1
|
de Souza SP, Caldas JR, Lopes MB, Duarte Silveira MA, Coelho FO, Oliveira Queiroz I, Domingues Cury P, Passos RDH. Physico-chemical characterization of acid base disorders in patients with COVID-19: A cohort study. World J Nephrol 2024; 13:92498. [PMID: 38983762 PMCID: PMC11229835 DOI: 10.5527/wjn.v13.i2.92498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 05/08/2024] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Acid-base imbalance has been poorly described in patients with coronavirus disease 2019 (COVID-19). Study by the quantitative acid-base approach may be able to account for minor changes in ion distribution that may have been overlooked using traditional acid-base analysis techniques. In a cohort of critically ill COVID-19 patients, we looked for an association between metabolic acidosis surrogates and worse clinical outcomes, such as mortality, renal dialysis, and length of hospital stay. AIM To describe the acid-base disorders of critically ill COVID-19 patients using Stewart's approach, associating its variables with poor outcomes. METHODS This study pertained to a retrospective cohort comprised of adult patients who experienced an intensive care unit stay exceeding 4 days and who were diagnosed with severe acute respiratory syndrome coronavirus 2 infection through a positive polymerase chain reaction analysis of a nasal swab and typical pulmonary involvement observed in chest computed tomography scan. Laboratory and clinical data were obtained from electronic records. Categorical variables were compared using Fisher's exact test. Continuous data were presented as median and interquartile range. The Mann-Whitney U test was used for comparisons. RESULTS In total, 211 patients were analyzed. The mortality rate was 13.7%. Overall, 149 patients (70.6%) presented with alkalosis, 28 patients (13.3%) had acidosis, and the remaining 34 patients (16.2%) had a normal arterial pondus hydrogenii. Of those presenting with acidosis, most had a low apparent strong ion difference (SID) (20 patients, 9.5%). Within the group with alkalosis, 128 patients (61.0%) had respiratory origin. The non-survivors were older, had more comorbidities, and had higher Charlson's and simplified acute physiology score 3. We did not find severe acid-base imbalance in this population. The analyzed Stewart's variables (effective SID, apparent SID, and strong ion gap and the effect of albumin, lactate, phosphorus, and chloride) were not different between the groups. CONCLUSION Alkalemia is prevalent in COVID-19 patients. Although we did not find an association between acid-base variables and mortality, the use of Stewart's methodology may provide insights into this severe disease.
Collapse
Affiliation(s)
- Sergio Pinto de Souza
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
- Faculty of Medicine, Escola Bahiana de Medicina e Saúde Pública-EBMSP, Salvador, BA 40290000, Brazil
| | - Juliana R Caldas
- Department of Intensive Care, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Marcelo Barreto Lopes
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Marcelo Augusto Duarte Silveira
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Fernanda Oliveira Coelho
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Igor Oliveira Queiroz
- Hospital São Rafael, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Pedro Domingues Cury
- Hospital São Rafael, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Rogério da Hora Passos
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652900, Brazil
| |
Collapse
|
2
|
Barletta JF, Muir J, Brown J, Dzierba A. A Systematic Approach to Understanding Acid-Base Disorders in the Critically Ill. Ann Pharmacother 2024; 58:65-75. [PMID: 37125739 DOI: 10.1177/10600280231165787] [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: 05/02/2023] Open
Abstract
OBJECTIVE The objective of this review is to discuss acid-base physiology, describe the essential steps for interpreting an arterial blood gas and relevant laboratory tests, and review the 4 distinct types of acid-base disorders. DATA SOURCES A comprehensive literature search and resultant bibliography review of PubMed from inception through March 7, 2023. STUDY SELECTION AND DATA EXTRACTION Relevant English-language articles were extracted and evaluated. DATA SYNTHESIS Critically ill patients are prone to significant acid-base disorders that can adversely affect clinical outcomes. Assessing these acid-base abnormalities can be complex because of dynamic aberrations in plasma proteins, electrolytes, extracellular volume, concomitant therapies, and use of mechanical ventilation. This article provides a systematic approach to acid-base abnormalities which is necessary to facilitate prompt identification of acid-base disturbances and prevent untoward morbidity and mortality. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Many acid-base disorders result from medication therapy or are treated with medications. Pharmacists are uniquely poised as the medication experts on the multidisciplinary team to assist with acid-base assessments in the context of pharmacotherapy. CONCLUSION The use of a systematic approach to address acid-base disorders can be performed by all pharmacists to improve pharmacotherapy and optimize patient outcomes.
Collapse
Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ, USA
| | - Justin Muir
- Department of Pharmacy, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Judah Brown
- Department of Pharmacy, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Amy Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
- Center for Acute Respiratory Failure, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
3
|
Abstract
The bedside Stewart approach to acid–base disorders is a simple, pragmatic tool that can assist anesthesiologists in analyzing and managing acid–base changes in the operating room, particularly metabolic acidosis.
Collapse
Affiliation(s)
- David A Story
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| |
Collapse
|
4
|
Henrique LR, Souza MB, El Kadri RM, Boniatti MM, Rech TH. Prognosis of critically ill patients with extreme acidosis: A retrospective study. J Crit Care 2023; 78:154381. [PMID: 37480659 DOI: 10.1016/j.jcrc.2023.154381] [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: 04/01/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVE This study aims to assess the impact of different subtypes of extreme acidosis on the mortality of critically ill patients. METHODS This retrospective cohort study included critically ill patients who were admitted to the intensive care unit (ICU) with a pH level <7. Clinical data and blood gas analyses were collected from electronic medical records. The primary outcome was in-hospital mortality. The use of vasopressors, mechanical ventilation (MV), and renal replacement therapy (RRT), the duration of MV and RRT, and the length of ICU and hospital stay were secondary outcomes. The simplified Stewart approach to acid-base disorders was used to analyze the causes of acidosis. RESULTS A total of 231 patients with 371 arterial blood gas analyses with pH < 7 were admitted from January 2012 to December 2021 and 222 were included in the study. Out of the 222 patients analyzed, respiratory acidosis was the primary disorder in 11.3% of patients (n = 25), metabolic acidosis in 33.8% (n = 75), and mixed acidosis in 55% (n = 122). Overall mortality was 42.8% (n = 95). No significant difference was observed in mortality among patients with respiratory, metabolic, or mixed acidosis (28%, 42.7%, and 45.9%, respectively; p = 0.26). The primary disorder affected the use of vasopressors and MV, the duration of MV, and the length of ICU and hospital stay. Patients with extreme acidosis due to unmeasured anions with lactate levels of 4 mmol/L or higher had higher mortality compared with patients with lactate levels <4 mmol/L (55.6% and 27.7%, respectively; p = 0.007). CONCLUSION Among critically ill patients with extreme acidosis, the primary disorder is not associated with mortality, but it is associated with the use of vasopressors and MV, the duration of MV, and the length of ICU and hospital stay. Additionally, hyperlactatemia is a predictor of poor prognosis in patients with extreme acidosis.
Collapse
Affiliation(s)
- Lílian Rodrigues Henrique
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Riad Mahmoud El Kadri
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Márcio Manozzo Boniatti
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Tatiana H Rech
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| |
Collapse
|
5
|
Peri V, Jiang M, Lindsay H, Beavis V, Makar T, Story DA, Miles LF. Reperfusion acidosis in patients undergoing orthotopic liver transplantation. Eur J Anaesthesiol 2023; 40:788-790. [PMID: 37466100 DOI: 10.1097/eja.0000000000001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Varun Peri
- From the Department of Anaesthesia, Austin Health, Melbourne, Australia (VP, MJ, TM, DAS, LFM), Department of Anaesthesia & Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand (HL, VB) and Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia (TM, DAS, LFM)
| | | | | | | | | | | | | |
Collapse
|
6
|
Altun HI, Altun G, Altas OF, Aran G. Prognostic Significance of the Strong Ion Gap in Patients in Medical and Surgical Intensive Care Units. Cureus 2023; 15:e47964. [PMID: 38034207 PMCID: PMC10685706 DOI: 10.7759/cureus.47964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Background This study aimed to analyze acid-base imbalance by assessing the arterial blood gas (ABG) samples of the medical and surgical intensive care unit (ICU) patients by the Stewart approach and demonstrate the advantages of this method in delineating the acid-base status in cases where Henderson-Hasselbalch, anion gap, and base excess cannot optimally depict the imbalance and create recognition in the clinicians in this regard. Methodology Adult (i.e., age > 18 years) patients admitted to the ICU of our institution during a one-year study period were included in this study. The patients were divided into two groups based on the indication of admission to the ICU as medical or surgical. The ABG, sodium, potassium, calcium, magnesium, phosphate, chloride, albumin, lactate, hemoglobin, hematocrit, leukocyte, blood urea nitrogen, and creatinine values determined during the first 24-hour period were used for calculating the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE II), strong ion difference apparent (SIDa), and SID effective (SIDe) scores, which were subsequently compared between the groups. Results Overall, 220 (110 medical and 110 surgical) patients were included. The mean patient age was 63.56 ± 18.08 years. The mean APACHE II scores were 21.99 and 19.63 in the medical and surgical groups, respectively. Overall, 110 patients died, while 110 were referred to the regular patient floor. The mean APACHE II score of the patients who died was 28.3, and the latter group had a mean APACHE II score of 13.57. There was a significant difference between the surgical and medical patient groups regarding mean values of APACHE II, SIDa, and SIDe scores. Also, the differences were significant between the patients who died and were discharged. There was a significant difference between the patients who died and were discharged regarding the strong ion gap (SIG); however, the medical and surgical patient groups were not different concerning the SIG values. Conclusions We conclude that SIDa, SIDe, and SIG can be used in medical and surgical ICU patients to predict prognosis.
Collapse
Affiliation(s)
- Halil Ibrahim Altun
- Anesthesiology and Reanimation, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, TUR
| | - Gozde Altun
- Anesthesiology and Reanimation, Institute of Cardiology, Istanbul University-Cerrahpasa, Istanbul, TUR
| | - Omer Faruk Altas
- Anesthesiology and Reanimation, Bakırcay University Cigli Training and Research Hospital, Izmir, TUR
| | - Gulcin Aran
- Anesthesiology and Reanimation, Katip Celebi University Ataturk Training and Research Hospital, Izmir, TUR
| |
Collapse
|
7
|
Potasso L, Monnerat S, Refardt J, Lindner G, Burst V, Winzeler B, Christ-Crain M. Chloride and Potassium Assessment Is a Helpful Tool for Differential Diagnosis of Thiazide-Associated Hyponatremia. J Clin Endocrinol Metab 2023; 108:2248-2254. [PMID: 36899489 PMCID: PMC10438879 DOI: 10.1210/clinem/dgad133] [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: 11/04/2022] [Revised: 02/10/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023]
Abstract
CONTEXT Differential diagnosis of thiazide-associated hyponatremia (TAH) is challenging. Patients can either have volume depletion or a syndrome of inappropriate antidiuresis (SIAD)-like presentation. OBJECTIVE To evaluate the impact of the simplified apparent strong ion difference in serum (aSID; sodium + potassium - chloride) as well as the urine chloride and potassium score (ChU; chloride - potassium in urine) in the differential diagnosis of TAH, in addition to assessment of fractional uric acid excretion (FUA). METHODS Post hoc analysis of prospectively collected data from June 2011 to August 2013 from 98 hospitalized patients with TAH < 125 mmol/L enrolled at University Hospital Basel and University Medical Clinic Aarau, Switzerland. Patients were categorized according to treatment response in volume-depleted TAH requiring volume substitution or SIAD-like TAH requiring fluid restriction. We computed sensitivity analyses with ROC curves for positive predictive value (PPV) and negative predictive value (NPV) of aSID, ChU, and FUA in differential diagnosis of TAH. RESULTS An aSID > 42 mmol/L had a PPV of 79.1% in identifying patients with volume-depleted TAH, whereas a value < 39 mmol/L excluded it with a NPV of 76.5%. In patients for whom aSID was inconclusive, a ChU < 15 mmol/L had a PPV of 100% and a NPV of 83.3%, whereas FUA < 12% had a PPV of 85.7% and a NPV of 64.3% in identifying patients with volume-depleted TAH. CONCLUSION In patients with TAH, assessment of aSID, potassium, and chloride in urine can help identifying patients with volume-depleted TAH requiring fluid substitution vs patients with SIAD-like TAH requiring fluid restriction.
Collapse
Affiliation(s)
- Laura Potasso
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Gregor Lindner
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, 4500 Solothurn, Switzerland
- Department of Emergency Medicine, Inselspital, University Hospital Bern, 3008 Bern, Switzerland
| | - Volker Burst
- Department II of Internal Medicine (Nephrology, Rheumatology, Diabetes, and General Internal Medicine) and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
- Emergency Department, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Bettina Winzeler
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| |
Collapse
|
8
|
Bossel D, Bourgeat M, Pantet O, Zingg T. Effect of Pre-Hospital Intravenous Fluids on Initial Metabolic Acid-Base Status in Trauma Patients: A Retrospective Cohort Study. Metabolites 2023; 13:937. [PMID: 37623880 PMCID: PMC10456668 DOI: 10.3390/metabo13080937] [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: 06/29/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
Despite its known harmful effects, normal saline is still commonly used in the treatment of hypovolemia in polytrauma patients. Given the lack of pre-hospital research on this topic, the current study aims to assess the current practice of fluid administration during the pre-hospital phase of care and its effects on initial metabolic acid-base status in trauma patients. We extracted and completed data from patients recorded in the Lausanne University Hospital (CHUV) trauma registry between 2008 and 2019. Patients were selected according to their age, the availability of a blood gas analysis after arrival at the emergency room, data availability in the trauma registry, and the modality of arrival in the ED. The dominantly administered pre-hospital fluid was normal saline. No association between the type of fluid administered during the pre-hospital phase and the presence of hyperchloremic acidosis in the ED was observed.
Collapse
Affiliation(s)
- Damien Bossel
- Faculty of Biology and Medicine, Lausanne University, 1011 Lausanne, Switzerland
| | - Mylène Bourgeat
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois—CHUV, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois—CHUV, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois—CHUV, Lausanne University Hospital, 1011 Lausanne, Switzerland
| |
Collapse
|
9
|
Lankadeva YR. LOVIT or leave it: The vitamin C debate continues. CRIT CARE RESUSC 2023; 25:63-64. [PMID: 37876602 PMCID: PMC10581254 DOI: 10.1016/j.ccrj.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Yugeesh R. Lankadeva
- Corresponding author at: Preclinical Critical Care Unit Florey Institute of Neuroscience and Mental Health, University of Melbourne 30 Royal Parade, Parkville, Victoria, 3052, Australia, Tel.: +61 (3) 8334 0417, +61 (4) 0664 9976 (mobile).
| |
Collapse
|
10
|
Plasma volume expansion reveals hidden metabolic acidosis in patients with diabetic ketoacidosis. Intensive Care Med Exp 2022; 10:36. [PMID: 36038699 PMCID: PMC9424448 DOI: 10.1186/s40635-022-00464-5] [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: 05/03/2022] [Accepted: 08/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background Hyperchloremic metabolic acidosis that develops during the treatment of diabetic ketoacidosis is usually attributed to the chloride content of resuscitation fluids. We explored an alternative explanation, namely that fluid-induced plasma volume expansion alters the absolute differences in the concentrations of sodium and chloride (the Na–Cl gap) enough to affect the acid–base balance. We analyzed data from a prospective single-center cohort study of 14 patients treated for diabetic ketoacidosis. All patients received 1 L of 0.9% saline over 30 min on two consecutive days. Blood gases were sampled before and after the infusions. Results The initial plasma volume was estimated to be 25 ± 13% (mean ± SD) below normal on admission to the intensive care unit. At that time, most patients had an increased actual Na–Cl gap, which counteracts acidosis. However, the correction of the plasma volume deficit revealed that these patients would have had a decreased Na–Cl gap upon admission if they had been normovolemic at that time; the estimated “virtual Na–Cl gap” of 29 ± 5 mmol/L was significantly lower than the uncorrected value, which was 39 ± 5 mmol/L (P < 0.001). On Day 2, most patients had a decreased actual Na–Cl gap (33 ± 5 mmol/L), approaching the corrected value on Day 1. Conclusions The hyperchloremic acidosis commonly seen in diabetic ketoacidosis may not be primarily caused by the chloride content of resuscitation fluids but, rather, by the restoration of plasma volume, which reveals the hidden metabolic acidosis caused by a decreased Na–Cl gap. Trial registration Clinical Trials Identifier NCT02172092, registered June 24, 2014, https://www.clinicaltrials.gov/NCT02172092 Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00464-5.
Collapse
|
11
|
Shaw I, Magee P. Acid-base quantification: a review of developing technology. BJA Educ 2022; 22:440-447. [PMID: 36313591 PMCID: PMC9596322 DOI: 10.1016/j.bjae.2022.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 10/31/2022] Open
Affiliation(s)
- I. Shaw
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | | |
Collapse
|
12
|
Trimmel NE, Hierweger MM, Jucker S, Windhofer L, Weisskopf M. Physiologic Effects of Prolonged Terminal Anesthesia in Sheep ( Ovis gmelini aries). Comp Med 2022; 72:257-266. [PMID: 35835539 PMCID: PMC9413522 DOI: 10.30802/aalas-cm-21-000103] [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: 02/03/2023]
Abstract
The ruminant alimentary tract and its effects on blood homeostasis complicate prolonged terminal studies conducted under general anesthesia in sheep. We therefore studied 15 healthy female white alpine sheep that were undergoing prolonged anesthesia (> 30 h) for an unrelated terminal study. In the current study, all sheep developed a decreased hematocrit and hemoglobin concentration after induction of anesthesia, which fell further, along with a significant decrease in white blood cell count, over the course of anesthesia. Sheep also showed an initial hyponatremia, a persistent hypokalemia, hypocalcemia, and a progressive hyperchloremia. A significant drop in blood pH developed over time despite normal values of blood lactate and a marked decline in partial pressure of carbon dioxide over the course of the experiment. The latter consequently reduced the efficacy of mechanical ventilation, as reflected in a reduced oxygen partial pressure. A significant increase in lactate dehydrogenase and creatinine kinase was observed. Arterial blood pressure and heart rate significantly decreased over time, but remained within normotensive and normocardic limits. Central venous pressure rose significantly over the course of anesthesia. In conclusion, prolonged anesthesia in sheep is associated with a wide range of complex physi- ologic changes. An in-depth understanding of all metabolic compensatory mechanisms and their underlying cause during prolonged anesthesia is necessary for interpreting data from the primary study, with special considerations to account for ruminant-specific physiology.
Collapse
Affiliation(s)
- Nina E Trimmel
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melanie M Hierweger
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simone Jucker
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lisa Windhofer
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland,Corresponding author.
| |
Collapse
|
13
|
Tabuchi M, Morozumi K, Maki Y, Toyoda D, Kotake Y. Hyperchloremic metabolic acidosis due to saline absorption during laser enucleation of the prostate: a case report. JA Clin Rep 2022; 8:20. [PMID: 35267114 PMCID: PMC8913822 DOI: 10.1186/s40981-022-00499-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recent technological advancements have enabled the use of electrolyte solutions such as saline or buffered electrolyte solution during transurethral resection or laser enucleation of the prostate. However, saline absorption may cause hyperchloremic metabolic acidosis. Case presentation A male in his late seventies underwent holmium laser enucleation of the prostate under a combination of subarachnoid block and general anesthesia. Intraoperatively, abdominal distension prompted the attending anesthesiologist to consider the possibility of SGA malposition, and the trachea was intubated. Oropharyngeal and neck edema was observed, and laboratory examination revealed considerable acidosis with hyperchloremia. Further evaluation confirmed the absorption of a large amount of saline into the circulation via the perforated bladder. Application of the simplified Stewart approach clearly suggested that hyperchloremia was the principal cause of metabolic acidosis. The dilution of albumin attenuated acidosis. Conclusions Absorption of normal saline during laser enucleation of prostate caused hyperchloremic metabolic acidosis and airway edema.
Collapse
Affiliation(s)
- Makiko Tabuchi
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan.
| | - Kohei Morozumi
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Yuichi Maki
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Daisuke Toyoda
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| |
Collapse
|
14
|
Muzaffar SN, Patnaik R, Siddiqui SS, Azim A. Letter to the Editor: "Impact of hypoalbuminemia on mortality in critically ill patients requiring continuous renal replacement therapy". J Crit Care 2022; 69:154017. [PMID: 35272099 DOI: 10.1016/j.jcrc.2022.154017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| | - Rupali Patnaik
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneshwar 751003, Odisha, India.
| | - Suhail Sarwar Siddiqui
- Department of Critical Care Medicine, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, Uttar Pradesh, India
| |
Collapse
|
15
|
Connolly L, Briggs E. Acquired pyroglutamic acidaemia in a critically ill patient with chronic paracetamol use: A case report. SAGE Open Med Case Rep 2022; 10:2050313X211068561. [PMID: 35035973 PMCID: PMC8753234 DOI: 10.1177/2050313x211068561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/02/2021] [Indexed: 11/21/2022] Open
Abstract
Pyroglutamic acid is an endogenous organic acid and a metabolite in the γ-glutamyl cycle, involved in glutathione metabolism. Accumulation of pyroglutamic acid is a rare cause of high anion gap metabolic acidosis. There are multiple risk factors for pyroglutamic acid accumulation, such as chronic paracetamol use and sepsis. In this case report, we discuss how we came to this diagnosis, how it was subsequently managed and why it is an important consideration for critically ill patients with risk factors who are likely to end up in an intensive care setting. Pyroglutamic acid recognition and treatment could benefit patients in the critically ill population as pyroglutamic acid is a rare cause of high anion gap metabolic acidosis, which is likely under-recognised and easily treated. Inappropriate management of metabolic disorders can contribute to patient morbidity and mortality. Therefore, the recognition and appropriate management of pyroglutamic acidaemia could benefit patients with risk factors for its development in a critical care setting.
Collapse
Affiliation(s)
- Lee Connolly
- Department of Intensive Care, Joondalup Health Campus, Joondalup, WA, Australia
| | - Ed Briggs
- Department of Intensive Care, Joondalup Health Campus, Joondalup, WA, Australia
| |
Collapse
|
16
|
Tontu F, Asar S, Oren Bilgin B. Effect of pH, lactate, electrolyte, and strong ion difference variability on prediction of intensive care unit mortality: A retrospective study. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.357458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
17
|
Clinical Use of Lactate Measurements: Reply. Anesthesiology 2021; 135:766-767. [PMID: 34388819 DOI: 10.1097/aln.0000000000003906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
18
|
|
19
|
João Pedro AM, Marques TM, dos Santos Leal LD, Alves Santos PS, de Souza Ferreira JP, Dominguez R, da Silva SF, Story DA, Rossiter HB, Effros RM, van Schalkwyk JM. Commentaries on Viewpoint: Stewart's approach to quantitative acid-base physiology should replace traditional bicarbonate-centered models. J Appl Physiol (1985) 2021; 130:2022-2023. [PMID: 34142891 DOI: 10.1152/japplphysiol.00327.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Assis Moreira João Pedro
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Thais Melo Marques
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Ludmila Dias dos Santos Leal
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Paula Souza Alves Santos
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Joao Pedro de Souza Ferreira
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Raul Dominguez
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Departamento de Motricidad Humana y Rendimiento Deportivo, Universidad de Sevilla, Sevilla, Spain
| | - Sandro Fernandes da Silva
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - David A Story
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Harry B Rossiter
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Richard M Effros
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | | |
Collapse
|
20
|
Janssen JW, van Fessem JMK, Ris T, Stolker RJ, Klimek M. The hidden secrets of a neutral pH-blood gas analysis of postoperative patients according to the Stewart approach. Perioper Med (Lond) 2021; 10:15. [PMID: 34099036 PMCID: PMC8186181 DOI: 10.1186/s13741-021-00186-4] [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: 07/21/2020] [Accepted: 04/03/2021] [Indexed: 12/24/2022] Open
Abstract
Background The superiority of either the traditional or Stewart based approach to acid-base balance has focused primarily on analyzing metabolic acidemia, with little attention given to patients with neutral pH. In this study, we evaluate metabolic disturbances in patients in the immediate postoperative period focusing on patients with neutral pH, while comparing the Stewart and traditional approach. Methods We conducted a single center retrospective observational cohort study. Over a 17-month period, data on arterial blood gas analysis, electrolytes, and albumin on the morning after surgery were retrieved from patients admitted to the postsurgical high dependency unit (HDU). Albumin-corrected anion gap (AG), apparent (SIDa) and effective strong ion difference (SIDe), and strong ion gap (SIG) were calculated. Results Out of 1207 HDU admissions, 400 cases had a complete set of laboratory-data including albumin of which 281 presented with neutral pH (7.35 ≤ pH ≤ 7.45), 64 with acidemia (pH < 7.35) and 55 with alkalemia (pH > 7.45). In pH neutral patients, the following acidifying disturbances were found: SIDa was lowered in 101 (36%), and SIG was raised in 60 (21%). Base excess (BE) was decreased in 16 (6%) and corrected AG raised in 107 (38%). The alkalizing effect of hypoalbuminemia was present in 137 (49%). Out of 134 cases with normal BE and corrected AG, SIDa was lowered in 58 (43%). Out of 136 cases with normal SIDa and SIG, none had lowered BE and 28 increased AG (21%). Length of stay was significantly longer in patients with hypoalbuminemia, lowered SIDa, and increased corrected AG, but not decreased BE (hypoalbuminemia: 16 days vs. 10 days, P < 0.001; low SIDa: 15 days vs. 12 days, P = 0.015; increased AG: 16 days vs. 11 days, P < 0.001; low BE: 14 days vs. 13 days, P = 0.736). Conclusions Metabolic disturbances, characterized mainly by the presence of lowered SIDa, increased AG, and hypoalbuminemia, are frequent in our population with apparent neutral acid-base balance based on pH and base excess. These changes on the morning after surgery are associated with increased length of stay.
Collapse
Affiliation(s)
- Joost W Janssen
- Department of Anesthesiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Joris M K van Fessem
- Department of Anesthesiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Tijmen Ris
- Department of Anesthesiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Markus Klimek
- Department of Anesthesiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| |
Collapse
|
21
|
Leypoldt JK, Kurz J, Echeverri J, Storr M, Harenski K. Modeling acid-base balance for in-series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices. Artif Organs 2021; 45:1036-1049. [PMID: 33909323 DOI: 10.1111/aor.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/10/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023]
Abstract
Patients with acute respiratory distress syndrome and acute kidney injury (AKI) treated by kidney replacement therapy may also require treatment with extracorporeal carbon dioxide removal (ECCO2 R) devices to permit protective or ultraprotective mechanical ventilation. We developed a mathematical model of acid-base balance during extracorporeal therapy using ECCO2 R and continuous venovenous hemofiltration (CVVH) devices applied in series for the treatment of mechanically ventilated AKI patients. Published data from clinical studies of mechanically ventilated AKI patients treated by CVVH at known infusion rates of substitution fluid without ECCO2 R were used to adjust the model parameters to fit plasma levels of arterial partial pressure of carbon dioxide (PaCO2 ), arterial plasma bicarbonate concentration ([HCO3 ]), and plasma pH (as well as certain other unmeasured physiological variables). The effects of applying ECCO2 R at an unchanged and a reduced tidal volume on PaCO2 , [HCO3 ] and plasma pH were then simulated assuming carbon dioxide removal rates from the ECCO2 R device measured in the clinical studies. Agreement of such model predictions with clinical data was good whether the ECCO2 R device was positioned proximal or distal to the CVVH device in the extracorporeal circuit. Although carbon dioxide removal rates from the ECCO2 R device measured in one previous clinical study were higher when it was placed proximal to the CVVH device, suggesting that such in-series positioning was optimal, the current mathematical model demonstrates that proximal positioning of the ECCO2 R device also results in lower bicarbonate (and, therefore, total carbon dioxide) removal from the distal CVVH device. Thus, the removal of total carbon dioxide by such extracorporeal circuits is relatively independent of the position of the in-series devices. It is concluded that the described mathematical model has quantitative accuracy; these results suggest that the overall acid-base balance when using ECCO2 R and CVVH devices in a single extracorporeal circuit will be similar, independent of their in-series position.
Collapse
Affiliation(s)
- John K Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Jörg Kurz
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Jorge Echeverri
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, IL, USA
| | - Markus Storr
- Research and Development, Baxter International, Hechingen, Germany
| | - Kai Harenski
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| |
Collapse
|
22
|
Comparison of a modified Story approach to traditional evaluation of acid-base disturbances in patients with shock: a cohort study. J Clin Monit Comput 2021; 36:817-822. [PMID: 33934281 DOI: 10.1007/s10877-021-00713-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
To compare whether the diagnostic evaluation of metabolic acidosis can be improved by using a modified Story method compared to the traditional evaluation in a population of critically ill patients with shock. This prospective cohort study included shock patients admitted to the ICU of a tertiary hospital in Brazil between May 2018 and November 2019. We collected laboratory data necessary for traditional evaluation and the simplified Stewart's method. During the study period, 149 patients were included in the final analysis. Of the 17 patients with a normal SBE and AGcorrected, 13 (76.5%) presented with metabolic acidosis according to the modified Story assessment. Therefore, of the 149 patients included in the study, the traditional approach failed to identify metabolic acidosis that was identified by the modified Story assessment in 13 (8.7%) patients. In addition, the determination of the severity of metabolic acidosis also differed between the two methods by a mean of - 7.8 mEq/L. We found that a modified Story method can identify and quantify metabolic acidosis in patients with disorders that were not revealed by the traditional approach.
Collapse
|
23
|
Modeling acid-base balance during continuous kidney replacement therapy. J Clin Monit Comput 2021; 36:179-189. [PMID: 33389356 DOI: 10.1007/s10877-020-00635-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Clinical studies have suggested that use of bicarbonate-containing substitution and dialysis fluids during continuous kidney replacement therapy may result in excessive increases in the carbon dioxide concentration of blood; however, the technical parameters governing such changes are unclear. The current work used a mathematical model of acid-base chemistry of blood to predict its composition within and exiting the extracorporeal circuit during continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodiafiltration (CVVHDF). Model predictions showed that a total substitution fluid infusion rate of 2 L/h (33% predilution) with a bicarbonate concentration of 32 mEq/L during CVVH at a blood flow rate of 200 mL/min resulted in only modest increases in plasma bicarbonate concentration by 2.0 mEq/L and partial pressure of dissolved carbon dioxide by 4.4 mmHg in blood exiting the extracorporeal circuit. The relative increase in bicarbonate concentration (9.7%) was similar to that in partial pressure of dissolved carbon dioxide (8.2%), resulting in no significant change in plasma pH in the blood exiting the CVVH circuit. The changes in plasma acid-base levels were larger with a higher infusion rate of substitution fluid but smaller with a higher blood flow rate or use of substitution fluid with a lower bicarbonate concentration (22 mEq/L). Under comparable flow conditions and substitution fluid composition, model predicted changes in acid-base levels during CVVHDF were similar, but smaller, than those during CVVH. The described mathematical model can predict the effect of operating conditions on acid-base balance within and exiting the extracorporeal circuit during continuous kidney replacement therapy.
Collapse
|
24
|
Cove ME, Kellum JA. Reply by Cove and Kellum to Swenson. Am J Respir Crit Care Med 2020; 202:907-908. [PMID: 32459981 PMCID: PMC7491412 DOI: 10.1164/rccm.202005-1747le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
25
|
Verma A, Qayyum R. Non-lactate strong ion difference and cardiovascular, cancer and all-cause mortality. Clin Chem Lab Med 2020; 59:403-409. [PMID: 32853162 DOI: 10.1515/cclm-2020-0233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/06/2020] [Indexed: 11/15/2022]
Abstract
Objectives Non-lactate strong ion difference (SID) has been shown to be associated with predictors of mortality in intensive care unit. However, the existence of any association between non-lactate SID (nlSID) and all cause, cardiovascular and cancer mortality has not been explored before in community dwelling US adults. Methods In a nationally representative cross-sectional survey of the US non-institutionalized population, all adult participants (≥20 years of age) using National Health and Nutrition Examination Survey data (1999-2010) combined with National Death Index for mortality status through December 2011. Cox proportional hazard models were built to estimate the hazard ratios for cardiovascular, cancer, and all-cause mortality for each unit increase in non-lactate SID. The models were adjusted for demographic and confounder variables. Results In the study population the mean (SD) age was 49.6 (18.4) years. Of the study population, 31,475 (91.5%) were alive and 2,893 (8.4%) died during the mean (SD) follow-up period of 5.5 (3.5) years. In univariate regression model using nlSID as continuous variable, we found 2% (unadjusted hazard ratio, HR=1.02; 95% CI, 1.004-1.05) increase in all-cause but not in cardiovascular and cancer mortality (HR=1.03; 95% CI, 0.99-1.08, HR=1.01; 95% CI, 0.97-1.06). After adjusting for potential confounders, we found 7% (adjusted HR=1.07; 95% CI, 1.04-1.10), 5% (HR=1.05; 95% CI, 1.00-1.11) and 7% (HR=1.07; 95% CI, 1.02-1.12) increase in all-cause, cardiovascular, and cancer mortality. Conclusions A high nlSID is associated with an increase in cardiovascular, cancer and all-cause mortality and may be a prognostic indicator of mortality in general adult population. These findings may provide a point of reference for further studies.
Collapse
Affiliation(s)
- Ashish Verma
- Renal Division, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rehan Qayyum
- Division of Hospital Medicine, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
26
|
Bihari S, Galluccio S, Prakash S. Electrolyte measurement - myths and misunderstandings- Part II. J Crit Care 2020; 60:341-343. [PMID: 32622663 DOI: 10.1016/j.jcrc.2020.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/04/2020] [Accepted: 06/04/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Shailesh Bihari
- Department of ICCU, Flinders Medical Centre, Bedford Park, 5042, Australia; College of Medicine and Public health, Flinders University Bedford Park, 5042, Australia.
| | - Steven Galluccio
- Department of ICCU, Flinders Medical Centre, Bedford Park, 5042, Australia
| | - Shivesh Prakash
- Department of ICCU, Flinders Medical Centre, Bedford Park, 5042, Australia; College of Medicine and Public health, Flinders University Bedford Park, 5042, Australia
| |
Collapse
|
27
|
Effects of alkaline agents on respiratory characteristics in rabbit models of respiratory failure. Respir Physiol Neurobiol 2020; 280:103485. [PMID: 32622903 DOI: 10.1016/j.resp.2020.103485] [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: 04/10/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 11/21/2022]
Abstract
This study aimed to investigate the effects of alkaline agents on reducing strong inspiratory effort. Rabbits with hypercapnia or lung injury, induced via repeated lung lavage following injurious ventilation, were treated with Saline, NaHCO3, or Trometamol. In the hypercapnia, minute ventilation and tidal volume were unchanged during NaHCO3 administration; however, one hour after the end of NaHCO3 these parameters decreased (82.1+/-7.8 %, 90.8+/-6.0 % of the baseline, respectively, p < 0.05). Trometamol reduced minute ventilation, tidal volume, and respiratory rate after infusion (59.8+/-19.0 %, 87.0+/-9.2 %, 68.2+/-18.4 % of the baseline, respectively, p < 0.05). Alkaline agents did not cause a large change in the cerebrospinal fluid acid-base balance. In the lung injury model, NaHCO3 and Trometamol had little effect on ventilation. However, Trometamol reduced transpulmonary pressure. Trometamol exerted more inhibitory effects on ventilation than NaHCO3 in the hypercapnia model, and Trometamol reduced the transpulmonary pressure in the lung injury model.
Collapse
|
28
|
Cove M, Kellum JA. The End of the Bicarbonate Era? A Therapeutic Application of the Stewart Approach. Am J Respir Crit Care Med 2020; 201:757-758. [PMID: 31658424 PMCID: PMC7124708 DOI: 10.1164/rccm.201910-2003ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Matthew Cove
- Department of MedicineNational University Health SystemSingapore, Singaporeand
| | - John A Kellum
- Department of Critical Care MedicineUniversity of PittsburghPittsburgh, Pennsylvania
| |
Collapse
|
29
|
|
30
|
Chaiyakulsil C, Mueanpaopong P, Lertbunrian R, Chutipongtanate S. Connecting two worlds: positive correlation between physicochemical approach with blood gases and pH in pediatric ICU setting. BMC Res Notes 2019; 12:742. [PMID: 31706359 PMCID: PMC6842531 DOI: 10.1186/s13104-019-4770-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/29/2019] [Indexed: 01/12/2023] Open
Abstract
Objective Physicochemical approach such as strong ion difference provides a novel concept in understanding and managing acid–base disturbance in patients. However, its application in pediatrics is limited. This study aimed to evaluate a correlation between the physicochemical approach and blood gas pH for acid–base determination in critically ill pediatric patients. Results A total of 130 pediatric patients were included, corresponding to 1338 paired measures for analyses. Of these, the metabolic subgroup (743 paired measures) was defined. Among physicochemical parameters, the effective strong ion difference showed the best correlation with the blood gas pH in the whole cohort (R = 0.398; p < 0.001) and the metabolic subgroup (R = 0.685; p < 0.001). Other physicochemical parameters (i.e., the simplified and the apparent strong ion difference, the strong ion gap, and the sodium chloride gap) and the traditional measures (standard base excess, lactate, chloride and bicarbonate) also showed varying degrees of correlation. This study revealed the positive correlation between physicochemical parameters and the blood gas pH, serving as a connecting dot for further investigations using physicochemical approach to evaluate acid–base disturbance in pediatric population.
Collapse
Affiliation(s)
- Chanapai Chaiyakulsil
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Thammasat University, Bangkok, Thailand
| | - Papope Mueanpaopong
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Somchai Chutipongtanate
- Pediatric Translational Research Unit, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. .,Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
31
|
Hochrainer M, Funk GC. [Interpretation of acid-base disorders]. Med Klin Intensivmed Notfmed 2019; 114:765-776. [PMID: 31641791 DOI: 10.1007/s00063-019-00621-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 11/26/2022]
Abstract
Keeping blood pH levels stable within narrow limits is prerequisite for maintaining normal body function. Disruptions of this equilibrium can occur for a variety of reasons and may result in life-threatening conditions. Therefore, the identification and the interpretation of acid-base disorders are of great importance in emergency medicine. The same applies to intensive care as well as to almost all areas of internal medicine. In this article, we provide a practical overview of all relevant acid-base disorders that are due to both metabolic and respiratory disturbances. In addition, it shows how they can be diagnosed in everyday clinical practice by applying the simplified Stewart Approach.
Collapse
Affiliation(s)
- Mathis Hochrainer
- Abteilung für Innere Medizin und Pneumologie, Krankenhaus Nord - Klinik Floridsdorf, Brünner Str. 68, 1210, Wien, Österreich.
- Karl Landsteiner Institut für Lungenforschung und Pneumologische Onkologie, Wien, Österreich.
| | - Georg-Christian Funk
- Medizinische Abteilung mit Pneumologie, Wilhelminenspital, Wien, Österreich
- Karl Landsteiner Institut für Lungenforschung und Pneumologische Onkologie, Wien, Österreich
| |
Collapse
|
32
|
Semler MW, Singer M. Deconstructing Hyperlactatemia in Sepsis Using Central Venous Oxygen Saturation and Base Deficit. Am J Respir Crit Care Med 2019; 200:526-527. [PMID: 31106572 PMCID: PMC6727157 DOI: 10.1164/rccm.201904-0899ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashville, Tennesseeand
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care MedicineUniversity College LondonLondon, UK
| |
Collapse
|
33
|
Affiliation(s)
- Michael Emmett
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas,
| |
Collapse
|
34
|
Lühker O, Berger MM, Pohlmann A, Hotz L, Gruhlke T, Hochreiter M. Changes in acid-base and ion balance during exercise in normoxia and normobaric hypoxia. Eur J Appl Physiol 2017; 117:2251-2261. [PMID: 28914359 PMCID: PMC5640730 DOI: 10.1007/s00421-017-3712-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/06/2017] [Indexed: 12/01/2022]
Abstract
Purpose Both exercise and hypoxia cause complex changes in acid–base homeostasis. The aim of the present study was to investigate whether during intense physical exercise in normoxia and hypoxia, the modified physicochemical approach offers a better understanding of the changes in acid–base homeostasis than the traditional Henderson–Hasselbalch approach. Methods In this prospective, randomized, crossover trial, 19 healthy males completed an exercise test until voluntary fatigue on a bicycle ergometer on two different study days, once during normoxia and once during normobaric hypoxia (12% oxygen, equivalent to an altitude of 4500 m). Arterial blood gases were sampled during and after the exercise test and analysed according to the modified physicochemical and Henderson–Hasselbalch approach, respectively. Results Peak power output decreased from 287 ± 9 Watts in normoxia to 213 ± 6 Watts in hypoxia (−26%, P < 0.001). Exercise decreased arterial pH to 7.21 ± 0.01 and 7.27 ± 0.02 (P < 0.001) during normoxia and hypoxia, respectively, and increased plasma lactate to 16.8 ± 0.8 and 17.5 ± 0.9 mmol/l (P < 0.001). While the Henderson–Hasselbalch approach identified lactate as main factor responsible for the non-respiratory acidosis, the modified physicochemical approach additionally identified strong ions (i.e. plasma electrolytes, organic acid ions) and non-volatile weak acids (i.e. albumin, phosphate ion species) as important contributors. Conclusions The Henderson–Hasselbalch approach might serve as basis for screening acid–base disturbances, but the modified physicochemical approach offers more detailed insights into the complex changes in acid–base status during exercise in normoxia and hypoxia, respectively. Electronic supplementary material The online version of this article (doi:10.1007/s00421-017-3712-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Olaf Lühker
- Department of Anesthesiology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Anesthesiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Marc Moritz Berger
- Department of Anesthesiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Department of Anesthesiology, Perioperative and General Critical Care Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Pohlmann
- Department of Anesthesiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Lorenz Hotz
- Division of Sports Medicine, Department of Internal Medicine VII, University of Heidelberg, Heidelberg, Germany
| | - Tilmann Gruhlke
- Department of Anesthesiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Marcel Hochreiter
- Department of Anesthesiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| |
Collapse
|
35
|
Muir W. Effect of Intravenously Administered Crystalloid Solutions on Acid-Base Balance in Domestic Animals. J Vet Intern Med 2017; 31:1371-1381. [PMID: 28833697 PMCID: PMC5598900 DOI: 10.1111/jvim.14803] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/30/2017] [Accepted: 07/13/2017] [Indexed: 12/28/2022] Open
Abstract
Intravenous fluid therapy can alter plasma acid-base balance. The Stewart approach to acid-base balance is uniquely suited to identify and quantify the effects of the cationic and anionic constituents of crystalloid solutions on plasma pH. The plasma strong ion difference (SID) and weak acid concentrations are similar to those of the administered fluid, more so at higher administration rates and with larger volumes. A crystalloid's in vivo effects on plasma pH are described by 3 general rules: SID > [HCO3-] increases plasma pH (alkalosis); SID < [HCO3-] decreases plasma pH (alkalosis); and SID = [HCO3-] yields no change in plasma pH. The in vitro pH of commercially prepared crystalloid solutions has little to no effect on plasma pH because of their low titratable acidity. Appreciation of IV fluid composition and an understanding of basic physicochemical principles provide therapeutically valuable insights about how and why fluid therapy can produce and correct alterations of plasma acid-base equilibrium. The ideal balanced crystalloid should (1) contain species-specific concentrations of key electrolytes (Na+ , Cl- , K+ , Ca++ , Mg++ ), particularly Na+ and Cl- ; (2) maintain or normalize acid-base balance (provide an appropriate SID); and (3) be isosmotic and isotonic (not induce inappropriate fluid shifts) with normal plasma.
Collapse
Affiliation(s)
- W. Muir
- College of Veterinary MedicineLincoln Memorial UniversityHarrogateTN
| |
Collapse
|
36
|
Johansson J, Lindahl M, Gyllencreutz E, Hahn RG. Symptomatic absorption of isotonic saline during transcervical endometrial resection. Acta Anaesthesiol Scand 2017; 61:121-124. [PMID: 27918101 DOI: 10.1111/aas.12834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/01/2016] [Indexed: 12/01/2022]
Affiliation(s)
- J Johansson
- Department of Anesthesiology and Intensive Care, Östersund Hospital, Östersund, Sweden
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care, Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden
| | - M Lindahl
- Department of Anesthesiology and Intensive Care, Östersund Hospital, Östersund, Sweden
| | - E Gyllencreutz
- Department of Obstetrics and Gynecology, Östersund Hospital, Östersund, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - R G Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden
| |
Collapse
|
37
|
Friesen JHP. An App to Calculate Bedside Stewart Acid–Base Equations. Anesth Analg 2016; 123:1638. [DOI: 10.1213/ane.0000000000001630] [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]
|
38
|
Story DA. In Response. Anesth Analg 2016; 123:1064. [DOI: 10.1213/ane.0000000000001455] [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]
|