the form of a 0.01 per cent (100 micrograms/ml) infusion, was used as a hypotensive agent. The mean arterial blood pressure (MABP) was lowered from 108 to 64 mmHg (range 60--70) (P less than 0.001). The average blood loss during the operations was 212 ml and none of the patients required homologous blood transfusion. In comparison with 25 normotensive patients undergoing similar surgery, the difference in the mean volume of haemorrhage between the two groups was 826 ml (P less than 0.001). The difference in the total haemorrhage, however, between the same two groups was 518 ml (mean) (P less than 0.01). The results were compared with those of another investigation in which epidural anaesthesia was used to diminish bleeding during surgery on the hip.

The reactivity of canine cerebral arteries to O2 and CO2 in vitro

The responses of canine middle cerebral arteries to changes in pCO2 and pO2 were tested in vitro. It was found that there was no response to changes in pCO2 from 38.1 mm. Hg to 26.6 mm. Hg, but there was some constriction of the vessels with lowering of the pCO2 below 26.6 mm. Hg and there was minimal dilatation of the vessels when the pCO2 was increased from 38.1 mm. Hg to 87.2 mm. Hg. There was no response to changes in pO2 from more than 55 mm. Hg to 59.6 mm. Hg, but when pO2 was lowered below 50 mm. Hg there was a sudden, massive constriction of the arteries tested. It is postulated that this constriction is due to build-up of a substance (substances) during a period of hypoxia (pO2 less than 50 mm. Hg). The significance of the results obtained are discussed.

Neurologic manifestations of diabetic comas: correlation with biochemical alterations in the brain

Coma and other neurologic abnormalities are present in patients with either diabetic ketoacidosis (DKA) or nonketotic coma (NKC), and the cause of such phenomena are not known. Patients with NKC also manifest seizures and focal neurologic changes. Treatment of diabetic coma with insulin may induce cerebral edema by as yet undefined mechanism(s). In patients with DKA, cerebral oxygen utilization is impaired, and there is hyperviscosity of the blood. A substantial part of the brain's energy source is derived from ketones, which in themselves can depress sensorium. Extracellular hyperosomolality is present, which may also contribute to the genesis of coma. In addition, most ketoacidotic patients have associated medical conditions, which may further impair consciousness. Biochemical changes in the brains of animals with DKA include impairment of both phosphofructokinase activity and pyruvate oxidation, and accumulation of citrate. The net effect upon sensorium in ketoacidotic patients probably represents the interaction of most of the above factors and differs markedly among individuals. Patients with NKC manifest not only depression of sensorium, but also focal motor seizures, hemiparesis, and other neurologic changes, such as aphasia, hypereflexia, sensory defects, autonomic changes, and brainstem dysfunction. Most of the aforementioned changes revert to normal after correction of hyperosomolality. Gamma amino butyric acid, which has been shown to elevate the seizure threshold, is normal in brains of ketoacidotic animals, but may be low in nonketotic coma. Also, hyperosomolality per se may produce seizures. Cerebral edema may complicate the treatment of either DKA or NKC. The available experimental evidence suggests that many of the commonly held theories for the production of such brain swelling probably do not occur. There is no breakdown of the sodium pump, sorbitol or fructose do not accumulate in brain, and brain glucose is only about 25 percent of that in plasma; Cerebral edema is probably produced largely by a direct action of insulin on brain at a time when plasma glucose is approaching normal values. Cerebral edema can thus theoretically be avoided by stopping insulin when plasma glucose has been lowered to values approaching normal.

Influence of intracranial osmotic stimuli on renal nerve activity in anaesthetized cats

In baroreceptor denervated cats one internal carotid artery (ICA) or the cerebral ventricular system (CVS) was perfused with isotonic, hypertonic and hypotonic sodium chloride solutions. Renal sympathetic activity (RSA) and blood pressure (BP) were recorded. ICA perfusion with isotonic sodium chloride (150 mM NaCl) produced no changes of RSA compared to control level,. RSA was increased from plus 30% to plus 350% in 44 tests out of 45 tests following hypertonic (425 mM NaCl) ICA perfusion. RSA was decreased following hypotonic (aqua dest.) ICA perfusion from minus 30% to minus 100% in 37 tests out of 50 tests. The degree of RSA changes was found to depend upon the osmolarity of the solutions. 425mM NaCl and aqua dest. produced greater RSA changes than 290 mM NaCl and 75 mM NaCl. CVS perfusion with isotonic sodium chloride produced a slight increase of RSA compared to control levels (plus 15%). Hypertonic sodium chloride produced a RSA increase from plus 15% to plus 135% in 10 tests out of 14 tests. Hypotonic sodium chloride produced a RSA decrease from minus 15% to minus 80% in 8 tests out of 14 tests. Changes of RSA following ICA perfusions and CVS perfusions were accompanied by changes of BP in the same direction. A quantitative correlation between delta RSA and delta BP could not be found. Results suggest that renal osmoregulatory response to osmotic stimuli in the carotid artery may not just arise in response to changing ADH levels but may also be induced by changes in RSA.

The influence of nonrespiratory alkalosis on cerebral blood flow in cats

Cerebral blood flow was measured with the 133 Xenon clearance method during short-lasting (20 minutes) and more prolonged (90 minutes) infusions of Na 2 CO 3 solutions in anesthetized cats under controlled ventilation. The infusion protocol was regulated so as to produce a given increase in the plasma [HCO 3 - ] in the first 15 minutes, followed by a constant high plasma level for the rest of the infusion period. A high Pa co 3 level was induced before and at the end of the infusion, when prolonged infusions were made. The results indicate that, in acute experiments (20 minutes), an increase in plasma [HCO 3 - ] of 14 mEq/l does not influence CBF. During more prolonged infusions (90 minutes), an increase of 12 mEq/l produces a reduction of CBF and an increase in the CSF [HCO 3 - ]. These changes are more pronounced when the increase in plasma [HCO 3 - ] is more marked (18 mEq/l).

Dependency of pial arterial and arteriolar diameter on perivascular osmolarity in the cat. A microapplication study

The effect of perivascular osmolarity on the diameter of pial arteries was studied in cats by the microapplication technique. Between 251 and 360 mosmoles/liter, concentration-response curves were obtained for single vessels. Constriction occurred when perivascular osmolarity was decreased below 317 mosmoles/liter, and dilation occurred at osmolarities above this value. The effect was the same whether the osmolarity was changed by addition of mannitol or NaCl. Reduction of sodium concentration from 156 to 133 mEq/liter at constant osmolarity did not affect arteriolar diameter, but greater reductions in sodium concentration induced vasoconstriction. The results indicate that the resistance of pial arteries can be influenced by local changes in perivascular osmolarity.

Step hypocapnia to separate arterial from tissue PCO2 in the regulation of cerebral blood flow

The change in cerebral blood flow was determined after a step decrease in the Pco 2 of arterial blood from 40 to 25 mm Hg in awake man. Subjects monitored their own end-tidal Pco 2 (infrared analyzer) and adjusted their voluntary ventilation to produce the step change, which they maintained for at least 1 hour. Cerebral blood flow relative to control was determined from the arterial-jugular venous oxygen saturation differences. After the step change, arterial Pco 2 fell in less than 30 sec to a plateau, cerebral blood flow fell with a time constant (to 1/e) of 0.3 min to a plateau of 68% of control, while jugular venous Pco 2 fell with a time constant for the fast component of 3.5 min. Base excess rose 1.2 mEq/liter within 1 min and remained at that level. It is concluded that CO 2 affects cerebral blood flow by direct diffusion into arteriolar walls, rather than by its effect on brain tissue Pco 2 or pH. It is postulated that the pH of the extracellular fluid of arteriolar smooth muscle is the common controlled variable through which CO 2 , and possibly hypoxia and blood pressure, determine vascular tone.

Cerebral blood flow in man at high altitude. Role of cerebrospinal fluid pH in normalization of flow in chronic hypocapnia

Cerebral blood flow was determined by an N 2 O method in 7 normal men at sea level and after 6 to 12 hr and 3 to 5 days at 3810 m altitude. An infrared N 2 O analyzer was used both to measure end-tidal PN 2 O so that it could be kept constant for 15 min and to determine blood N 2 O, for which a simple gas extraction method was devised. In addition, acute changes in cerebral blood flow were estimated from cerebral A-V O 2 differences. Control cerebral blood flow was 43 ml per 100 g per min; it increased 24% at 6 to 12 hours and 13% at 3 to 5 days at altitude. After 3 to 5 days, pH of cerebrospinal fluid was normal (7.31) in four subjects while arterial blood pH was alkaline (7.47); arterial blood Pco 2 had fallen from 41 to 30 mm Hg. Acute correction of hypoxia restored cerebral blood flow to control while mean Pco 2 was still 31 mm Hg. Addition of O 2 and CO 2 to inspired air raised cerebral blood flow 34% above control at Pao 2 = 170, Paco 2 = 35 mm Hg. Values obtained by extrapolation suggest that if arterial Pco 2 was raised to control (41 mm Hg), cerebral blood flow would have been 60% above control. Cerebral blood flow thus appears to return to normal at the prevailing Paco 2 , probably because the pH of cerebrospinal fluid and of the extracellular fluid of cerebral vascular smooth muscle is kept normal by active transport across the ‘blood-brain’ barrier. It is postulated that an ion-impermeable barrier separates the blood stream from extracellular fluid of the smooth muscle of cerebral arterioles.

Evaluation of respiratory compensation in metabolic alkalosis

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