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van Wyk L, Austin T, Barzilay B, Bravo MC, Breindahl M, Czernik C, Dempsey E, de Boode WP, de Vries W, Eriksen BH, Fauchére JC, Kooi EMW, Levy PT, McNamara PJ, Mitra S, Nestaas E, Rabe H, Rabi Y, Rogerson SR, Savoia M, Schena F, Seghal A, Schwarz CE, Thome U, van Laere D, Zaharie GC, Gupta S. A recommendation for the use of electrical biosensing technology in neonatology. Pediatr Res 2024:10.1038/s41390-024-03369-z. [PMID: 38977797 DOI: 10.1038/s41390-024-03369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024]
Abstract
Non-invasive cardiac output monitoring, via electrical biosensing technology (EBT), provides continuous, multi-parameter hemodynamic variable monitoring which may allow for timely identification of hemodynamic instability in some neonates, providing an opportunity for early intervention that may improve neonatal outcomes. EBT encompasses thoracic (TEBT) and whole body (WBEBT) methods. Despite the lack of relative accuracy of these technologies, as compared to transthoracic echocardiography, the use of these technologies in neonatology, both in the research and clinical arena, have increased dramatically over the last 30 years. The European Society of Pediatric Research Special Interest Group in Non-Invasive Cardiac Output Monitoring, a group of experienced neonatologists in the field of EBT, deemed it appropriate to provide recommendations for the use of TEBT and WBEBT in the field of neonatology. Although TEBT is not an accurate determinant of cardiac output or stroke volume, it may be useful for monitoring longitudinal changes of hemodynamic parameters. Few recommendations can be made for the use of TEBT in common neonatal clinical conditions. It is recommended not to use WBEBT to monitor cardiac output. The differences in technologies, study methodologies and data reporting should be addressed in ongoing research prior to introducing EBT into routine practice. IMPACT STATEMENT: TEBT is not recommended as an accurate determinant of cardiac output (CO) (or stroke volume (SV)). TEBT may be useful for monitoring longitudinal changes from baseline of hemodynamic parameters on an individual patient basis. TEBT-derived thoracic fluid content (TFC) longitudinal changes from baseline may be useful in monitoring progress in respiratory disorders and circulatory conditions affecting intrathoracic fluid volume. Currently there is insufficient evidence to make any recommendations regarding the use of WBEBT for CO monitoring in neonates. Further research is required in all areas prior to the implementation of these monitors into routine clinical practice.
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Affiliation(s)
- Lizelle van Wyk
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
| | - Topun Austin
- Neonatal Intensive Care Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Bernard Barzilay
- Neonatal Intensive Care Unit, Assaf Harofeh Medical Center, Tzrifin, Israel
| | - Maria Carmen Bravo
- Department of Neonatology, La Paz University Hospital and IdiPaz, Madrid, Spain
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christoph Czernik
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Willem de Vries
- Division of Woman and Baby, Department of Neonatology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jean-Claude Fauchére
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Elisabeth M W Kooi
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Philip T Levy
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, UK
| | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Clinic of Paediatrics and Adolescence, Akershus University Hospital, Lørenskog, Norway
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | | | - Sheryle R Rogerson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
| | - Marilena Savoia
- Neonatal Intensive Care Unit, S Maria Della Misericordia Hospital, Udine, Italy
| | | | - Arvind Seghal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Christop E Schwarz
- Department of Neonatology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Thome
- Division of Neonatology, Department of Pediatrics, University of Leipzig Medical Centre, Leipzig, Germany
| | - David van Laere
- Neonatal Intensive Care Unit, Universitair Ziekenhuis, Antwerp, Belgium
| | - Gabriela C Zaharie
- Neonatology Department, University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj -Napoca, Romania
| | - Samir Gupta
- Department of Engineering, Durham University, Durham, UK
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
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2
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Davids R, Robinson G, Van Tonder C, Robinson J, Ahmed N, Domingo A. Jehovah's Witness Needing Critical Care: A Narrative Review on the Expanding Arsenal. Crit Care Res Pract 2024; 2024:1913237. [PMID: 38813134 PMCID: PMC11136542 DOI: 10.1155/2024/1913237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/08/2024] [Accepted: 04/13/2024] [Indexed: 05/31/2024] Open
Abstract
Present day Jehovah's Witness (JW) religion accounts for 8.5 million followers. A tenant feature of the JW faith is religious objection to transfusions of blood and blood products. Interpatient variability, as it pertains to blood and blood products may occur; hence, a confidential interview will determine which products individual may consent to (Marsh and Bevan, 2002). This belief and practice place great restrictions on treating medical professionals in scenarios of life-threatening anaemia and active haemorrhage. The review to follow explores the physiological and pathophysiological consequences of severe anaemia. Non-blood transfusion practices are explored, many of which are potentially lifesaving. Particular attention is drawn to the evolving science involving artificial oxygen carriers and their use in emergency situations. A greater safety profile ensures its future use amongst religious objectors to be greatly beneficial. Intravenous iron supplementation has enjoyed a lively debate within the critical care community. A review of recent systematic and meta-analysis supports its use in the ICU; however, more investigation is needed into the complementary use of hepcidin.
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Affiliation(s)
- Ryan Davids
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Gareth Robinson
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Charmé Van Tonder
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Jordan Robinson
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Nadiyah Ahmed
- Department of Critical Care, University of Free State, Bloemfontein, South Africa
| | - Abdurragmaan Domingo
- Department of Anaesthesiology and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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3
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Hu J, Jin Q, Fang H, Zhang W. Evaluating the predictive value of initial lactate/albumin ratios in determining prognosis of sepsis patients. Medicine (Baltimore) 2024; 103:e37535. [PMID: 38518050 PMCID: PMC10957005 DOI: 10.1097/md.0000000000037535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/16/2024] [Indexed: 03/24/2024] Open
Abstract
Sepsis remains a significant clinical challenge owing to its complex pathophysiology and variable prognosis. The early identification of patients at a higher risk of poor outcomes can be crucial for improving treatment strategies. This study aimed to evaluate the predictive value of early serum lactate and albumin levels and the lactate/albumin (L/A) ratio for 28-day prognosis in patients with sepsis. Patients diagnosed with sepsis between January 2021 and December 2022 were evaluated using a retrospective cohort methodology. Inclusion followed the International Consensus on sepsis and septic shock (Sepsis-3) guidelines and patients were selected based on well-defined criteria. Variables such as lactate, albumin, and the L/A ratio were documented within the first 24 hours of admission. Statistical analyses were performed using various tools, including the nonparametric Mann-Whitney U test and receiver operating characteristic curves. A total of 301 patients were divided into the survival (n = 167) and death (n = 134) groups. Notable differences were detected in the incidence of pulmonary infection, shock, lactate, albumin, and the L/A ratio. The L/A ratio was identified as a key predictor with an area under the curve of 0.868, an optimal cutoff value of >0.17, a sensitivity of 56.21%, and a specificity of 94.18%. Significant disparities in mortality rates and survival times were observed for the lactate, albumin, and L/A levels. This study underscores the predictive value of early serum lactate and albumin levels and the L/A ratio for 28-day prognosis in patients with sepsis, with the L/A ratio showing a superior predictive capability. These findings highlight the importance of L/A ratio as a robust and precise marker for evaluating the future clinical course of patients with sepsis, potentially aiding early detection and management.
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Affiliation(s)
- Jianhua Hu
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, Zhejiang Province, China
| | - Qun Jin
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, Zhejiang Province, China
| | - Honglong Fang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, Zhejiang Province, China
| | - Weiwen Zhang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, Zhejiang Province, China
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Hegemann N, Barth L, Döring Y, Voigt N, Grune J. Implications for neutrophils in cardiac arrhythmias. Am J Physiol Heart Circ Physiol 2024; 326:H441-H458. [PMID: 38099844 PMCID: PMC11219058 DOI: 10.1152/ajpheart.00590.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 02/03/2024]
Abstract
Cardiac arrhythmias commonly occur as a result of aberrant electrical impulse formation or conduction in the myocardium. Frequently discussed triggers include underlying heart diseases such as myocardial ischemia, electrolyte imbalances, or genetic anomalies of ion channels involved in the tightly regulated cardiac action potential. Recently, the role of innate immune cells in the onset of arrhythmic events has been highlighted in numerous studies, correlating leukocyte expansion in the myocardium to increased arrhythmic burden. Here, we aim to call attention to the role of neutrophils in the pathogenesis of cardiac arrhythmias and their expansion during myocardial ischemia and infectious disease manifestation. In addition, we will elucidate molecular mechanisms associated with neutrophil activation and discuss their involvement as direct mediators of arrhythmogenicity.
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Affiliation(s)
- Niklas Hegemann
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Lukas Barth
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Yannic Döring
- Institute of Pharmacology and Toxicology, University Medical Center Göttingen, Georg August University Göttingen, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), Göttingen, Germany
| | - Niels Voigt
- Institute of Pharmacology and Toxicology, University Medical Center Göttingen, Georg August University Göttingen, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), Göttingen, Germany
- Cluster of Excellence "Multiscale Bioimaging: from Molecular Machines to Networks of Excitable Cells" (MBExC), University of Göttingen, Göttingen, Germany
| | - Jana Grune
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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5
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Zheng D, Yu GL, Zhou YP, Zhang QM, Wang CG, Zhang S. Association between lactic acidosis and multiple organ dysfunction syndrome after cardiopulmonary bypass. PeerJ 2024; 12:e16769. [PMID: 38313014 PMCID: PMC10838087 DOI: 10.7717/peerj.16769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/16/2023] [Indexed: 02/06/2024] Open
Abstract
Background The relationship between hyperlactatemia and prognosis after cardiopulmonary bypass (CPB) is controversial, and some studies ignore the presence of lactic acidosis in patients with severe hyperlactacemia. This study explored the association between lactic acidosis (LA) and the occurrence of multiple organ dysfunction syndrome (MODS) after cardiopulmonary bypass. Methods This study was a post hoc analysis of patients who underwent cardiac surgery between February 2017 and August 2018 and participated in a prospective study at Taizhou Hospital. The data were collected at: ICU admission (H0), and 4, 8, 12, 24, and 48 h after admission. Blood lactate levels gradually increased after CPB, peaking at H8 and then gradually decreasing. The patients were grouped as LA, hyperlactatemia (HL), and normal control (NC) based on blood test results 8 h after ICU admission. Basic preoperative, perioperative, and postoperative conditions were compared between the three groups, as well as postoperative perfusion and oxygen metabolism indexes. Results There were 22 (19%), 73 (64%), and 19 (17%) patients in the LA, HL, and NC groups, respectively. APACHE II (24h) and SOFA (24h) scores were the highest in the LA group (P < 0.05). ICU stay duration was the longest for the LA group (48.5 (42.5, 50) h), compared with the HL (27 (22, 48) h) and NC (27 (25, 46) h) groups (P = 0.012). The LA group had the highest incidence of MODS (36%), compared with the HL (14%) and NC (5%) groups (P = 0.015). In the LA group, the oxygen extraction ratio (O2ER) was lower (21.5 (17.05, 32.8)%) than in the HL (31.3 (24.8, 37.6)%) and the NC group (31.3 (29.0, 35.4) %) (P = 0.018). In the univariable analyses, patient age (OR = 1.054, 95% CI [1.003-1.109], P = 0.038), the LA group (vs. the NC group, (OR = 10.286, 95% CI [1.148-92.185], P = 0.037), and ΔPCO2 at H8 (OR = 1.197, 95% CI [1.022-1.401], P = 0.025) were risk factor of MODS after CPB. Conclusions We speculated that there was correlation between lactic acidosis and MODS after CPB. In addition, LA should be monitored intensively after CPB.
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Affiliation(s)
- Dan Zheng
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Guo-Liang Yu
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Yi-Ping Zhou
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Qiao-Min Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Chun-Guo Wang
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
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Fernandez CA. Damage Control Surgery and Transfer in Emergency General Surgery. Surg Clin North Am 2023; 103:1269-1281. [PMID: 37838467 DOI: 10.1016/j.suc.2023.06.004] [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] [Indexed: 10/16/2023]
Abstract
Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.
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Affiliation(s)
- Carlos A Fernandez
- Department of Surgery, Creighton University Medical Center, 7710 Mercy Road, Suite 2000, Omaha, NE 68124, USA.
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Kim Y, Kwon S, Kim SG, Lee J, Han CH, Yu S, Kim B, Paek JH, Park WY, Jin K, Han S, Kim DK, Lim CS, Kim YS, Lee JP. Impact of decreased levels of total CO2 on in-hospital mortality in patients with COVID-19. Sci Rep 2023; 13:16717. [PMID: 37794030 PMCID: PMC10550989 DOI: 10.1038/s41598-023-41988-4] [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: 10/19/2022] [Accepted: 09/04/2023] [Indexed: 10/06/2023] Open
Abstract
Decreased total CO2 (tCO2) is significantly associated with all-cause mortality in critically ill patients. Because of a lack of data to evaluate the impact of tCO2 in patients with COVID-19, we assessed the impact of tCO2 on all-cause mortality in this study. We retrospectively reviewed the data of hospitalized patients with COVID-19 in two Korean referral hospitals between February 2020 and September 2021. The primary outcome was in-hospital mortality. We assessed the impact of tCO2 as a continuous variable on mortality using the Cox-proportional hazard model. In addition, we evaluated the relative factors associated with tCO2 ≤ 22 mmol/L using logistic regression analysis. In 4,423 patients included, the mean tCO2 was 24.8 ± 3.0 mmol/L, and 17.9% of patients with tCO2 ≤ 22 mmol/L. An increase in mmol/L of tCO2 decreased the risk of all-cause mortality by 4.8% after adjustment for age, sex, comorbidities, and laboratory values. Based on 22 mmol/L of tCO2, the risk of mortality was 1.7 times higher than that in patients with lower tCO2. This result was maintained in the analysis using a cutoff value of tCO2 24 mmol/L. Higher white blood cell count; lower hemoglobin, serum calcium, and eGFR; and higher uric acid, and aspartate aminotransferase were significantly associated with a tCO2 value ≤ 22 mmol/L. Decreased tCO2 significantly increased the risk of all-cause mortality in patients with COVID-19. Monitoring of tCO2 could be a good indicator to predict prognosis and it needs to be appropriately managed in patients with specific conditions.
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Affiliation(s)
- Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Soie Kwon
- Department of Internal Medicine, Chung-Ang University Heukseok Hospital, Seoul, Korea
| | - Seong Geun Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chung-Hee Han
- Department of Obstetrics and Gynecology, Bagae Hospital, Pyeongtaek, Gyeonggi-Do, Korea
| | - Sungbong Yu
- Department of General Surgery, Bagae Hospital, Pyeongtaek, Gyeonggi-Do, Korea
| | - Byunggun Kim
- Department of Orthopedic Surgery, Bagae Hospital, Pyeongtaek, Gyeonggi-Do, Korea
| | - Jin Hyuk Paek
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Woo Yeong Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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8
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Kim J, Lee KW, Kim K, Kang H, Yang J, Park JB, Kim G. Factors to consider during anesthesia in patients undergoing preemptive kidney transplantation: a propensity-score matched analysis. BMC Anesthesiol 2023; 23:263. [PMID: 37543574 PMCID: PMC10403880 DOI: 10.1186/s12871-023-02208-8] [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: 02/01/2023] [Accepted: 07/15/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND International guidelines have recommended preemptive kidney transplantation (KT) as the preferred approach, advocating for transplantation before the initiation of dialysis. This approach is advantageous for graft and patient survival by avoiding dialysis-related complications. However, recipients of preemptive KT may undergo anesthesia without the opportunity to optimize volume status or correct metabolic disturbances associated with end-stage renal disease. In these regard, we aimed to investigate the anesthetic events that occur more frequently during preemptive KT compared to nonpreemptive KT. METHODS This is a single-center retrospective study. Of the 672 patients who underwent Living donor KT (LDKT), 388 of 519 who underwent nonpreemptive KT were matched with 153 of 153 who underwent preemptive KT using propensity score based on preoperative covariates. The primary outcome was intraoperative hypotension defined as area under the threshold (AUT), with a threshold set at a mean arterial blood pressure below 70 mmHg. The secondary outcomes were intraoperative metabolic acidosis estimated by base excess and serum bicarbonate, electrolyte imbalance, the use of inotropes or vasopressors, intraoperative transfusion, immediate graft function evaluated by the nadir creatinine, and re-operation due to bleeding. RESULTS After propensity score matching, we analyzed 388 and 153 patients in non-preemptive and preemptive groups. The multivariable analysis revealed the AUT of the preemptive group to be significantly greater than that of the nonpreemptive group (mean ± standard deviation, 29.7 ± 61.5 and 14.5 ± 37.7, respectively, P = 0.007). Metabolic acidosis was more severe in the preemptive group compared to the nonpreemptive group. The differences in the nadir creatinine value and times to nadir creatinine were statistically significant, but clinically insignificant. CONCLUSION Intraoperative hypotension and metabolic acidosis occurred more frequently in the preemptive group during LDKT. These findings highlight the need for anesthesiologists to be prepared and vigilant in managing these events during surgery.
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Kyo Won Lee
- Department of Transplantation Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keoungah Kim
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Dankook University, Cheonan, Korea
| | - Hyeryung Kang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Jaehun Yang
- Department of Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jae Berm Park
- Department of Transplantation Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaabsoo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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Abstract
Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.
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Affiliation(s)
- Jason E. Bloom
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - William Chan
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - David M. Kaye
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - Dion Stub
- Department of CardiologyAlfred HealthMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
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Wardi G, Holgren S, Gupta A, Sobel J, Birch A, Pearce A, Malhotra A, Tainter C. A Review of Bicarbonate Use in Common Clinical Scenarios. J Emerg Med 2023; 65:e71-e80. [PMID: 37442665 PMCID: PMC10530341 DOI: 10.1016/j.jemermed.2023.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/29/2023] [Accepted: 04/10/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND The use of sodium bicarbonate to treat metabolic acidosis is intuitive, yet data suggest that not all patients benefit from this therapy. OBJECTIVE In this narrative review, we describe the physiology behind commonly encountered nontoxicologic causes of metabolic acidosis, highlight potential harm from the indiscriminate administration of sodium bicarbonate in certain scenarios, and provide evidence-based recommendations to assist emergency physicians in the rational use of sodium bicarbonate. DISCUSSION Sodium bicarbonate can be administered as a hypertonic push, as a resuscitation fluid, or as an infusion. Lactic acidosis and cardiac arrest are two common scenarios where there is limited benefit to routine use of sodium bicarbonate, although certain circumstances, such as patients with concomitant acute kidney injury and lactic acidosis may benefit from sodium bicarbonate. Patients with cardiac arrest secondary to sodium channel blockade or hyperkalemia also benefit from sodium bicarbonate therapy. Recent data suggest that the use of sodium bicarbonate in diabetic ketoacidosis does not confer improved patient outcomes and may cause harm in pediatric patients. Available evidence suggests that alkalinization of urine in rhabdomyolysis does not improve patient-centered outcomes. Finally, patients with a nongap acidosis benefit from sodium bicarbonate supplementation. CONCLUSIONS Empiric use of sodium bicarbonate in patients with nontoxicologic causes of metabolic acidosis is not warranted and likely does not improve patient-centered outcomes, except in select scenarios. Emergency physicians should reserve use of this medication to conditions with clear benefit to patients.
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Affiliation(s)
- Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California.
| | - Sarah Holgren
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology. University of California at San Diego, San Diego, California
| | - Arnav Gupta
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Julia Sobel
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Aaron Birch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Alex Pearce
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Christopher Tainter
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology. University of California at San Diego, San Diego, California
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11
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Schulze AB, Mohr M, Sackarnd J, Schmidt LH, Tepasse PR, Rosenow F, Evers G. Risk Factors in HIV-1 Positive Patients on the Intensive Care Unit: A Single Center Experience from a Tertiary Care Hospital. Viruses 2023; 15:v15051164. [PMID: 37243250 DOI: 10.3390/v15051164] [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: 04/29/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
HIV-positive patients with acquired immunodeficiency syndrome (AIDS) often require treatment on intensive care units (ICUs). We aimed to present data from a German, low-incidence region cohort, and subsequently evaluate factors measured during the first 24 h of ICU stay to predict short- and long-term survival, and compare with data from high-incidence regions. We documented 62 patient courses between 2009 and 2019, treated on a non-operative ICU of a tertiary care hospital, mostly due to respiratory deterioration and co-infections. Of these, 54 patients required ventilatory support within the first 24 h with either nasal cannula/mask (n = 12), non-invasive ventilation (n = 16), or invasive ventilation (n = 26). Overall survival at day 30 was 77.4%. While ventilatory parameters (all p < 0.05), pH level (c/o 7.31, p = 0.001), and platelet count (c/o 164,000/µL, p = 0.002) were significant univariate predictors of 30-day and 60-day survival, different ICU scoring systems, such as SOFA score, APACHE II, and SAPS 2 predicted overall survival (all p < 0.001). Next to the presence or history of solid neoplasia (p = 0.026), platelet count (HR 6.7 for <164,000/µL, p = 0.020) and pH level (HR 5.8 for <7.31, p = 0.009) remained independently associated with 30-day and 60-day survival in multivariable Cox regression. However, ventilation parameters did not predict survival multivariably.
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Affiliation(s)
- Arik Bernard Schulze
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Jan Sackarnd
- Department of Cardiovascular Medicine, Internal Intensive Care Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Lars Henning Schmidt
- Medical Department IV, Pneumology, Respiratory Medicine and Thoracic Oncology, Klinikum Ingolstadt, 85049 Ingolstadt, Germany
- Department of Internal Medicine II, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Phil-Robin Tepasse
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Münster, 48149 Münster, Germany
| | - Felix Rosenow
- Department of Cardiovascular Medicine, Internal Intensive Care Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Georg Evers
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, 48149 Münster, Germany
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12
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Min KJ, Owrey MW. The hidden costs of normal saline: Increased transfusions and vasopressor infusions. J Clin Anesth 2023; 88:111141. [PMID: 37167797 DOI: 10.1016/j.jclinane.2023.111141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Kevin J Min
- Thomas Jefferson University, Department of Anesthesia, 111 S 11th St., Gibbon Building 8330, Philadelphia, PA 19107, United States.
| | - Matthew W Owrey
- Thomas Jefferson University, Sidney Kimmel Medical College, 1025 Walnut St., Philadelphia, PA 19107, United States.
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13
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Milne A, Radhakrishnan A. Biochemical disturbance in damage control resuscitation: mechanisms, management and prognostic utility. Curr Opin Anaesthesiol 2023; 36:176-182. [PMID: 36728975 DOI: 10.1097/aco.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW With advances in resuscitative techniques, trauma patients are surviving increasingly severe injuries and physiological insult. Timely recognition of futility remains important in terms of patient dignity and resource preservation yet is increasingly challenging in the face of these advances. The understanding of biochemical derangement from pathophysiological processes of trauma and iatrogenic effects of resuscitation has expanded recently. RECENT FINDINGS Acidosis and hypocalcaemia have been recognized as important contributors to mortality among trauma patients. Although less well recognized and studied, critical injury and high blood product volume resuscitation render patients vulnerable to life-threatening hyperkalaemia. The methods of correcting disruptions to acid-base and electrolyte homeostasis during damage control resuscitation have changed little recently and often rely on evidence from undifferentiated populations. Biochemical disturbances have value as ancillary predictors of futility in trauma resuscitation. SUMMARY These findings will contribute to a greater understanding among anaesthesiologists of the causative mechanisms and effects of biochemical derangement after severe injury and aid them in the delivery of well tolerated and effective damage control resuscitation. Gaps in the evidence base are highlighted to encourage future work.
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Affiliation(s)
- Andrew Milne
- Trauma Anaesthesia Group, Barts Health NHS Trust, Royal London Hospital, London, UK
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14
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Zaki SA, Shanbag P. Metabolic Acidosis in Children: A Literature Review. EUROPEAN MEDICAL JOURNAL 2023. [DOI: 10.33590/emj/10302459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Metabolic acidosis is characterised by a primary decrease in the serum bicarbonate concentration, a secondary decrease in the arterial partial pressure of CO2, and a reduction in blood pH. Metabolic acidosis, acute or chronic, may have deleterious effects on cellular function and cause increased morbidity and mortality. A systematic review of the available literature was performed to identify data on the prevalence, manifestations, cause, outcomes, and treatment of metabolic acidosis in children. Online databases (Ovid Medline, Embase, and PubMed), commercial search engines (including Google), and chapters on metabolic acidosis in the standard textbooks of paediatrics and medicine were reviewed.
Systematic approach to acute metabolic acidosis starts with proper history taking and examination. This is followed by assessment of acid-base parameters, including pH, partial pressure of CO2, and bicarbonate concentration in arterial blood. Blood gas is needed to differentiate primary metabolic acidosis from compensated respiratory alkalosis. Once the diagnosis of a metabolic acidosis has been confirmed, serum electrolyte values are used to determine the serum anion gap. The various causes of increased and normal anion gap metabolic acidosis have been discussed in the article. The main aim of treatment in metabolic acidosis is to reverse the primary pathophysiology. In acute metabolic acidosis, sodium bicarbonate therapy is not beneficial due to potential complications and is reserved for specific situations. Base therapy is used in chronic metabolic acidosis where it ameliorates many of its untoward effects. Other modalities of treatment of metabolic acidosis include peritoneal or haemodialysis and tris-hydroxymethyl aminomethane.
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Affiliation(s)
- Syed Ahmed Zaki
- Department of Pediatrics, All India Institute of Medical Sciences, Hyderabad, India
| | - Preeti Shanbag
- Sir Jamshedjee Jeejeebhoy Group of Hospital and Grant Medical College, Mumbai, India
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15
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Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock. Anesthesiol Clin 2023; 41:1-25. [PMID: 36871993 DOI: 10.1016/j.anclin.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.
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16
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Martín-Rodríguez F, Ortega GJ, Castro Villamor MA, Del Pozo Vegas C, Delgado Benito JF, Martín-Conty JL, Sanz-García A, López-Izquierdo R. Development of a prehospital lactic acidosis score for early-mortality. A prospective, multicenter, ambulance-based, cohort study. Am J Emerg Med 2023; 65:16-23. [PMID: 36580696 DOI: 10.1016/j.ajem.2022.12.030] [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: 07/01/2022] [Revised: 12/02/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Lactic acidosis is a clinical status related to clinical worsening. Actually, higher levels of lactate is a well-established trigger of emergency situations. The aim of this work is to build-up a prehospital early warning score to predict 2-day mortality and intensive care unit (ICU) admission, constructed with other components of the lactic acidosis besides the lactate. METHODS Prospective, multicenter, observational, derivation-validation cohort study of adults evacuated by ambulance and admitted to emergency department with acute diseases, between January 1st, 2020 and December 31st, 2021. Including six advanced life support, thirty-eight basic life support units, referring to four hospitals (Spain). The primary and secondary outcome of the study were 2-day all-cause mortality and ICU-admission. The prehospital lactic acidosis (PLA) score was derived from the analysis of prehospital blood parameters associated with the outcome using a logistic regression. The calibration, clinical utility, and discrimination of PLA were determined and compared to the performance of each component of the score alone. RESULTS A total of 3334 patients were enrolled. The final PLA score included: lactate, pCO2, and pH. For 2-day mortality, the PLA showed an AUC of 0.941 (95%CI: 0.914-0.967), a better performance in calibration, and a higher net benefit as compared to the other score components alone. For the ICU admission, the PLA only showed a better performance for AUC: 0.75 (95%CI: 0.706-0.794). CONCLUSIONS Our results showed that PLA predicts 2-day mortality better than other lactic acidosis components alone. Including PLA score in prehospital setting could improve emergency services decision-making.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain
| | - Guillermo J Ortega
- Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain; CONICET, Argentina
| | - Miguel A Castro Villamor
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain; Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Juan F Delgado Benito
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain
| | - José L Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain
| | - Ancor Sanz-García
- Prehospital early warning scoring-system investigation group, Valladolid, Spain; Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain.
| | - Raúl López-Izquierdo
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain; Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
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17
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Current Evidence Surrounding the Use of Sodium Bicarbonate in the Critically Ill Patient. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2023. [DOI: 10.1007/s40138-023-00260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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18
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Seol J, Jung S, Koh H, Jung J, Kang Y. Echocardiographic Assessment of Patients with Glycogen Storage Disease in a Single Center. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2191. [PMID: 36767559 PMCID: PMC9916218 DOI: 10.3390/ijerph20032191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
Glycogen storage disease (GSD) is a hereditary metabolic disorder caused by enzyme deficiency resulting in glycogen accumulation in the liver, muscle, heart, or kidney. GSD types II, III, IV, and IX are associated with cardiac involvement. However, cardiac manifestation in other GSD types is unclear. This study aimed to describe whether energy deprivation and the toxic effects of accumulated glycogen affect the heart of patients with GSD. We evaluated the left ventricle (LV) wall mass, LV systolic and diastolic function and myocardial strain with conventional echocardiography and two-dimensional speckle-tracking echocardiography (2D STE) in 62 patients with GSD type I, III, VI and IX who visited the Wonju Severance Hospital in 2021. Among the GSD patients, the echocardiographic parameters of 55 pediatrics were converted into z-scores and analyzed. Of the patients, 43 (62.3%), 7 (11.3%) and 12 (19.4%) patients were diagnosed with GSD type I, type III, and type IX, respectively. The median age was 9 years (range, 1-36 years), with 55 children under 18 years old and seven adults over 18 years. For the 55 pediatric patients, the echocardiographic parameters were converted into a z-score and analyzed. Multiple linear regression analysis showed that the BMI z-score (p = 0.022) and CK (p = 0.020) predicted increased LV mass z-score, regardless of GSD type. There was no difference in the diastolic and systolic functions according to myocardial thickness; however, 2D STE showed a negative correlation with the LV mass (r = -0.28, p = 0.041). Given that patients with GSD tend to be overweight, serial evaluation with echocardiography might be required for all types of GSD.
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Affiliation(s)
- Jaehee Seol
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Seyong Jung
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hong Koh
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Severance Children’s Hospital, Severance Pediatric Liver Disease Research Group, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jowon Jung
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yunkoo Kang
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
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19
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Adie MA, Martes Gomez M, Yom J, Durand M, Wertheimer F, McGowan R, Yano S, Ramanathan R. Twin Premature Infants With Riboflavin and Biotin Deficiency Presenting With Refractory Lactic Acidosis, Rash, and Multiorgan Failure During Prolonged Parenteral Nutrition. J Investig Med High Impact Case Rep 2023; 11:23247096231168111. [PMID: 37085971 PMCID: PMC10126694 DOI: 10.1177/23247096231168111] [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: 01/24/2023] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 04/23/2023] Open
Abstract
We are reporting monochorionic, diamniotic twin premature infants born at 25 weeks and 6 days gestation with riboflavin (vitamin B2) and biotin (vitamin B7) deficiency, while on prolonged total parenteral nutrition (TPN) during vitamin shortage. They presented initially with skin rash, lactic acidosis, and thrombocytopenia. Both twins progressed to severe respiratory failure, severe lactic acidosis, with refractory vasodilatory shock, pancytopenia, ischemic bowel injury, acute kidney injury, liver injury, and capillary leak syndrome leading to death of twin A. The surviving twin B was diagnosed with riboflavin and biotin deficiency that presented with abnormal metabolic work up suggestive of maple syrup urine disease, glutaric acidemia type 2, and X-linked adrenoleukodystrophy. Twin B was started on riboflavin and biotin supplementation at 41 days of life, with rapid improvement in clinical findings and laboratory abnormalities within days of starting biotin and riboflavin supplementation. He was discharged home in stable condition at 49 weeks of postmenstrual age.
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Affiliation(s)
- Mohammad Amin Adie
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Maria Martes Gomez
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Jessica Yom
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Manuel Durand
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Fiona Wertheimer
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Rachel McGowan
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Shoji Yano
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Rangasamy Ramanathan
- Keck School of Medicine of University
of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
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20
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Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ. Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest. Resuscitation 2023; 182:109641. [PMID: 36403821 PMCID: PMC9877137 DOI: 10.1016/j.resuscitation.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sodium bicarbonate ("bicarb") administration in out-of-hospital cardiac arrest (OHCA) is intended to counteract acidosis, although there is limited clinical evidence to support its routine administration. We sought to analyze the association of bicarb with resuscitation outcomes in non-traumatic OHCA. METHODS Records were obtained from the 2019-2020 ESO Data Collaborative prehospital electronic health record database, spanning 1,322 agencies in 50 states. OHCAs with resuscitations lasting 5-40 minutes were stratified by presenting ECG rhythm (VF/VT, pulseless electrical activity (PEA), asystole) for analysis. The outcomes of any prehospital ROSC and survival to discharge were compared by bicarb status using propensity score matching and logistic regressions with/without adjustment. RESULTS We analyzed 23,567 records, 6,663 (28.3 %) of which included bicarb administration. Most patients presented in asystole (67.4 %), followed by PEA (16.6 %), and VF/VT (15.1 %). In the propensity-matched cohort, ROSC was higher in the bicarb group for the asystole group (bicarb 10.6 % vs control 8.8 %; p = 0.013), without differences in the PEA or VF/VT groups. Survival was higher in the bicarb group for asystole (bicarb 3.3 % vs control 2.4 %; p = 0.020) and for PEA (bicarb 8.1 % vs control 5.4 %; p = 0.034), without differences in the VF/VT group. These results were consistent across adjusted/unadjusted logistic regression analyses: bicarb was associated with ROSC and survival in asystole [uOR (95 % CI): ROSC 1.23 (1.04-1.44), survival 1.40 (1.05-1.87)] and with survival in PEA (1.54 (1.03-2.31). CONCLUSIONS Bicarb was associated with survival in non-shockable rhythms and ROSC in asystole. Findings from this observational study should be corroborated with prospective randomized work.
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Affiliation(s)
| | | | - David D Salcido
- University of Pittsburgh, Department of Emergency Medicine, Pittsburgh, PA, USA.
| | - James J Menegazzi
- University of Pittsburgh, Department of Emergency Medicine, Pittsburgh, PA, USA.
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21
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Hopper K. Acid–Base. Vet Clin North Am Small Anim Pract 2022; 53:191-206. [DOI: 10.1016/j.cvsm.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Razazi K, Labbé V, Laine L, Bedet A, Carteaux G, de Prost N, Boissier F, Bagate F, Mekontso Dessap A. Hemodynamic effects and tolerance of dobutamine for myocardial dysfunction during septic shock: An observational multicenter prospective echocardiographic study. Front Cardiovasc Med 2022; 9:951016. [PMID: 36158835 PMCID: PMC9500364 DOI: 10.3389/fcvm.2022.951016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background The role of dobutamine during septic shock resuscitation is still controversial. Methods The aim of this prospective multicentre study was to comprehensively characterize the hemodynamic response of septic shock patients with systolic myocardial dysfunction to incremental doses of dobutamine (0, 5, 10, and 15 μg/kg/min). Results Thirty two patients were included in three centers. Dobutamine significantly increased contractility indices of both ventricles [crude and afterload-adjusted left ventricular (LV) ejection fraction, global LV longitudinal peak systolic strain, tissue Doppler peak systolic wave at mitral and tricuspid lateral annulus, and tricuspid annular plane excursion) as well as global function indices (stroke volume and cardiac index) and diastolic function (increased e' and decreased E/e' ratio at lateral mitral annulus). Dobutamine also induced a significant decrease in arterial pressure and cardiac afterload indices (effective arterial elastance, systemic vascular resistance and diastolic shock index). Oxygen transport, oxygen consumption and carbon dioxide production all increased with dobutamine, without change in the respiratory quotient or lactate. Dobutamine was discontinued for poor tolerance in a majority of patients (n = 21, 66%) at any dose and half of patients (n = 15, 47%) at low-dose (5 μg/kg/min). Poor tolerance to low-dose dobutamine was more frequent in case of acidosis, was associated with lower vasopressor-free days and survival at day-14. Conclusion In patients with septic myocardial dysfunction, dobutamine induced an overall improvement of echocardiographic parameters of diastolic and systolic function, but was poorly tolerated in nearly two thirds of patients, with worsening vasoplegia. Patients with severe acidosis seemed to have a worse response to dobutamine.
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Affiliation(s)
- Keyvan Razazi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- INSERM, Institut Mondor de Recherche Biomedicale (IMRB), Univ Paris Est Créteil, Créteil, France
- Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomedicale (IMRB), GRC CARMAS, Université Paris Est Créteil, Créteil, France
- *Correspondence: Keyvan Razazi
| | - Vincent Labbé
- Département Médico-Universitaire APPROCHES, AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Sorbonne Université, Paris, France
| | - Laurent Laine
- Hôpital Delafontaine, Service de Réanimation, Saint-Denis, France
| | - Alexandre Bedet
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- INSERM, Institut Mondor de Recherche Biomedicale (IMRB), Univ Paris Est Créteil, Créteil, France
- Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomedicale (IMRB), GRC CARMAS, Université Paris Est Créteil, Créteil, France
| | - Guillaume Carteaux
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- INSERM, Institut Mondor de Recherche Biomedicale (IMRB), Univ Paris Est Créteil, Créteil, France
- Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomedicale (IMRB), GRC CARMAS, Université Paris Est Créteil, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- INSERM, Institut Mondor de Recherche Biomedicale (IMRB), Univ Paris Est Créteil, Créteil, France
- Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomedicale (IMRB), GRC CARMAS, Université Paris Est Créteil, Créteil, France
| | - Florence Boissier
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Francois Bagate
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- INSERM, Institut Mondor de Recherche Biomedicale (IMRB), Univ Paris Est Créteil, Créteil, France
- Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomedicale (IMRB), GRC CARMAS, Université Paris Est Créteil, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- INSERM, Institut Mondor de Recherche Biomedicale (IMRB), Univ Paris Est Créteil, Créteil, France
- Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomedicale (IMRB), GRC CARMAS, Université Paris Est Créteil, Créteil, France
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Verma S, Graham MM, Lecamwasam A, Romanovsky A, Duggan S, Bagshaw S, Senaratne JM. Cardiorenal Interactions: A Review. CJC Open 2022; 4:873-885. [PMID: 36254331 PMCID: PMC9568715 DOI: 10.1016/j.cjco.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/24/2022] [Indexed: 10/29/2022] Open
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Dos Santos F, Li JB, Mazor R, Aletti F, Kistler EB. Efficacy of Tranexamic Acid in Blood Versus Crystalloid-Resuscitated Trauma/Hemorrhagic Shock. J Surg Res 2022; 279:89-96. [PMID: 35752157 DOI: 10.1016/j.jss.2022.05.028] [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: 04/12/2021] [Revised: 04/22/2022] [Accepted: 05/22/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Whole blood (WB) or blood products are not always immediately available for repletion of lost intravascular volume in trauma/hemorrhagic shock (T/HS), and thus, resuscitation with crystalloid solutions is often necessary. Recently, we have shown enteral tranexamic acid (TXA) to be effective as a mild protease inhibitor in blood-resuscitated T/HS by counteracting proteolytic activity in and leaking from the gut with resultant preservation of systemic vascular integrity. We hypothesized that enteral TXA would improve hemodynamic stability after T/HS in the absence of blood reperfusion. METHODS We directly compared resuscitation with enteral TXA versus intravenous (IV) TXA in conjunction with lactated Ringer's solution (LR) or WB reperfusion in an experimental T/HS model. Rats were subjected to laparotomy and exsanguinated to a mean arterial blood pressure of 35-40 mm Hg for 90 min, followed by LR or WB reperfusion and monitored for 120 min. TXA was administered via IV (10 mg/kg) or enteral infusion (150 mM) 20 min after establishment of hemorrhage for 150 min. RESULTS Animals resuscitated with LR were unable to restore or maintain a survivable mean arterial blood pressure (>65 mm Hg), regardless of TXA treatment route. In contrast, rats reperfused with WB and given TXA either enterally or IV displayed hemodynamic improvements superior to WB controls. CONCLUSIONS Results suggest that the beneficial hemodynamic responses to enteral or IV TXA after experimental T/HS depend upon reperfusion of WB or components present in WB as TXA, regardless of delivery mode, does not have appreciable hemodynamic effects when paired with LR reperfusion.
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Affiliation(s)
- Fernando Dos Santos
- Department of Anesthesiology & Critical Care, University of California, San Diego, La Jolla, California.
| | - Joyce B Li
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Rafi Mazor
- Department of Anesthesiology & Critical Care, University of California, San Diego, La Jolla, California
| | - Federico Aletti
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Erik B Kistler
- Department of Anesthesiology & Critical Care, University of California, San Diego, La Jolla, California; Department of Bioengineering, University of California, San Diego, La Jolla, California; Veterans Affairs San Diego Healthcare System, San Diego, California
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25
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Jentzer JC, Schrage B, Patel PC, Kashani KB, Barsness GW, Holmes DR, Blankenberg S, Kirchhof P, Westermann D. Association Between the Acidemia, Lactic Acidosis, and Shock Severity With Outcomes in Patients With Cardiogenic Shock. J Am Heart Assoc 2022; 11:e024932. [PMID: 35491996 PMCID: PMC9238598 DOI: 10.1161/jaha.121.024932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Lactic acidosis is associated with mortality in patients with cardiogenic shock (CS). Elevated lactate levels and systemic acidemia (low blood pH) have both been proposed as drivers of death. We, therefore, analyzed the association of both high lactate concentrations and low blood pH with 30‐day mortality in patients with CS. Methods and Results This was a 2‐center historical cohort study of unselected patients with CS with available data for admission lactate level or blood pH. CS severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock classification. All‐cause survival at 30 days was analyzed using Kaplan‐Meier curves and Cox proportional‐hazards analysis. There were 1814 patients with CS (mean age, 67.3 years; 68.5% men); 51.8% had myocardial infarction and 53.0% had cardiac arrest. The distribution of SCAI shock stages was B, 10.8%; C, 30.7%; D, 38.1%; and E, 18.7%. In both cohorts, higher lactate or lower pH predicted a higher risk of adjusted 30‐day mortality. Patients with a lactate ≥5 mmol/L or pH <7.2 were at increased risk of adjusted 30‐day mortality; patients with both lactate ≥5 mmol/L and pH <7.2 had the highest risk of adjusted 30‐day mortality. Patients in SCAI shock stages C, D, and E had higher 30‐day mortality in each SCAI shock stage if they had lactate ≥5 mmol/L or pH <7.2, particularly if they met both criteria. Conclusions Higher lactate and lower pH predict mortality in patients with cardiogenic shock beyond standard measures of shock severity. Severe lactic acidosis may serve as a risk modifier for the SCAI shock classification. Definitions of refractory or hemometabolic shock should include high lactate levels and low blood pH.
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Affiliation(s)
- Jacob C. Jentzer
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
- Division of Pulmonary and Critical Care Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Benedikt Schrage
- Department of Cardiology University Heart and Vascular Center UKE Hamburg Hamburg Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel Hamburg Germany
| | - Parag C. Patel
- Department of Cardiovascular Medicine Mayo Clinic Jacksonville FL
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine Department of Medicine Mayo Clinic Rochester MN
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Rochester MN
| | | | - David R. Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Stefan Blankenberg
- Department of Cardiology University Heart and Vascular Center UKE Hamburg Hamburg Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel Hamburg Germany
| | - Paulus Kirchhof
- Department of Cardiology University Heart and Vascular Center UKE Hamburg Hamburg Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel Hamburg Germany
- Institute of Cardiovascular Sciences University of Birmingham UK
| | - Dirk Westermann
- Department of Cardiology and Angiology Medical Faculty University Heart Center Freiburg ‐ Bad KrozingenUniversity of Freiburg Germany
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26
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McPherson KL, Kovacic Scherrer NL, Hays WB, Greco AR, Garavaglia JM. A Review of Push-Dose Vasopressors in the Peri-operative and Critical Care Setting. J Pharm Pract 2022:8971900221096967. [PMID: 35459405 DOI: 10.1177/08971900221096967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
During hospitalization, the risk of hypotension and associated sequelae remain important considerations for patient outcomes. The use of push-dose vasopressors (PDP) outside of the operating room has increased in recent years to combat the negative effects of hypotension. This narrative review evaluates the utility of PDP in its traditional perioperative setting as well as in areas of increasing use such as the emergency department and intensive care unit. Articles evaluating PDP highlight successful increases in blood pressure with all agents but differ in rates of adverse events and most lack direct comparison of PDP agents in regard to safety and efficacy. Agents utilized as PDP, including epinephrine, phenylephrine, norepinephrine, vasopressin, and ephedrine vary in mechanism of action, onset of action, and duration of action. These variations in pharmacology along with published literature may lead to differences in the preferred PDP for various clinical scenarios. Many adverse events associated with PDP have been due to dosing errors highlighting the importance of education surrounding the use of these agents. Additional research is necessary to further elucidate the risks and benefits of PDP in clinical practice, and to determine which PDP is truly preferred. Careful consideration should be given when determining the appropriateness of this administration method of vasopressors in various clinical scenarios.
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Affiliation(s)
- Kaitlyn L McPherson
- Emergency Medicine Pharmacist, Department of Pharmacy, 20205Charleston Area Medical Center General Hospital, Charleston, WV, USA
| | | | - William B Hays
- Emergency Medicine Pharmacist, Department of Pharmacy, Indiana University Health West Hospital, Avon, IN, USA
| | - Alexandra R Greco
- Critical Care Pharmacist, Department of Pharmacy, WVU Medicine, Morgantown, WV, USA
| | - Jeffrey M Garavaglia
- Neurology Intensive Care Pharmacist, Department of Pharmacy, WVU Medicine, Morgantown, WV, USA
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Wang H, Liang R, Liang T, Chen S, Zhang Y, Zhang L, Chen C. Effectiveness of Sodium Bicarbonate Infusion on Mortality in Critically Ill Children With Metabolic Acidosis. Front Pharmacol 2022; 13:759247. [PMID: 35370669 PMCID: PMC8970597 DOI: 10.3389/fphar.2022.759247] [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: 08/16/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: Metabolic acidosis often occurs in the paediatric intensive care unit (PICU). Although sodium bicarbonate (SB) has been widely used in paediatrics, data on the effect of SB on children with metabolic acidosis in the PICU are scarce. Methods: Patients with metabolic acidosis who were treated with SB within 48 h of PICU admission were screened. Multivariate logistic regression, subgroup analysis, and propensity score matching (PSM) were used to investigate the relationships between SB infusion and clinical outcomes. Results: A total of 1,595 patients with metabolic acidosis were enrolled in this study. In the multivariate logistic regression model, SB infusion was not correlated with in-hospital mortality (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.47–1.63, p = 0.668), but was significantly correlated with hypernatraemia (OR 1.98, 95% CI 1.14–3.46, p = 0.016), hypokalaemia (OR 2.01, 95% CI 1.36–2.96, p < 0.001), and hypocalcaemia (OR 4.29, 95% CI 2.92–6.31, p < 0.001). In the pH value, lactate level, acute kidney injury level, age grouping, and anion gap level subgroups, the ORs for SB and in-hospital mortality were not statistically significant. After PSM, the results remained unchanged. Conclusion: SB infusion does not reduce the in-hospital mortality of severely ill children with metabolic acidosis and increases the risk of hypernatraemia, hypokalaemia, and hypocalcaemia. More effort should be focused on eliminating the causes of metabolic acidosis rather than SB infusion.
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Affiliation(s)
- Huabin Wang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China.,Department of Pediatric Intensive Care Unit, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Rui Liang
- Department of Colorectal Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Tianqi Liang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China.,Department of Pediatric Intensive Care Unit, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Songyao Chen
- Center of Digestive Disease, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Yulong Zhang
- Scientific Research Center, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Lidan Zhang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China.,Department of Pediatric Intensive Care Unit, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Chun Chen
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China.,Department of Pediatric Intensive Care Unit, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
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GOMES C, FERREIRA A, SOARES N, CHAVES V, LEMOS L, TAVARES S, COUTO M. Metformin-associated lactic acidosis: underlying multiple myeloma. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.20.04320-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rapid Classification and Treatment Algorithm of Cardiogenic Shock Complicating Acute Coronary Syndromes: The SAVE ACS Classification. J Interv Cardiol 2022; 2022:9948515. [PMID: 35095349 PMCID: PMC8769867 DOI: 10.1155/2022/9948515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 12/20/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction. We aimed to identify the independent “frontline” predictors of 30-day mortality in patients with acute coronary syndromes (ACS) and propose a rapid cardiogenic shock (CS) classification and management pathway. Materials and Methods. From 2011 to 2019, a total of 11439 incident ACS patients were treated in our institution. Forward conditional logistic regression analysis was performed to determine the “frontline” predictors of 30 day mortality. The C-statistic assessed the discriminatory power of the model. As a validation cohort, we used 431 incident ACS patients admitted from January 1, 2020, to July 20, 2020. Results. Independent predictors of 30-day mortality included age (OR 1.05; 95% CI 1.04 to 1.07,
), intubation (OR 7.4; 95% CI 4.3 to 12.74,
), LV systolic impairment (OR severe_vs_normal 1.98; 95% CI 1.14 to 3.42,
, OR moderate_vs_normal 1.84; 95% CI 1.09 to 3.1,
), serum lactate (OR 1.25; 95% CI 1.12 to 1.41,
), base excess (OR 1.1; 95% CI 1.04 to 1.07,
), and systolic blood pressure (OR 0.99; 95% CI 0.982 to 0.999,
). The model discrimination was excellent with an area under the curve (AUC) of 0.879 (0.851 to 0.908) (
). Based on these predictors, we created the SAVE (SBP, Arterial blood gas, and left Ventricular Ejection fraction) ACS classification, which showed good discrimination for 30-day AUC 0.814 (0.782 to 0.845) and long-term mortality
. A similar AUC was demonstrated in the validation cohort (AUC 0.815). Conclusions. In the current study, we introduce a rapid way of classifying CS using frontline parameters. The SAVE ACS classification could allow for future randomized studies to explore the benefit of mechanical circulatory support in different CS stages in ACS patients.
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Dudoignon E, Quennesson T, De Tymowski C, Moreno N, Coutrot M, Chaussard M, Guillemet L, Abid S, Fratani A, Ressaire Q, Cupaciu A, Weinmann V, Pharaboz A, Benyamina M, Mebazaa A, Legrand M, Depret F, Deniau B. Usefulness of lactate albumin ratio at admission to predict 28-day mortality in critically ill severely burned patients: A retrospective cohort study. Burns 2022; 48:1836-1844. [PMID: 35012801 DOI: 10.1016/j.burns.2022.01.003] [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: 05/25/2021] [Revised: 11/19/2021] [Accepted: 01/03/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Lactate albumin ratio (LAR) has been used as a prognostic marker associated with organ failure in critically ill septic patients. LAR and its association with outcomes has never been studied in burned patients. The aim of this study was to evaluate the ability of LAR to predict 28-day mortality. METHODS A retrospective cohort study including all burn patients hospitalized in intensive care unit. The primary endpoint was the 28-day mortality. RESULTS One thousand three hundred thirty four patients were screened, and 471 were included between June 2012 and December 2018. Briefly, the population study was mainly composed by men (249, 59.1%), the median age, TBSA burned, full thickness, ABSI and IGS2 were 52 [34-68], 20 [10-40], 8 [1-23], 7 [5-9] and 25 [15-40] respectively. Fifty-two patients (12.4%) died at day 28 after admission. At admission, the LAR level was lower in 28-day survivors compared non-survivors (0.05 [0.04, 0.08] vs 0.12 [0.07, 0.26], p < 0.001 respectively). In multivariate analysis accounting for ABSI, LAR levels at admission> 0.13 was independently associated with 28-day mortality (adjusted OR = 3.98 (IC95 1.88-8.35)). The ability of LAR at admission to discriminate 28-day mortality showed an AUC identical when compared to SOFA and ABSI scores (0.81 (IC95 0.74-0.88), 0.80 (IC95 0.72-0.85) and (0.85 (IC95 0.80-0.90), p < 0.05, respectively). Patients with LAR levels ≥ 0.13 at admission had higher 28-day mortality (40.6% vs 6.8%, p < 0.001, HR 7.39 (IC95 4.28-12.76)). CONCLUSION At admission, LAR is an easy and reliable marker independently associated to 28-day mortality in patients with severe burn injury, but prediction by LAR does not perform better than lactate level alone.
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Affiliation(s)
- Emmanuel Dudoignon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; FHU PROMICE, Paris, France.
| | - Thomas Quennesson
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Christian De Tymowski
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France
| | - Nabila Moreno
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Biochemistry Laboratory, Paris, France
| | - Maxime Coutrot
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maïté Chaussard
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Lucie Guillemet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Sonia Abid
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Alexandre Fratani
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Quentin Ressaire
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France
| | - Alexandru Cupaciu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Vagh Weinmann
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Alexandre Pharaboz
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Mourad Benyamina
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Alexandre Mebazaa
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France; INI-CRCT Network, Nancy, France; FHU PROMICE, Paris, France
| | - Matthieu Legrand
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France; INI-CRCT Network, Nancy, France; Department of Anaesthesiology and Peri-operative Medicine and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - François Depret
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France; INI-CRCT Network, Nancy, France; FHU PROMICE, Paris, France
| | - Benjamin Deniau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France; FHU PROMICE, Paris, France
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Jentzer JC, Kashani KB, Wiley BM, Patel PC, Baran DA, Barsness GW, Henry TD, Van Diepen S. Laboratory Markers of Acidosis and Mortality in Cardiogenic Shock: Developing a Definition of Hemometabolic Shock. Shock 2022; 57:31-40. [PMID: 33988540 DOI: 10.1097/shk.0000000000001812] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acidosis and higher lactate predict worse outcomes in cardiogenic shock (CS) patients. We sought to determine whether overall acidosis severity on admission predicted in-hospital mortality in CS patients. METHODS This retrospective descriptive analysis included CS patients admitted to a single academic tertiary cardiac intensive care unit from 2007 to 2015. Admission arterial pH, base excess, and anion gap values were used to generate a Composite Acidosis Score (range 0-5, with a score ≥2 defining Severe Acidosis). Adjusted in-hospital mortality was analyzed using multivariable logistic regression. RESULTS We included 1,065 patients with median age of 68.9 (59.0, 77.2) years (36.4% females). Concomitant diagnoses included cardiac arrest in 38.1% and acute coronary syndrome in 59.1%. Severe Acidosis was present in 35.2%, and these patients had worse shock and more organ failure. In-hospital mortality occurred in 34.1% and was higher among patients with Severe Acidosis (54.9% vs. 22.4%, adjusted odds ratio [OR] 2.01, 95% CI 1.43-2.83, P < 0.001). Increasing Composite Acidosis Score was associated with higher in-hospital mortality (adjusted OR 1.25 per point, 95% CI 1.11-1.40, P < 0.001). Severe Acidosis was associated with higher hospital mortality at every level of shock severity and organ failure (all P < 0.05). Admission lactate level had equivalent discrimination for in-hospital mortality as the Composite Acidosis Score (0.69 vs. 0.66; P = 0.32 by De Long test). CONCLUSION Given its incremental association with higher in-hospital mortality among CS patients beyond shock severity and organ failure, we propose Severe Acidosis as a marker of hemometabolic shock. Lactate levels performed as well as a composite measure of acidosis for predicting mortality.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Parag C Patel
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - David A Baran
- Sentara Heart Hospital, Advanced Heart Failure Center and Eastern Virginia Medical School, Norfolk, Virginia
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, Ohio
| | - Sean Van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta
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Anbalagan LC, Arora N, Pannu AK. Management of Acute Aluminum Phosphide Poisoning: Has Anything Changed? Drug Metab Lett 2021; 14:106-116. [PMID: 34818996 DOI: 10.2174/1872312814666210813115625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/22/2022]
Abstract
Due to its easy availability, rapid and severe toxicity, and no specific antidote, aluminum phosphide has emerged as a lethal toxin, commonly used for suicidal intent in agricultural communities. Despite various advances in medicine, this compound's toxicity is poorly understood, and it still has a very high case fatality rate with no definitive treatment options available. This review aims to understand the mechanism of toxicity, clinical toxidrome of acute aluminum phosphide poisoning, and the available therapeutic options, including recent advances. A literature review was performed searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("aluminum phosphide poisoning" OR "aluminum phosphide poisoning toxicity" OR "aluminum phosphide ingestion") AND ("management" OR "therapy" OR "treatment"). Selected articles were discussed amongst all the authors to shape this review. High case fatality rate and lack of any specific antidote are persisting challenges. Therapeutic measures need to be implemented from all fronts - reducing easy access to the poison, developing less toxic alternatives for use as a pesticide, and more studies directed at developing an effective reversal agent for phosphine. The advent of promising agents like glucose-insulin-potassium infusion and lipid emulsion is a new ray of hope in the complete recovery in this fatal poisoning. The need of the hour is to find an agent that rapidly and effectively reverses aluminum phosphide's toxic effects. Large multicenter controlled trials are required to establish the role of glucose-insulin-potassium and lipid emulsion.
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Affiliation(s)
- Lokhesh C Anbalagan
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Navneet Arora
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Ashok K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Cheng CK, Huang Y. The gut-cardiovascular connection: new era for cardiovascular therapy. MEDICAL REVIEW (BERLIN, GERMANY) 2021; 1:23-46. [PMID: 37724079 PMCID: PMC10388818 DOI: 10.1515/mr-2021-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/02/2021] [Indexed: 09/20/2023]
Abstract
Our gut microbiome is constituted by trillions of microorganisms including bacteria, archaea and eukaryotic microbes. Nowadays, gut microbiome has been gradually recognized as a new organ system that systemically and biochemically interact with the host. Accumulating evidence suggests that the imbalanced gut microbiome contributes to the dysregulation of immune system and the disruption of cardiovascular homeostasis. Specific microbiome profiles and altered intestinal permeability are often observed in the pathophysiology of cardiovascular diseases. Gut-derived metabolites, toxins, peptides and immune cell-derived cytokines play pivotal roles in the induction of inflammation and the pathogenesis of dysfunction of heart and vasculature. Impaired crosstalk between gut microbiome and multiple organ systems, such as gut-vascular, heart-gut, gut-liver and brain-gut axes, are associated with higher cardiovascular risks. Medications and strategies that restore healthy gut microbiome might therefore represent novel therapeutic options to lower the incidence of cardiovascular and metabolic disorders.
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Affiliation(s)
- Chak Kwong Cheng
- School of Biomedical Sciences and Li Ka Shing Institute of Health Science; The Chinese University of Hong Kong, Hong Kong SAR999077, China
- Heart and Vascular Institute and Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR999077, China
| | - Yu Huang
- School of Biomedical Sciences and Li Ka Shing Institute of Health Science; The Chinese University of Hong Kong, Hong Kong SAR999077, China
- Heart and Vascular Institute and Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR999077, China
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Roux SG, Garnier NB, Abry P, Gold N, Frasch MG. Distance to Healthy Metabolic and Cardiovascular Dynamics From Fetal Heart Rate Scale-Dependent Features in Pregnant Sheep Model of Human Labor Predicts the Evolution of Acidemia and Cardiovascular Decompensation. Front Pediatr 2021; 9:660476. [PMID: 34414140 PMCID: PMC8369259 DOI: 10.3389/fped.2021.660476] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/21/2021] [Indexed: 01/27/2023] Open
Abstract
The overarching goal of the present work is to contribute to the understanding of the relations between fetal heart rate (FHR) temporal dynamics and the well-being of the fetus, notably in terms of predicting the evolution of lactate, pH and cardiovascular decompensation (CVD). It makes uses of an established animal model of human labor, where 14 near-term ovine fetuses subjected to umbilical cord occlusions (UCO) were instrumented to permit regular intermittent measurements of metabolites lactate and base excess, pH, and continuous recording of electrocardiogram (ECG) and systemic arterial blood pressure (to identify CVD) during UCO. ECG-derived FHR was digitized at the sampling rate of 1,000 Hz and resampled to 4 Hz, as used in clinical routine. We focused on four FHR variability features which are tunable to temporal scales of FHR dynamics, robustly computable from FHR sampled at 4 Hz and within short-time sliding windows, hence permitting a time-dependent, or local, analysis of FHR which helps dealing with signal noise. Results show the sensitivity of the proposed features for early detection of CVD, correlation to metabolites and pH, useful for early acidosis detection and the importance of coarse time scales (2.5-8 s) which are not disturbed by the low FHR sampling rate. Further, we introduce the performance of an individualized self-referencing metric of the distance to healthy state, based on a combination of the four features. We demonstrate that this novel metric, applied to clinically available FHR temporal dynamics alone, accurately predicts the time occurrence of CVD which heralds a clinically significant degradation of the fetal health reserve to tolerate the trial of labor.
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Affiliation(s)
- Stephane G. Roux
- Laboratoire de Physique, Université Lyon, Ens de Lyon, Université Claude Bernard, CNRS, Lyon, France
| | - Nicolas B. Garnier
- Laboratoire de Physique, Université Lyon, Ens de Lyon, Université Claude Bernard, CNRS, Lyon, France
| | - Patrice Abry
- Laboratoire de Physique, Université Lyon, Ens de Lyon, Université Claude Bernard, CNRS, Lyon, France
| | - Nathan Gold
- Department of Mathematics and Statistics, York University, Toronto, ON, Canada
- Centre for Quantitative Analysis and Modelling, Fields Institute, Toronto, ON, Canada
| | - Martin G. Frasch
- Department of OBGYN, Center on Human Development and Disability, University of Washington, Seattle, WA, United States
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Abstract
PURPOSE OF REVIEW Cardiogenic shock continues to carry a high mortality, and recent randomized trials have not identified novel therapies that improve survival. Early optimization of patients with confirmed or suspected cardiogenic shock is crucial, as patients can quickly transition from a hemodynamic shock state to a treatment-resistant hemometabolic shock state, where accumulated metabolic derangements trigger a self-perpetuating cycle of worsening shock. RECENT FINDINGS We describe a structured ABCDE approach involving stabilization of the airway, breathing and circulation, followed by damage control and etiologic assessment. Respiratory failure is common and many cardiogenic shock patients require invasive mechanical ventilation. Norepinephrine is titrated to restore mean arterial pressure and dobutamine is titrated to restore cardiac output and organ perfusion. Echocardiography is essential to identify potential causes and characterize the phenotype of cardiogenic shock. Coronary angiography is usually indicated, particularly when acute myocardial ischemia is suspected, followed by culprit-vessel revascularization if indicated. An invasive hemodynamic assessment can clarify whether temporary mechanical circulatory support is necessary. SUMMARY Early stabilization of hemodynamics and end-organ function is necessary to achieve best outcomes in cardiogenic shock. Using a structured approach tailored to initial cardiogenic shock resuscitation may help to demonstrate benefit from novel therapies in the future.
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Effect of sodium-chloride ion difference on pH regulation. Clin Biochem 2021; 96:75-77. [PMID: 34197812 DOI: 10.1016/j.clinbiochem.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND In the Stewart approach, the difference between the cation and anion concentrations, especially between sodium, accounting for the majority of cations, and chloride, comprising the majority of anions, is an important factor in pH regulation. This study investigated the effect of sodium-chloride ion difference (SCD) on pH regulation comparing with those of PaCO2 and lactate. METHODS Arterial blood gas samples measured at our pediatric intensive care unit of a tertiary children's hospital between January and June 2020 were included. Samples that met the following criteria were excluded: samples collected from patients taking potassium bromide and samples with lactate concentration of >25 mmol/L. From the eligible data, pH was chosen as the dependent variable and SCD, lactate, and PaCO2 as independent variables, and then, a multiple regression analysis was performed. RESULTS In total, 5360 samples were included. Of these, five samples were excluded according to the exclusion criteria. Finally, 5355 samples were analyzed. As the variance inflation factors were <2.0 for all three variables, there was no multicollinearity. The following model was derived: pH = 7.384 + [0.97 × SCD (mEq/L) - 0.66 × PaCO2 (mmHg) - 1.33 × Lac (mmol/L)] × 10-2 (adjusted R-squared = 0.73; P value < 0.001). Based on the standardized partial regression coefficients (β), pH was affected in the order of PaCO2 (βPaCO2 = -0.95), SCD (βSCD = 0.72), and lactate (βlactate = -0.33). CONCLUSIONS The prevention of SCD reduction, together with respiratory and metabolic management, is important for pH regulation.
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Waskowski J, Hess B, Cioccari L, Irincheeva I, Pfortmueller CA, Schefold JC. Effects of sodium bicarbonate infusion on mortality in medical-surgical ICU patients with metabolic acidosis-A single-center propensity score matched analysis. Med Intensiva 2021; 46:S0210-5691(21)00106-6. [PMID: 34120787 DOI: 10.1016/j.medin.2021.04.010] [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: 02/23/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Metabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. DESIGN Retrospective analysis. SETTING Academic medical center. PATIENTS OR PARTICIPANTS 971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. INTERVENTIONS 441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). MAIN VARIABLES OF INTEREST Primary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. RESULTS In the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99-1.17; p=.08; OR ATT 1.09; 95%-CI 0.99-1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86-1.56, p=.33) showed similar survival in the two study groups. CONCLUSIONS We did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis.
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Affiliation(s)
- J Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - B Hess
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Center of Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - L Cioccari
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - C A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - J C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ranjan AK, Zhang Z, Briyal S, Gulati A. Centhaquine Restores Renal Blood Flow and Protects Tissue Damage After Hemorrhagic Shock and Renal Ischemia. Front Pharmacol 2021; 12:616253. [PMID: 34012389 PMCID: PMC8126696 DOI: 10.3389/fphar.2021.616253] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/24/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Centhaquine (CQ) (Lyfaquin®) is in late stage clinical development as a safe and effective first-in-class resuscitative agent for hemorrhagic shock patients (NCT02408731, NCT04056065, and NCT04045327). Acute kidney injury (AKI) is known to be associated with hemorrhagic shock. Hence, effect of CQ on protection of kidneys from damage due to hemorrhagic shock was investigated. Methods: To assess effect of CQ on AKI in shock, we created a rat model with hemorrhagic shock and AKI. Renal arteries were clamped and de-clamped to induce AKI like ischemia/reperfusion model and hemorrhage was carried out by withdrawing blood for 30 min. Rats were resuscitated with CQ (0.02 mg/kg) for 10 min. MAP, heart rate (HR), and renal blood flow (RBF) were monitored for 120 min. Results: CQ produced a significant improvement in RBF compared to vehicle (p< 0.003) even though MAP and HR was similar in CQ and vehicle groups. Blood lactate level was lower (p = 0.0064) in CQ than vehicle at 120 min post-resuscitation. Histopathological analysis of tissues indicated greater renal damage in vehicle than CQ. Western blots showed higher HIF-1α (p = 0.0152) and lower NGAL (p = 0.01626) levels in CQ vs vehicle. Immunofluorescence in the kidney cortex and medulla showed significantly higher (p< 0.045) expression of HIF-1α and lower expression of Bax (p< 0.044) in CQ. Expression of PHD 3 (p< 0.0001) was higher, while the expression of Cytochrome C (p = 0.01429) was lower in the cortex of CQ than vehicle. Conclusion: Results show CQ (Lyfaquin®) increased renal blood flow, augmented hypoxia response, decreased tissue damage and apoptosis following hemorrhagic shock induced AKI, and may be explored to prevent/treat AKI. Translational Statement: Centhaquine (CQ) is safe for human use and currently in late stage clinical development as a first-in-class resuscitative agent to treat hemorrhagic shock. In the current study, we have explored a novel role of CQ in protection from hemorrhagic shock induced AKI, indicating its potential to treat/prevent AKI.
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Affiliation(s)
- Amaresh K. Ranjan
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
| | - Zhong Zhang
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
| | - Seema Briyal
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
| | - Anil Gulati
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
- Pharmazz Inc. Research and Development, Willlowbrook, IL, United States
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López R, Pérez-Araos R, Salazar Á, Espinoza M, Vial C, Cuiza A, Vial PA, Graf J. Targeted high volume hemofiltration could avoid extracorporeal membrane oxygenation in some patients with severe Hantavirus cardiopulmonary syndrome. J Med Virol 2021; 93:4738-4747. [PMID: 33710670 PMCID: PMC8359853 DOI: 10.1002/jmv.26930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 12/15/2022]
Abstract
Background Hantavirus cardiopulmonary syndrome (HCPS) has a high lethality. Severe cases may be rescued by venoarterial extracorporeal membrane oxygenation (VA ECMO), alongside substantial complications. High volume hemofiltration (HVHF) is a depurative technique that provides homeostatic balance allowing hemodynamic stabilization in some critically ill patients. Methods We implemented HVHF before VA ECMO consideration in the last five severe HCPS patients requiring mechanical ventilation and vasoactive drugs admitted to our intensive care unit. Patients were considered HVHF‐responders if VA ECMO was avoided and HVHF‐nonresponders if VA ECMO support was needed despite HVHF. A targeted‐HVHF strategy compounded by aggressive hyperoncotic albumin, sodium bicarbonate, and calcium supplementation plus ultrafiltration to avoid fluid overload was implemented on three patients. Results Patients had maximum serum lactate of 8.8 (8.7–12.8) mmol/L and a lowest cardiac index of 1.8 (1.8–1.9) L/min/m2. The first two required VA ECMO. They were connected later to HVHF, displayed progressive tachycardia and declining stroke volume. The opposite was true for HVHF‐responders who received targeted‐HVHF. All patients survived, but one of the VA ECMO patients suffered a vascular complication. Conclusion HVHF may contribute to support severe HCPS patients avoiding the need for VA ECMO in some. Early connection and targeted‐HVHF may increase the chance of success.
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Affiliation(s)
- René López
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.,Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Rodrigo Pérez-Araos
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.,Carrera de Kinesiología, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Álvaro Salazar
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile
| | - Mauricio Espinoza
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.,Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Cecilia Vial
- Programa Hantavirus, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Analia Cuiza
- Programa Hantavirus, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Pablo A Vial
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.,Programa Hantavirus, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Departamento de Pediatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Jerónimo Graf
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.,Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
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Valverde A. Fluid Resuscitation for Refractory Hypotension. Front Vet Sci 2021; 8:621696. [PMID: 33778035 PMCID: PMC7987676 DOI: 10.3389/fvets.2021.621696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/01/2021] [Indexed: 12/22/2022] Open
Abstract
Hypotension is a common occurrence, especially in anesthetized patients and in critical patients suffering from hypovolemia due to shock and sepsis. Hypotension can also occur in normovolemic animals, anesthetized or conscious, under conditions of vasodilation or decreased cardiac function. The main consequence of hypotension is decreased organ perfusion and tissue injury/dysfunction. In the human literature there is no consensus on what is the threshold value for hypotension, and ranges from < 80 to < 100 mmHg for systolic blood pressure and from < 50 to < 70 mmHg for mean arterial blood pressure have been referenced for intraoperative hypotension. In veterinary medicine, similar values are referenced, despite marked differences in normal arterial blood pressure between species and with respect to humans. Therapeutic intervention involves fluid therapy to normalize volemia and use of sympathomimetics to enhance cardiac function and regulate peripheral vascular resistance. Despite these therapeutic measures, there is a subset of patients that are seemingly refractory and exhibit persistent hypotension. This review covers the physiological aspects that govern arterial blood pressure control and blood flow to tissues/organs, the pathophysiological mechanisms involved in hypotension and refractory hypotension, and therapeutic considerations and expectations that include proper interpretation of cardiovascular parameters, fluid recommendations and therapy rates, use of sympathomimetics and vasopressors, and newer approaches derived from the human literature.
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Affiliation(s)
- Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Thongprayoon C, Petnak T, Kaewput W, Qureshi F, Mao MA, Pivovarova AI, Boonpheng B, Bathini T, Vallabhajosyula S, Medaura J, Cheungpasitporn W. Acute kidney injury among salicylate intoxication hospitalisations in the United States. Int J Clin Pract 2021; 75:e13745. [PMID: 32991024 DOI: 10.1111/ijcp.13745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/12/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the risk factors and the association of acute kidney injury (AKI) with outcomes, and resource utilisation in patients hospitalised because of salicylate intoxication in the United States. METHODS Hospitalised patients with a primary diagnosis of salicylate intoxication from 2003 to 2014 were identified in the National Inpatient Sample (NIS) database. End-stage kidney disease patients were excluded. The occurrence of AKI was identified using hospital diagnosis code. Clinical characteristics, in-hospital treatment, outcomes and resource utilisation were compared between patients with and without AKI. RESULTS A total of 13 787 eligible hospital admissions were included in the analysis. AKI occurred in 1279 (9.3%) admissions. Older age, male sex, more recent year of hospitalisation, anaemia, hypertension, congestive heart failure, chronic kidney disease, volume depletion, sepsis and ventricular arrhythmia/cardiac arrest were significantly associated with increased risk of AKI, whereas Hispanic race was associated with decreased risk. AKI was significantly associated with increased risk of organ failure, and in-hospital mortality. In addition, the need for ventilation support, blood component transfusion, renal replacement therapy, length of hospital stay and hospitalisation cost were higher in AKI patients. CONCLUSION Approximately one tenth of salicylate intoxication patients developed AKI during hospitalisation. AKI was associated with higher morbidity, mortality and resource utilisations.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Aleksandra I Pivovarova
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Boonphiphop Boonpheng
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Juan Medaura
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Wang T, Yi L, Zhang H, Wang T, Xi J, Zeng L, He J, Zhang Z, Ma P. Risk Potential for Organ Dysfunction Associated With Sodium Bicarbonate Therapy in Critically Ill Patients With Hemodynamic Worsening. Front Med (Lausanne) 2021; 8:665907. [PMID: 34307402 PMCID: PMC8292723 DOI: 10.3389/fmed.2021.665907] [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: 02/09/2021] [Accepted: 06/11/2021] [Indexed: 02/05/2023] Open
Abstract
Background: The role of sodium bicarbonate therapy (SBT) remains controversial. This study aimed to investigate whether hemodynamic status before SBT contributed to the heterogeneous outcomes associated with SBT in acute critically ill patients. Methods: We obtained data from patients with metabolic acidosis from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score matching (PSM) was applied to match the SBT group with the control group. Logistic regression and Cox regression were used to analyze a composite of newly "developed or exacerbated organ dysfunction" (d/eOD) within 7 days of ICU admission and 28-day mortality associated with SBT for metabolic acidosis. Results: A total of 1,765 patients with metabolic acidosis were enrolled, and 332 pairs obtained by PSM were applied to the final analyses in the study. An increased incidence of newly d/eOD was observed in the SB group compared with the control group (54.8 vs. 44.6%, p < 0.01). Multivariable logistic regression indicated that the adjusted OR of SBT for this composite outcome was no longer significant [OR (95% CI): 1.39 (0.9, 1.85); p = 0.164]. This effect of SBT did not change with the quintiles stratified by pH. Interestingly, SBT was associated with an increased risk of the composite of newly d/eOD in the subgroup of patients with worsening hemodynamics before SBT [adjusted OR (95% CI): 3.6 (1.84, 7.22), p < 0.001]. Moreover, the risk potential for this composite of outcomes was significantly increased in patients characterized by both worsening [adjusted OR (95% CI): 2.91 (1.54, 5.47), p < 0.001] and unchanged hemodynamics [adjusted OR (95% CI): 1.94 (1.01, 3.72), p = 0.046] compared to patients with improved hemodynamics before SBT. Our study failed to demonstrate an association between SBT and 28-day mortality in acute critically ill patients with metabolic acidosis. Conclusions: Our findings did not demonstrate an association between SBT and outcomes in critically ill patients with metabolic acidosis. However, patients with either worsening or unchanged hemodynamic status in initial resuscitation had a significantly higher risk potential of newly d/eOD subsequent to SBT.
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Affiliation(s)
- Tiehua Wang
- Critical Care Medicine Department, Peking University Third Hospital, Beijing, China
| | - Lingxian Yi
- Critical Care Medicine Department, Strategic Support Force Characteristic Medical Center of People's Liberation Army, Beijing, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Tianhao Wang
- Emergency Department, The 8th Medical Centre of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jingjing Xi
- Critical Care Medicine Department, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Junlin He
- Department of Medical Affairs, Shanghai Palan DataRx Co. Ltd., Shanghai, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Penglin Ma
- Critical Care Medicine Department, Peking University Third Hospital, Beijing, China
- Critical Care Medicine Department, Guiqian International General Hospital, Guiyang, China
- *Correspondence: Penglin Ma
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Muthukumar V, Arumugam P, Narasimhan A, Kumar S, Sharma U, Sharma S, Kain R. Blood Lactate And Lactate Clearance: Refined Biomarker And Prognostic Marker In Burn Resuscitation. ANNALS OF BURNS AND FIRE DISASTERS 2020; 33:293-298. [PMID: 33708018 PMCID: PMC7894842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 06/12/2023]
Abstract
Adequate resuscitation of acute burn patients is important to ensure end organ perfusion and oxygenation. The ideal marker to the endpoint of burn resuscitation is still not established. We aimed to evaluate the role of blood lactate and lactate clearance in burn resuscitation and their association with mortality and sepsis in burn patients. The retrospective study included patients (18-50 years) with thermal and scald burns with total body surface area of 30% to 60% over a period of 9 months who had achieved target urine output of at least 0.5ml/kg/hr within 24 hours of resuscitation. Patients were divided based on their admission blood lactate levels (Group A < 2 mmol/L and Group B > 2 mmol/L). Group B was further subdivided into Group B1 in whom blood lactate levels reached less than 2 mmol/L within 24 hours of burn resuscitation and Group B2 in whom it did not. Total patients included were 203. Mortality (M) and sepsis (S) rates in subgroup B2 were higher (M=57.9%; S=43.5%) and rates in subgroup B1 (M=25.8%; S=27.4%) were comparable to Group A (M=27.8%; S=26.4%). Persistent lactic acidosis at 24 hours was independently associated with significantly increased mortality and sepsis. Our data suggests a correlation of blood lactate levels and lactate clearance within 24 hours of admission with mortality and sepsis related to burn injury.
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Affiliation(s)
| | | | | | - S. Kumar
- Dr. Shalabh Kumar MCh (Plastic Surgery), Professor and Head Dept. of Plastic, Burns & Maxillofacial Surgery
V.M. Medical College & Safdarjung HospitalDelhi - 110029India+91 9818710366
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Robba C, Siwicka-Gieroba D, Sikter A, Battaglini D, Dąbrowski W, Schultz MJ, de Jonge E, Grim C, Rocco PR, Pelosi P. Pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. Intensive Care Med Exp 2020; 8:19. [PMID: 33336311 PMCID: PMC7746422 DOI: 10.1186/s40635-020-00307-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Post cardiac arrest syndrome is associated with high morbidity and mortality, which is related not only to a poor neurological outcome but also to respiratory and cardiovascular dysfunctions. The control of gas exchange, and in particular oxygenation and carbon dioxide levels, is fundamental in mechanically ventilated patients after resuscitation, as arterial blood gases derangement might have important effects on the cerebral blood flow and systemic physiology. In particular, the pathophysiological role of carbon dioxide (CO2) levels is strongly underestimated, as its alterations quickly affect also the changes of intracellular pH, and consequently influence metabolic energy and oxygen demand. Hypo/hypercapnia, as well as mechanical ventilation during and after resuscitation, can affect CO2 levels and trigger a dangerous pathophysiological vicious circle related to the relationship between pH, cellular demand, and catecholamine levels. The developing hypocapnia can nullify the beneficial effects of the hypothermia. The aim of this review was to describe the pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. According to our findings, the optimal ventilator strategies in post cardiac arrest patients are not fully understood, and oxygen and carbon dioxide targets should take in consideration a complex pattern of pathophysiological factors. Further studies are warranted to define the optimal settings of mechanical ventilation in patients after cardiac arrest.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Andras Sikter
- Internal Medicine, Municipal Clinic of Szentendre, Szentendre, Hungary
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Chloe Grim
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Qian X, Zhang Z, Li F, Wu L. Intravenous thiamine for septic shock: A meta-analysis of randomized controlled trials. Am J Emerg Med 2020; 38:2718-2722. [PMID: 33036854 DOI: 10.1016/j.ajem.2020.08.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION The efficacy of intravenous thiamine to treat septic shock remains controversial. We conduct a systematic review and meta-analysis to explore the impact of intravenous thiamine on treatment efficacy of septic shock. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2020 and included randomized controlled trials (RCTs) assessing the effect of intravenous thiamine on septic shock. This meta-analysis was performed using the random-effect model. RESULTS Four RCTs were included in the meta-analysis. Overall, compared with control group in patients with septic shock, intravenous thiamine revealed no substantial impact on mortality (odd ratio [OR] = 0.87; 95% confidence interval [CI) = 0.62 to 1.21; P = 0.40), lactate change (standard mean difference [SMD] = 0.04; 95% CI = -0.28 to 0.35; P = 0.82), Sequential Organ Failure Assessment (SOFA) change (SMD = 0.02; 95% CI = -0.18 to 0.21; P = 0.87), intensive care unit (ICU) stay (SMD = -0.02; 95% CI = -0.33 to 0.30; P = 0.90) or renal replacement therapy (OR = 0.47; 95% CI = 0.07 to 3.15; P = 0.43). CONCLUSIONS Intravenous thiamine showed no benefit over placebo in treating patients with septic shock.
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Affiliation(s)
- Xiangfeng Qian
- Emergency Department, The first people's hospital of yuhang district, Hangzhou, Zhejiang, China
| | - Zhe Zhang
- Emergency Department, The first people's hospital of yuhang district, Hangzhou, Zhejiang, China
| | - Feng Li
- Emergency Department, The first people's hospital of yuhang district, Hangzhou, Zhejiang, China
| | - Longchuan Wu
- Emergency Department, The first people's hospital of yuhang district, Hangzhou, Zhejiang, China.
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Munoz C, Aletti F, Govender K, Cabrales P, Kistler EB. Resuscitation After Hemorrhagic Shock in the Microcirculation: Targeting Optimal Oxygen Delivery in the Design of Artificial Blood Substitutes. Front Med (Lausanne) 2020; 7:585638. [PMID: 33195342 PMCID: PMC7652927 DOI: 10.3389/fmed.2020.585638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022] Open
Abstract
Microcirculatory preservation is essential for patient recovery from hemorrhagic shock. In hemorrhagic shock, microcirculatory flow and pressure are greatly reduced, creating an oxygen debt that may eventually become irreversible. During shock, tissues become hypoxic, cellular respiration turns to anaerobic metabolism, and the microcirculation rapidly begins to fail. This condition requires immediate fluid resuscitation to promote tissue reperfusion. The choice of fluid for resuscitation is whole blood; however, this may not be readily available and, on a larger scale, may be globally insufficient. Thus, extensive research on viable alternatives to blood has been undertaken in an effort to develop a clinically deployable blood substitute. This has not, as of yet, achieved fruition, in part due to an incomplete understanding of the complexities of the function of blood in the microcirculation. Hemodynamic resuscitation is acknowledged to be contingent on a number of factors other than volume expansion. The circulation of whole blood is carefully regulated to optimize oxygen delivery to the tissues via shear stress modulation through blood viscosity, inherent oxygen-carrying capacity, cell-free layer variation, and myogenic response, among other variables. Although plasma expanders can address a number of these issues, hemoglobin-based oxygen carriers (HBOCs) introduce a method of replenishing the intrinsic oxygen-carrying capacity of blood. There continue to be a number of issues related to HBOCs, but recent advances in the next-generation HBOCs show promise in the preservation of microcirculatory function and limiting toxicities. The development of HBOCs is now focused on viscosity and the degree of microvascular shear stress achieved in order to optimize vasoactive and oxygen delivery responses by leveraging the restoration and maintenance of physiological responses to blood flow in the microcirculation. Blood substitutes with higher viscous properties tend to improve oxygen delivery compared to those with lower viscosities. This review details current concepts in blood substitutes, particularly as they relate to trauma/hemorrhagic shock, with a specific focus on their complex interactions in the microcirculation.
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Affiliation(s)
- Carlos Munoz
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Federico Aletti
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Krianthan Govender
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Erik B Kistler
- Department of Anesthesiology and Critical Care, University of California, San Diego, La Jolla, CA, United States.,Department of Anesthesiology and Critical Care, Veterans Affairs San Diego Healthcare System, San Diego, CA, United States
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Drumheller BC, Sabolick EE. Hemodynamic Instability and Abnormal Vasopressor Responsiveness in the Setting of Severe Metabolic Acidosis Treated With Adapted Alkalinization and Continuous Renal Replacement Therapy in the Emergency Department. J Emerg Med 2020; 60:67-72. [PMID: 33875156 DOI: 10.1016/j.jemermed.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/04/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whereas laboratory data and clinical experience suggest that metabolic acidosis deleteriously affects certain cardiovascular functions and may contribute to hemodynamic compromise, treatment of acidemia itself with alkalinization therapy, predominantly in the form of bolus dosing of intravenous sodium bicarbonate, has not been shown to improve hemodynamics or patient-oriented outcomes in clinical trials. Detailed examination of the biochemical effects of standard sodium bicarbonate administration reveals a possible explanation: ionized serum hypocalcemia, serum hypercarbia, and a paradoxical decrease in intracellular pH occur when bicarbonate is given alone and rapidly, without adjustment in minute ventilation or calcium supplementation. "Adapted alkalinization" treatment countering these side effects through hyperventilation, calcium supplementation, and slower sodium bicarbonate infusion has been studied in animals, but not yet described in humans. CASE REPORT We report a case of successful treatment of severe hemodynamic instability and vasopressor hyporesponsiveness in the setting of profound metabolic acidosis with such an adapted alkalinization approach, plus short-term continuous renal replacement therapy, in a critically ill patient, all performed in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians encounter patients with severe metabolic acidosis, shock, and hemodynamic instability despite vasopressor agents. Adapted alkalinization therapy with sodium bicarbonate, hyperventilation, and calcium administration may promote hemodynamic stability in such patients and allow for successful treatment of the underlying disease process.
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Affiliation(s)
- Byron C Drumheller
- Department of Emergency Medicine, Einstein Healthcare Network, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
| | - Erin E Sabolick
- Department of Emergency Medicine, Einstein Healthcare Network, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
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Is It the pH That Matters? Challenging the Pathophysiology of Acidemia in a Case of Severe Hypercapnia Secondary to Intraoperative CO 2 Insufflation. Case Rep Crit Care 2020; 2020:1898759. [PMID: 33062341 PMCID: PMC7555461 DOI: 10.1155/2020/1898759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 08/18/2020] [Accepted: 09/07/2020] [Indexed: 12/04/2022] Open
Abstract
Background Acidemia has been long thought to lead to hemodynamic compromise. While some literature to date challenges this idea, there is no consensus on this topic. Case Summary To our knowledge, this is the most severe case of hypercapnia and acidosis due to carbon dioxide (CO2) insufflation during laparoscopy reported in the literature. Remarkably, this patient remained hemodynamically normal despite having a blood pH below 6.81. This prompts a wider discussion about the effects of blood pH on human physiology. Most patients who present acidotic are critically ill and have confounding underlying metabolic or respiratory pathophysiology driving their illness. In this case, the patient experienced no respiratory insult leading to an increase in blood CO2 but rather had CO2 iatrogenically introduced into the circulatory system, effectively detaching the deleterious effects of CO2 from the respiratory pathologies that so often cause its accumulation. Conclusion This raises the question, in patients with severe acidosis and hemodynamic compromise, is acidosis a symptom of the underlying process, or is the acidosis itself causing harm?
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Nikoo MH, Arjangzadeh A, Pakfetrat M, Boogar SS, Mohammadkarimi V, Ostovan VR, Khodamoradi Z, Roozbeh J, Khalili M, Shirazi FKH, Kouhi P, Heydari ST. Electrocardiographic findings of methanol toxicity: a cross-sectional study of 356 cases in Iran. BMC Cardiovasc Disord 2020; 20:415. [PMID: 32928149 PMCID: PMC7488223 DOI: 10.1186/s12872-020-01691-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/27/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Methanol is widely used in industry; however, methanol poisoning is not common. In this regard, a number of outbreaks have been recently reported due to inappropriate processing of alcoholic beverages. Shiraz, a city located in the southern part of Iran, faced one of such outbreaks in 2020 during COVID-19 pandemic. There is no sufficient literature on the electrocardiographic findings in methanol toxicity. This study aimed to address this gap in the literature. METHOD A total of 356 cases with methanol toxicity referred to Shiraz University of Medical Science Tertiary Hospitals (Faghihi and Namazi) in March and April, 2020. The clinical findings of blindness and impaired level of consciousness, lab data such as arterial blood gas, electrolytes, and creatinine, and the most common findings from ECGs were collected. RESULTS The most common ECG findings were J point elevation (68.8%), presence of U wave (59.2%), QTc prolongation (53.2% in males and 28.6% in females), and fragmented QRS (33.7%). An outstanding finding in this study was the presence of myocardial infarction in 5.3% of the cases. This finding, to the best of our knowledge, has only been reported in a few case reports. Brugada pattern (8.1%) and Osborn wave (3.7%) were the other interesting findings. In multivariate analysis, when confounding factors were adjusted, myocardial infarction, atrioventricular conduction disturbances, sinus tachycardia, and the prolonged QTC > 500 msecond were four independent factors correlated with methanol toxicity severity measured with arterial blood PH on arterial blood gas measurements, with odds ratios of 12.82, 4.46, 2.32 and 3.15 (P < 0.05 for all), respectively. CONCLUSION Electrocardiographic variations during methanol intoxication are remarkable and well-correlated with poisoning severity. Myocardial infarction was an egregious and yet a common concerning finding in this sample, which need to be ruled out in methanol toxicity.
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Affiliation(s)
- Mohammad Hossein Nikoo
- Non-communicable Disease Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Maryam Pakfetrat
- Department of Internal Medicine, Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahrokh Sadeghi Boogar
- Department of Internal Medicine, School Of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Mohammadkarimi
- Department of Internal Medicine, School Of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Reza Ostovan
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Poostchi Eye Research Centre, Ophthalmology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zohre Khodamoradi
- Department of Internal Medicine, School Of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Jamshid Roozbeh
- Department of Internal Medicine, Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammadreza Khalili
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Poostchi Eye Research Centre, Ophthalmology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Paryia Kouhi
- Department of Internal Medicine, School Of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Taghi Heydari
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Building No.2.8th Floor School of Medicine Zand Avenue, P.O.Box:71345-1877, Shiraz, Iran
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50
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Wieruszewski PM, Wittwer ED, Kashani KB, Brown DR, Butler SO, Clark AM, Cooper CJ, Davison DL, Gajic O, Gunnerson KJ, Tendler R, Mara KC, Barreto EF. Angiotensin II Infusion for Shock: A Multicenter Study of Postmarketing Use. Chest 2020; 159:596-605. [PMID: 32882250 DOI: 10.1016/j.chest.2020.08.2074] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor that may be suitable for use in these patients. RESEARCH QUESTION What is the safety and effectiveness of angiotensin II and what variables are associated with a favorable hemodynamic response? STUDY DESIGN AND METHODS We performed a multicenter, retrospective study at five tertiary medical centers in the United States. The primary end point of hemodynamic responsiveness to angiotensin II was defined as attainment of mean arterial pressure (MAP) of ≥ 65 mm Hg with a stable or reduced total vasopressor dosage 3 h after drug initiation. RESULTS Of 270 included patients, 181 (67%) demonstrated hemodynamic responsiveness to angiotensin II. Responders showed a greater increase in MAP (+10.3 mm Hg vs +1.6 mm Hg, P < .001) and reduction in vasopressor dosage (-0.20 μg/kg/min vs +0.04 μg/kg/min; P < .001) compared with nonresponders at 3 h. Variables associated with favorable hemodynamic response included lower lactate concentration (OR 1.11; 95% CI, 1.05-1.17, P < .001) and receipt of vasopressin (OR, 6.05; 95% CI, 1.98-18.6; P = .002). In severity-adjusted multivariate analysis, hemodynamic responsiveness to angiotensin II was associated with reduced likelihood of 30-day mortality (hazard ratio, 0.50; 95% CI, 0.35-0.71; P < .001). Arrhythmias occurred in 28 patients (10%) and VTE was identified in 4 patients. INTERPRETATION In postmarketing use for vasopressor-refractory shock, 67% of angiotensin II recipients demonstrated a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Patients who responded to angiotensin II experienced reduced mortality.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN
| | - Erica D Wittwer
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Daniel R Brown
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Angela M Clark
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Craig J Cooper
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Danielle L Davison
- Departments of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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