1
|
Carlton H, Shipman KE. Pitfalls in the diagnosis and management of acid-base disorders in humans: a laboratory medicine perspective. J Clin Pathol 2024:jcp-2024-209423. [PMID: 39025490 DOI: 10.1136/jcp-2024-209423] [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: 02/16/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024]
Abstract
Diagnostic errors affect patient management, and as blood gas analysis is mainly performed without the laboratory, users must be aware of the potential pitfalls. The aim was to provide a summary of common issues users should be aware of.A narrative review was performed using online databases such as PubMed, Google Scholar and reference lists of identified papers. Language was limited to English.Errors can be pre-analytical, analytical or post-analytical. Samples should be analysed within 15 min and kept at room temperature and taken at least 15-30 min after changes to inspired oxygen and ventilator settings, for accurate oxygen measurement. Plastic syringes are more oxygen permeable if chilled. Currently, analysers run arterial, venous, capillary and intraosseous samples, but variations in reference intervals may not be appreciated or reported. Analytical issues can arise from interference secondary to drugs, such as spurious hyperchloraemia with salicylate and hyperlactataemia with ethylene glycol, or pathology, such as spurious hypoxaemia with leucocytosis and alkalosis in hypoalbuminaemia. Interpretation is complicated by result adjustment, for example, temperature (alpha-stat adjustment may overestimate partial pressure of carbon dioxide (pCO2) in hypothermia, for example), and inappropriate reference intervals, for example, in pregnancy bicarbonate, and pCO2 ranges should be lowered.Lack of appreciation for patient-specific and circumstance-specific reference intervals, including extremes of age and altitude, and transformation of measurements to standard conditions can lead to inappropriate assumptions. It is vitally important for users to optimise specimen collection, appreciate the analytical methods and understand when reference intervals are applicable to their specimen type, clinical question or patient.
Collapse
Affiliation(s)
- Henry Carlton
- Chemical Pathology, University Hospitals Sussex NHS Foundation Trust, Chichester, UK
| | - Kate E Shipman
- Chemical Pathology, University Hospitals Sussex NHS Foundation Trust, Chichester, UK
- Department of Medical Education, Brighton and Sussex Medical School, Brighton, UK
| |
Collapse
|
2
|
Rief M, Eichinger M, Eichlseder M, Pichler A, Prause G, Bornemann-Cimenti H, Zajic P. Utilization of Multi-Parameter Blood Gas Analysis in Prehospital Emergency Medicine-A Scoping Review. J Emerg Med 2024:S0736-4679(24)00143-4. [PMID: 39025715 DOI: 10.1016/j.jemermed.2024.04.014] [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: 07/01/2023] [Revised: 01/19/2024] [Accepted: 04/26/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Prehospital blood gas analysis (BGA) is an evolving field that offers the potential for early identification and management of critically ill patients. However, the utility and accuracy of prehospital BGA are subjects of ongoing debate. OBJECTIVES We aimed to provide a comprehensive summary of the current literature on prehospital BGA, including its indications, methods, and feasibility. METHODS We performed a scoping review of prehospital BGA. A thorough search of the PubMed, Embase, and Web of Science databases was conducted to identify relevant studies focusing on prehospital BGA in adult patients. RESULTS Fifteen studies met the inclusion criteria. Prehospital BGA was most frequently performed in patients in out-of-hospital cardiac arrest, followed by traumatic and nontraumatic cases. The parameters most commonly analyzed were pH, pCO2, pO2, and lactate. Various sampling methods, including arterial, venous, and intraosseous, were reported for prehospital BGA. While prehospital BGA shows promise in facilitating early identification of critical patients and guiding resuscitation efforts, logistical challenges are to be considered. The handling of preclinical BGA is described as feasible and useful in most of the included studies. CONCLUSION Prehospital BGA holds significant potential for enhancing patient care in the prehospital setting, though technical challenges need to be considered. However, further research is required to establish optimal indications and demonstrate the benefits for prehospital BGA in specific clinical contexts.
Collapse
Affiliation(s)
- Martin Rief
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Michael Eichinger
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Michael Eichlseder
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Alexander Pichler
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Gerhard Prause
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria.
| | - Paul Zajic
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| |
Collapse
|
3
|
Yoshida R, Komukai K, Kubota T, Kinoshita K, Fukushima K, Yamamoto H, Niijima A, Matsumoto T, Nakayama R, Watanabe M, Yoshimura M. The relationship between the initial pH and neurological outcome in patients with out-of-hospital cardiac arrest is affected by the status of recovery of spontaneous circulation on hospital arrival. Heart Vessels 2024; 39:446-453. [PMID: 38300278 DOI: 10.1007/s00380-023-02352-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024]
Abstract
The early prediction of neurological outcomes is useful for out-of-hospital cardiac arrest (OHCA). The initial pH was associated with neurological outcomes, but the values varied among the studies. Patients admitted to our division with OHCA of cardiac origin between January 2015 and December 2022 were retrospectively examined (N = 199). A good neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1-2 at discharge. Patients were divided according to the achievement of recovery of spontaneous circulation (ROSC) on hospital arrival, and the efficacy of pH in predicting good neurological outcomes was compared. In patients with ROSC on hospital arrival (N = 100), the initial pH values for good and poor neurological outcomes were 7.26 ± 0.14 and 7.09 ± 0.18, respectively (p < 0.001). In patients without ROSC on hospital arrival (N = 99), the initial pH values for good and poor neurological outcomes were 7.06 ± 0.23 and 6.92 ± 0.15, respectively (p = 0.007). The pH associated with good neurological outcome was much lower in patients without ROSC than in those with ROSC on hospital arrival (P = 0.003). A higher initial pH is associated with good neurological outcomes in patients with OHCA. However, the pH for a good or poor neurological outcome depends on the ROSC status on hospital arrival.
Collapse
Affiliation(s)
- Ritsu Yoshida
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Kimiaki Komukai
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan.
| | - Takeyuki Kubota
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Koji Kinoshita
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Keisuke Fukushima
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Hiromasa Yamamoto
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Akira Niijima
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Takuya Matsumoto
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Ryo Nakayama
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Masato Watanabe
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
4
|
Yilmaz S, Tatliparmak AC, Karakayali O, Turk M, Uras N, Ipek M, Polat D, Yazici MM, Yilmaz S. February 6 th, Kahramanmaraş earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review. Turk J Emerg Med 2024; 24:80-89. [PMID: 38766417 PMCID: PMC11100575 DOI: 10.4103/tjem.tjem_32_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 05/22/2024] Open
Abstract
This compilation covers emergency medical management lessons from the February 6th Kahramanmaraş earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.
Collapse
Affiliation(s)
- Sarper Yilmaz
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Ali Cankut Tatliparmak
- Department of Emergency Medicine, Uskudar University Faculty of Medicine, Istanbul, Turkey
| | - Onur Karakayali
- Department of Emergency Medicine, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Mehmet Turk
- Department of Emergency Medicine, Silvan Dr. Yusuf Azizoğlu State Hospital, Diyarbakır, Turkey
| | - Nimet Uras
- Department of Emergency Medicine, Battalgazi State Hospital, Malatya, Turkey
| | - Mustafa Ipek
- Department of Emergency Medicine, Selahaddin Eyyubi State Hospital, Diyarbakır, Turkey
| | - Dicle Polat
- Department of Emergency Medicine, Mälarsjukhuset, Eskilstuna, Sweden
| | - Mümin Murat Yazici
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, Turkey
| | - Serkan Yilmaz
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| |
Collapse
|
5
|
Lagina M, Valley TS. Diagnosis and Management of Acute Respiratory Failure. Crit Care Clin 2024; 40:235-253. [PMID: 38432694 PMCID: PMC10910131 DOI: 10.1016/j.ccc.2024.01.002] [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] [Indexed: 03/05/2024]
Abstract
Acute hypoxemic respiratory failure is defined by Pao2 less than 60 mm Hg or SaO2 less than 88% and may result from V/Q mismatch, shunt, hypoventilation, diffusion limitation, or low inspired oxygen tension. Acute hypercapnic respiratory failure is defined by Paco2 ≥ 45 mm Hg and pH less than 7.35 and may result from alveolar hypoventilation, increased fraction of dead space, or increased production of carbon dioxide. Early diagnostic maneuvers, such as measurement of SpO2 and arterial blood gas, can differentiate the type of respiratory failure and guide next steps in evaluation and management.
Collapse
Affiliation(s)
- Madeline Lagina
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI, USA. https://twitter.com/maddielagina
| | - Thomas S Valley
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI, USA; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| |
Collapse
|
6
|
Walther LH, Lassen AT, Mogensen CB, Christensen EF, Mikkelsen S. Prehospital blood gas analyses in acute patients treated by a ground-based physician-manned emergency unit: a cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:102. [PMID: 38115069 PMCID: PMC10729417 DOI: 10.1186/s13049-023-01170-1] [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: 09/28/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The prehospital patients treated by ambulances and mobile emergency care units (MECU) are potentially critically ill or injured. Knowing the risks of serious outcomes in these patients is important for guiding their treatment. Some settings allow for prehospital arterial blood gas analyses. This study aimed to assess the outcomes of prehospital patients in relation to their prehospitally measured lactate, pH, and CO2 levels. The primary outcome was 7-day mortality. METHODS This register-based cohort study included patients with one or more prehospital blood gas analyses during their prehospital treatment by a physician-manned MECU, from January 2015 to December 2018. The blood samples were analyzed on an ABL90 Flex analyzer. Absolute values with percentages and odds ratios (OR) with 95% confidence intervals (CI) were calculated for the primary and secondary outcomes within prespecified subgroups. RESULTS The study included 745 patients, with an overall 7-day mortality rate of 20.0%. LACTATE LEVEL The 7-day mortality rates were 11.5% in patients with normal lactate levels (< 2.0 mmol/L), 14.4% with intermediate lactate levels (2.0-3.9 mmol/L), and 33.0% with high lactate levels (≥ 4.0 mmol/L). This corresponded to an OR of 1.30 (95% CI: 0.75-2.24) in the intermediate lactate group (2.0-3.9 mmol/L) and an OR of 3.77 (95% CI: 2.44-5.85) in the high lactate group (≥ 4.0 mmol/L), compared to the reference group with normal lactate. PH LEVEL The ORs of 7-day mortality rates were 4.82 (95% CI: 3.00-7.75) in patients with blood pH of < 7.35 and 1.33 (95% CI: 0.65-2.72) in patients with blood pH > 7.45, compared to the reference group with normal pH (7.35-7.45). CO2 LEVEL : The ORs of 7-day mortality rates were 2.54 (95% CI: 1.45-4.46) in patients with blood CO2 of < 4.3 kPa and 2.62 (95% CI: 1.70-4.03) in patients with blood CO2 > 6.0 kPa, compared to the reference group with normal CO2 (4.3-6.0 kPa). CONCLUSIONS This study found a strong correlation between increasing 7-day mortality rates and high blood lactate levels, low levels of pH, and abnormal CO2 blood levels, in prehospital patients undergoing prehospital blood analysis.
Collapse
Affiliation(s)
- Louise Houlberg Walther
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | | | - Christian Backer Mogensen
- Emergency Medicine Research Unit, Hospital Soenderjylland, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Institute of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Emergency and Trauma Care, Center for Internal Medicine and Emergency Care, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|