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Patel H, Paracha A, Singhal A, Wang K, Gostanian N. Clinical Warburg Effect in a Patient With Mantle Cell Lymphoma: A Case Report. Cureus 2024; 16:e58768. [PMID: 38779236 PMCID: PMC11111258 DOI: 10.7759/cureus.58768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
The clinical Warburg effect is a rare occurrence in cancer biology where tumor cells primarily utilize glycolysis for energy production, leading to significant hypoglycemia and lactate formation. This presentation is associated with a poor prognosis for the patient. In this context, we describe the case of a 53-year-old woman with stage IV mantle cell lymphoma who developed the clinical Warburg effect with solely arrhythmia and without neurological symptoms. She received prompt treatment for glucose stabilization and underwent inpatient chemotherapy. This case underscores the importance of early intervention to reduce tumor burden and highlights the effectiveness of hemodialysis in stabilizing metabolic acidosis. Further investigation into this approach is warranted.
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Affiliation(s)
- Himanshu Patel
- Internal Medicine, Northwell, New Hyde Park, USA
- Internal Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | | | - Adit Singhal
- Internal Medicine, Northwell, New Hyde Park, USA
| | - Kevin Wang
- Hematology and Oncology, Northwell, New Hyde Park, USA
| | - Nouneh Gostanian
- Hematology and Oncology, Northwell, New Hyde Park, USA
- Hematology and Oncology, Northwell Health Cancer Institute, Lake Success, USA
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Yan T, Zhang C, Ma Y, Xu K, Wu S, Xu F, Han Y, Wei W, Lyu J, Wang Z. Adverse Impact of Sodium Bicarbonate Administration on Multiple Outcomes in Acute Pancreatitis Patients With Hyperlactatemia. Pancreas 2024; 53:e62-e68. [PMID: 38258983 DOI: 10.1097/mpa.0000000000002275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Hyperlactatemia is likely to occur among patients with acute pancreatitis (AP). Sodium bicarbonate (SB) therapy could be applied to correct potential detrimental acidic disturbances, but the exact impact of SB treatment is unknown. This study aims to investigate the impact of SB on AP patients complicated with hyperlactatemia. METHODS The study was conducted based on the database named Medical Information Mart for Intensive Care-IV (MIMIC-IV). Propensity matching (PSM) and inverse probability weighting (IPTW) were used to balance the baseline differences. Multivariate regression and marginal structural Cox models were performed to investigate the association between SB and multiple outcomes. RESULTS Three hundred fifty-three AP patients with hyperlactatemia (initial serum lactate, >2.0 mmol/L) were extracted from the MIMIC-IV database. We found that SB treatment was significantly associated with worse multi-outcomes of AP patients with hyperlactatemia (in-hospital mortality: hazard ratio, 2.46; 95% confidence interval, 1.38-4.39; P < 0.01). Further analysis through marginal structural Cox models showed that SB had adverse impact on in-hospital prognosis of patients with severe lactic acidosis (pH < 7.15,lactate > 2.0 mmol/L). CONCLUSION Sodium bicarbonate might not be an appropriate treatment for AP patients with hyperlactatemia (lactate > 2.0 mmol/L) or with severe lactic acidosis (pH < 7.15, lactate > 2.0 mmol/L).
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Affiliation(s)
| | | | | | | | | | - Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, People's Republic of China
| | | | | | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, People's Republic of China
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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.
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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
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Liu H, Cao Y, Xue X, Bai Z, Wu S. Clinical efficacy of sodium bicarbonate in treating pediatric metabolic acidosis with varying level of acid-base balance parameters: a real-world study. BMC Med 2023; 21:473. [PMID: 38031038 PMCID: PMC10688456 DOI: 10.1186/s12916-023-03189-8] [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: 05/13/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Sodium bicarbonate (SB) infusion is commonly used to correct metabolic acidosis, but its clinical efficacy remains controversial. This study aims to investigate whether acid-base balance parameters should be a consideration for administering SB treatment. METHODS Children with metabolic acidosis (pH < 7.35 and bicarbonate < 22 mmol/L) who were treated with or without 50 mg/ml SB injection were grouped and extracted from a retrospective cohort database of the Pediatric Intensive Care Unit. The interaction between acid-base balance parameters and SB treatment on mortality was analyzed through mortality curves and cross-effect models. Logistic regression was conducted to estimate the risk of death following SB treatment in the overall children as well as in subgroups, and potential confounding factors were adjusted for. After employing propensity score matching to account for confounding factors, further analysis was performed to evaluate the effectiveness of SB treatment within each chloride subgroup. RESULTS A total of 5865 children with metabolic acidosis were enrolled, of which 2462 (42.0%) received SB treatment. In the overall population, it was found that SB treatment did not reduce hospital mortality or 28-day mortality. Interactions between acid-base balance parameters (chloride and anion gap) and SB treatment on mortality were observed. Subgroup analysis clarified that when chloride levels were below 107 mmol/L, children treated with SB had higher in-hospital mortality (29.8% vs 14.9%) and 28-day mortality (26.5% vs 13.4%), with adjusted ORs of 2.065 (95% CI, 1.435-2.97) and 1.947 (95% CI, 1.332-2.846), respectively. In contrast, when chloride levels were greater than or equal to 113 mmol/L, children treated with SB had a shorter stay in the PICU (median: 1.1 days vs 5.1 days, adjusted p = 0.004) and lower in-hospital mortality (4.3% vs 10.3%) and 28-day mortality (4.0% vs 8.4%), with adjusted ORs of 0.515 (95% CI, 0.337-0.788) and 0.614 (95% CI, 0.391-0.965), respectively. After controlling for confounding factors through matching, the impact of SB treatment on the risk of death in each chloride subgroup was consistent with the aforementioned results. However, treatment with SB did not significantly increase the risk of death in newborns or children with moderate to severe metabolic acidosis when chloride levels were below 107 mmol/L (p > 0.05). CONCLUSIONS The use of sodium bicarbonate for treating metabolic acidosis has been found to increase mortality in children with low chloride levels but decrease mortality in those with high chloride levels in this study. Further prospective multi-center clinical studies and basic research are needed to validate these findings.
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Affiliation(s)
- Huaqing Liu
- Health Supervision Institute of Gusu District, Suzhou, 215000, Jiangsu, China
| | - Yanmei Cao
- Department of Occupational Disease Medicine, The Fifth People's Hospital of Suzhou, The Affiliated Infectious Diseases Hospital of Soochow University, No.10, Guangqian Road, Suzhou, 215131, China
| | - Xiaoyan Xue
- People's Hospital of Ganzhou, Ganzhou, 341200, Jiangxi, China
| | - Zhenjiang Bai
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
| | - Shuiyan Wu
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
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Cao Y, Liu MC, Hanlon EL, Chen Y, Afzal MZ, Hayes CA, Hill JM. Clinical presentation of Warburg effect in aggressive lymphoma: a case report. J Med Case Rep 2023; 17:380. [PMID: 37608348 PMCID: PMC10464222 DOI: 10.1186/s13256-023-04079-6] [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: 04/12/2021] [Accepted: 07/14/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND The Warburg effect is a rare condition in tumor biology, illustrated by significant lactate production in the presence of oxygen. The Warburg effect is associated with very poor prognosis in patients with malignancy. CASE PRESENTATION We report a 76-year-old Caucasian woman with double-expressor diffuse large B cell lymphoma who presented with severe lactic acidosis and extreme hypoglycemia with normal mentation. Her lactic acidosis was initially controlled with a bicarbonate infusion, and the patient was started promptly on steroids, followed by chemotherapy, but her clinical course was complicated by tumor lysis syndrome, acute renal failure requiring hemodialysis, and progressive liver failure. She manifested a temporary clinical response to chemotherapy but eventually died of complications. CONCLUSIONS This case demonstrates the importance of prompt recognition of the Warburg effect, aggressive supportive measures, and early initiation of chemotherapy. Future studies are needed to characterize the role of hemodialysis in this setting.
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Affiliation(s)
- Yenong Cao
- Department of Hematology and Oncology, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA.
| | - Margaret C Liu
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Emma L Hanlon
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - York Chen
- Department of Internal Medicine, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH, 03756 , USA
| | - Muhammad Z Afzal
- Division of Hematology and Oncology, Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Christi A Hayes
- Division of Hematology and Oncology, Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - John M Hill
- Division of Hematology and Oncology, Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
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Abstract
Acid-base disorders are common in the intensive care unit. By utilizing a systematic approach to their diagnosis, it is easy to identify both simple and mixed disturbances. These disorders are divided into four major categories: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Metabolic acidosis is subdivided into anion gap and non-gap acidosis. Distinguishing between these is helpful in establishing the cause of the acidosis. Anion gap acidosis, caused by the accumulation of organic anions from sepsis, diabetes, alcohol use, and numerous drugs and toxins, is usually present on admission to the intensive care unit. Lactic acidosis from decreased delivery or utilization of oxygen is associated with increased mortality. This is likely secondary to the disease process, as opposed to the degree of acidemia. Treatment of an anion gap acidosis is aimed at the underlying disease or removal of the toxin. The use of therapy to normalize the pH is controversial. Non-gap acidoses result from disorders of renal tubular H + transport, decreased renal ammonia secretion, gastrointestinal and kidney losses of bicarbonate, dilution of serum bicarbonate from excessive intravenous fluid administration, or addition of hydrochloric acid. Metabolic alkalosis is the most common acid-base disorder found in patients who are critically ill, and most often occurs after admission to the intensive care unit. Its etiology is most often secondary to the aggressive therapeutic interventions used to treat shock, acidemia, volume overload, severe coagulopathy, respiratory failure, and AKI. Treatment consists of volume resuscitation and repletion of potassium deficits. Aggressive lowering of the pH is usually not necessary. Respiratory disorders are caused by either decreased or increased minute ventilation. The use of permissive hypercapnia to prevent barotrauma has become the standard of care. The use of bicarbonate to correct the acidemia is not recommended. In patients at the extreme, the use of extracorporeal therapies to remove CO 2 can be considered.
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Affiliation(s)
- Anand Achanti
- Internal Medicine/Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Harold M. Szerlip
- Internal Medicine/Nephrology, Medical University of South Carolina, Charleston, South Carolina
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Abstract
Significance: Cancer-associated tissue-specific lactic acidosis stimulates and mediates tumor invasion and metastasis and is druggable. Rarely, malignancy causes systemic lactic acidosis, the role of which is poorly understood. Recent Advances: The understanding of the role of lactate has shifted dramatically since its discovery. Long recognized as only a waste product, lactate has become known as an alternative metabolism substrate and a secreted nutrient that is exchanged between the tumor and the microenvironment. Tissue-specific lactic acidosis is targeted to improve the host body's anticancer defense and serves as a tool that allows the targeting of anticancer compounds. Systemic lactic acidosis is associated with poor survival. In patients with solid cancer, systemic lactic acidosis is associated with an extremely poor prognosis, as revealed by the analysis of 57 published cases in this study. Although it is considered a pathology worth treating, targeting systemic lactic acidosis in patients with solid cancer is usually inefficient. Critical Issues: Research gaps include simple questions, such as the unknown nuclear pH of the cancer cells and its effects on chemotherapy outcomes, pH sensitivity of glycosylation in cancer cells, in vivo mechanisms of response to acidosis in the absence of lactate, and overinterpretation of in vitro results that were obtained by using cells that were not preadapted to acidic environments. Future Directions: Numerous metabolism-targeting anticancer compounds induce lactatemia, lactic acidosis, or other types of acidosis. Their potential to induce acidic environments is largely overlooked, although the acidosis might contribute to a substantial portion of the observed clinical effects. Antioxid. Redox Signal. 37, 1130-1152.
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Affiliation(s)
- Petr Heneberg
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
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A Murine Model of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:e243-e250. [PMID: 36229020 DOI: 10.1097/mat.0000000000001828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The mechanisms driving the pathologic state created by extracorporeal membrane oxygenation (ECMO) remain poorly defined. We developed the first complete blood-primed murine model of veno-arterial ECMO capable of maintaining oxygenation and perfusion, allowing molecular studies that are unavailable in larger animal models. Fifteen C57BL/6 mice underwent ECMO by cannulating the left common carotid artery and the right external jugular vein. The mean arterial pressure was measured through cannulation of the femoral artery. The blood-primed circuit functioned well. Hemodynamic parameters remained stable and blood gas analyses showed adequate oxygenation of the animals during ECMO over a 1-hour timeframe. A significant increase in plasma-free hemoglobin was observed following ECMO, likely secondary to hemolysis within the miniaturized circuit components. Paralleling clinical data, ECMO resulted in a significant increase in plasma levels of multiple proinflammatory cytokines as well as evidence of early signs of kidney and liver dysfunction. These results demonstrate that this novel, miniature blood-primed ECMO circuit represents a functional murine model of ECMO that will provide unique opportunities for further studies to expand our knowledge of ECMO-related pathologies using the wealth of available genetic, pharmacological, and biochemical murine reagents not available for other species.
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9
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Han SJ, Zhou ZW, Yang C, Wei KP, Ma JZ, Chu ZF, Gu P. Hemorrhagic, hypovolemic shock resuscitated with Ringer's solution using bicarbonate versus lactate: A CONSORT-randomized controlled study comparing patient outcomes and blood inflammatory factors. Medicine (Baltimore) 2022; 101:e31671. [PMID: 36401445 PMCID: PMC9678593 DOI: 10.1097/md.0000000000031671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Isotonic crystalloids are the preferred solution for the initial clinical management of patients with multiple trauma, among which lactated Ringer's solution and normal saline are the most widely used, but both have clinical limitations. Bicarbonated Ringer's solution (BRS), which provides physiological levels of bicarbonate ions and electrolyte ions, can be used to supplement missing extracellular fluid and correct metabolic acidosis. METHODS A prospective, randomized controlled study enrolled 63 patients with traumatic hepatic rupture and hemorrhagic shock. They were randomly assigned to the Bicarbonated group (n = 33) or the Control group (n = 30), which received restrictive fluid resuscitation with sodium bicarbonate Ringer's solution or sodium lactate Ringer's solution, respectively. The levels of interleukin (IL)-6, tumor necrosis factor (TNF)-α, arterial blood lactic acid and potential of hydrogen (pH) were measured prior to, 1, 3, 24, and 72 hours following resuscitation. The primary outcomes were patient survival, shock-related complications, and comparison of the inflammatory factors. RESULTS The incidence of complications in the Bicarbonated group was significantly lower than in the Control group (15.15% vs 40.0%; P < .05). The intensive care unit length of stay and mechanical ventilation time in the Bicarbonated group were significantly shorter than in the Control group (all P < .01). The levels of IL-6 and TNF-α in the Bicarbonated group were significantly lower 1 hour following resuscitation than prior to resuscitation (P < .01), whereas these levels in the Control group were increased following 1h of resuscitation as compared with before resuscitation (P < .01). Following resuscitation, the levels of IL-6, TNF-α and lactate in the Bicarbonated group were significantly lower than in the Control group (P < .01). Moreover, in the Bicarbonated group, the lactic acid level decreased and the pH value increased significantly following resuscitation, whereas there was no difference in lactic acid levels and pH value between pre- and 1 hour post-resuscitation in the Control group (P > .05). CONCLUSION The shock-related complications were dramatically reduced from using BRS in these patients. Additionally, the BRS was found to better inhibit the expression of inflammatory factors in their peripheral blood and could correct acidosis.
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Affiliation(s)
- Sheng-Jin Han
- Department of Emergency Surgery, Lu’an Hospital of Anhui Medical University, Lu’an, China
| | - Zheng-Wu Zhou
- Department of Emergency Surgery, Lu’an Hospital of Anhui Medical University, Lu’an, China
- * Correspondence: Zheng-Wu Zhou, Department of Emergency Surgery, Lu‘an Hospital of Anhui Medical University, No. 21 Wanxi West Road, Lu’an, Anhui Province 237005, China (e-mail: )
| | - Cui Yang
- Department of Clinical Medicine, West Anhui Health Vocational College, Lu’an, China
| | - Kun-Peng Wei
- Department of Emergency Surgery, Lu’an Hospital of Anhui Medical University, Lu’an, China
| | - Jian-Zhong Ma
- Department of Emergency Surgery, Lu’an Hospital of Anhui Medical University, Lu’an, China
| | - Zeng-Fei Chu
- Department of Emergency Surgery, Lu’an Hospital of Anhui Medical University, Lu’an, China
| | - Peng Gu
- Department of Emergency Surgery, Lu’an Hospital of Anhui Medical University, Lu’an, China
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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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Abstract
Lactic acidosis occurs commonly and can be a marker of significant physiologic derangements. However what an elevated lactate level and acidemia connotes and what should be done about it is subject to inconsistent interpretations. This review examines the varied etiologies of lactic acidosis, the physiologic consequences, and the known effects of its treatment with sodium bicarbonate. Lactic acidosis is often assumed to be a marker of hypoperfusion, but it can also result from medications, organ dysfunction, and sepsis even in the absence of malperfusion. Acidemia causes deleterious effects in almost every organ system, but it can also have positive effects, increasing localized blood flow and oxygen delivery, as well as providing protection against hypoxic cellular injury. The use of sodium bicarbonate to correct severe acidemia may be tempting to clinicians, but previous studies have failed to show improved patient outcomes following bicarbonate administration. Bicarbonate use is known to decrease vasomotor tone, decrease myocardial contractility, and induce intracellular acidosis. This suggests that mild to moderate acidemia does not require correction. Most recently, a randomized control trial found a survival benefit in a subgroup of critically ill patients with serum pH levels <7.2 with concomitant acute kidney injury. There is no known benefit of correcting serum pH levels ≥ 7.2, and sparse evidence supports bicarbonate use <7.2. If administered, bicarbonate is best given as a slow IV infusion in the setting of adequate ventilation and calcium replacement to mitigate its untoward effects.
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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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13
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Tourky MS, Salman AA, Salman MA, Abdelfatah MM, Taha AE, Hagag H, Youssef MYS, Arafa MS, Khattab SA, Borham MM, Moustafa A. Intraoperative Factors Associated With Early Recipient Death After Adult-to-Adult Living Donor Liver Transplant. EXP CLIN TRANSPLANT 2021; 19:817-825. [PMID: 34085911 DOI: 10.6002/ect.2021.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
OBJECTIVES Living donor liver transplant is the gold standard therapy for patients with terminal hepatic disorders for whom no alternative therapy is available. The primary aim was to assess different intraoperative factors that may predict early death after adult-to-adult living donor liver transplant. The secondary aim was to assess the effect of small-for-size syndrome on mortality. MATERIALS AND METHODS This retrospective multicenter cohort study was performed on records from 145 adults with cirrhosis who had received a right lobe living donor liver transplant. Patients were divided according to the occurrence of short-term mortality (death within the first month after transplant). The primary intraoperative parameters included graft weight, surgical duration, mean blood pressure, serum lactate and sodium bicarbonate, transfusions, durations of cold and warm ischemia and anhepatic phase, input and output during surgery, and portal venous pressures. RESULTS There were statistically significant variations between both cohorts for number of units of packed red blood cells, durations of cold and warm ischemia and anhepatic phase, preclamp and postreperfusion portal venous pressures, average urine output, mean serum lactate, mean blood pressure, and surgical duration (P ⟨ .001). Also, there were significant differences in the number of platelets, units of fresh frozen plasma, and mean sodium bicarbonate (P = .025, .003, and .035, respectively). Of the 25 patients who died within the early postoperative period, 20 had developed small-for-size syndrome (P ⟨ .001). CONCLUSIONS A variety of intraoperative risk factors may affect early posttransplant mortality, which suggests the high complexity of living donor liver transplants and the need for well-trained experienced teams to perform these surgeries.
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Affiliation(s)
- Mohamed Sabry Tourky
- From the Department of Surgery, Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom
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Ma J, Han S, Liu X, Zhou Z. Sodium bicarbonated Ringer's solution effectively improves coagulation function and lactic acid metabolism in patients with severe multiple injuries and traumatic shock. Am J Transl Res 2021; 13:5043-5050. [PMID: 34150090 PMCID: PMC8205763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the effect of sodium bicarbonated Ringer's solution on the coagulation function and the lactic acid metabolism in patients with severe multiple injuries and traumatic shock. METHODS A prospective, randomized controlled study was designed to enroll 50 patients with severe multiple injuries and traumatic shock. The enrolled patients were randomly assigned into a Test group (n=25) or a Control group (n=25), which received restrictive fluid resuscitation with sodium bicarbonated Ringer's solution or sodium lactated Ringer's solution, respectively. The success rate of rescue, the changes in coagulation function indices, lactic acid level, arterial blood pH level, hemorheological indices, blood pressure and heart rate before and after resuscitation, as well as the shock-related complications were observed. RESULTS The coagulation function of the Test group was significantly improved after resuscitation as compared with the Control group (P<0.05). After resuscitation, the Test group had significantly lower lactic acid level and significantly higher pH level than those of the Control group (both P<0.05). The hemorheological indices of the Test group were improved more significantly after resuscitation as compared with those of the Control group (P<0.05). There was no significant difference in the success rate of rescue between the Test group and the Control group (92.0% vs. 80.0%; P>0.05), but the total incidence of complications in the Test group was significantly lower than that in the Control group (16.0% vs. 56.0%; P<0.01). CONCLUSION Sodium bicarbonated Ringer's solution is effective in early resuscitation for patients with severe multiple injuries and traumatic shock through improving the coagulation function and lactic acid metabolism, reducing the risk of related complications and improving the clinical outcome in patients.
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Affiliation(s)
- Jianzhong Ma
- Department of Emergency Surgery, Lu'an Hospital Affiliated to Anhui Medical University Lu'an, Anhui Province, China
| | - Shengjin Han
- Department of Emergency Surgery, Lu'an Hospital Affiliated to Anhui Medical University Lu'an, Anhui Province, China
| | - Xiaolin Liu
- Department of Emergency Surgery, Lu'an Hospital Affiliated to Anhui Medical University Lu'an, Anhui Province, China
| | - Zhengwu Zhou
- Department of Emergency Surgery, Lu'an Hospital Affiliated to Anhui Medical University Lu'an, Anhui Province, China
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Giustiniano E, Nisi F, Rocchi L, Zito PC, Ruggieri N, Cimino MM, Torzilli G, Cecconi M. Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist. Cancers (Basel) 2021; 13:cancers13092203. [PMID: 34063684 PMCID: PMC8125060 DOI: 10.3390/cancers13092203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Major high-risk surgery (HRS) exposes patients to potential perioperative adverse events. Hepatic resection of colorectal metastases can surely be included into the HRS class of operations. Limiting such risks is the main target of the perioperative medicine. In this context the collaboration between the anesthetist and the surgeon and the sharing of management protocols is of utmost importance and represents the key issue for a successful outcome. In our institution, we have been adopting consolidated protocols for patients undergoing this type of surgery for decades; this made our mixed team (surgeons and anesthetists) capable of achieving a safe outcome for the majority of our surgical population. In this narrative review, we report the most recent state of the art of perioperative management of hepatic resection of colorectal metastases along with our experience in this field, trying to point out the main issues. Abstract Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Correspondence: (E.G.); (F.N.); Tel.: +39-02-8224-7459 (E.G.); +39-02-8224-4115 (F.N.); Fax: +39-02-8224-4190 (E.G. & F.N.)
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Correspondence: (E.G.); (F.N.); Tel.: +39-02-8224-7459 (E.G.); +39-02-8224-4115 (F.N.); Fax: +39-02-8224-4190 (E.G. & F.N.)
| | - Laura Rocchi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Paola C. Zito
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Matteo M. Cimino
- Hepato-Biliary & Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (M.M.C.); (G.T.)
| | - Guido Torzilli
- Hepato-Biliary & Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (M.M.C.); (G.T.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
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Coppola S, Caccioppola A, Froio S, Chiumello D. Sodium Bicarbonate in Different Critically Ill Conditions: From Physiology to Clinical Practice. Anesthesiology 2021; 134:774-783. [PMID: 33721887 DOI: 10.1097/aln.0000000000003733] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Intravenous sodium bicarbonate is commonly used in several critically ill conditions for the management of acute acidemia independently of the etiology, and for the prevention of acute kidney injury, although this is still controversial from a physiologic point of view.
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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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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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Sun H, Liu S, Mao J, Yu Z, Lin Z, Mao J. New insights into the impacts of huangjiu compontents on intoxication. Food Chem 2020; 317:126420. [PMID: 32101783 DOI: 10.1016/j.foodchem.2020.126420] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/01/2020] [Accepted: 02/14/2020] [Indexed: 11/30/2022]
Abstract
Although huangjiu is a popular alcoholic beverage in China, the occurrence of quick-intoxication suppresses huangjiu consumption and impedes development of the huangjiu industry. In this study, the Cryprinus carpio intoxication model was used to compare the differences in intoxication effect of alcoholic beverages and to assess the impacts of huangjiu components on intoxication for the first time. Exposure to huangjiu led to the most rapid physical imbalance of C. carpio, followed by red wine and Western liquor. Higher alcohols, biogenic amines and aldehydes could cause physical imbalance of fish by themselves, and synergistic effects were observed when combined with ethanol. 2-Phenylethanoland and isopentanol had the greatest positive effect on huangjiu intoxication, followed by histamine and phenethylamine. No synergistic effect was observed between individual aldehydes and ethanol. Identification of these impactful huangjiu components provides a new perspective on the establishment of more rigorous control on the quality and flavor of huangjiu.
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Affiliation(s)
- Hailong Sun
- National Engineering Laboratory for Cereal Fermentation Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China; National Engineering Research Center of Chinese Rice Wine, Zhejiang Guyuelongshan Shaoxing Wine CO., LTD, Shaoxing, Zhejiang, China; Jiangsu Industrial Technology Research Institute (Rugao Food Biotechnology Research Institute Co. Ltd), Rugao, Jiangsu, China
| | - Shuangping Liu
- National Engineering Laboratory for Cereal Fermentation Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China; Jiangsu Provincial Research Center for Bioactive Product Processing Technology, Jiangnan University, China; National Engineering Research Center of Chinese Rice Wine, Zhejiang Guyuelongshan Shaoxing Wine CO., LTD, Shaoxing, Zhejiang, China; Jiangsu Industrial Technology Research Institute (Rugao Food Biotechnology Research Institute Co. Ltd), Rugao, Jiangsu, China.
| | - Jieqi Mao
- College of Agriculture and Environmental Sciences, University of California, Davis, USA
| | - Ziwei Yu
- National Engineering Laboratory for Cereal Fermentation Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China
| | - Zhijie Lin
- National Engineering Laboratory for Cereal Fermentation Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China
| | - Jian Mao
- National Engineering Laboratory for Cereal Fermentation Technology, School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China; Jiangsu Provincial Research Center for Bioactive Product Processing Technology, Jiangnan University, China; National Engineering Research Center of Chinese Rice Wine, Zhejiang Guyuelongshan Shaoxing Wine CO., LTD, Shaoxing, Zhejiang, China.
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20
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McNeillis R, Greystoke A, Walton J, Bacon C, Keun H, Siskos A, Petrides G, Leech N, Jenkinson F, Bowron A, Halford S, Plummer R. A case of malignant hyperlactaemic acidosis appearing upon treatment with the mono-carboxylase transporter 1 inhibitor AZD3965. Br J Cancer 2020; 122:1141-1145. [PMID: 32076124 PMCID: PMC7156442 DOI: 10.1038/s41416-020-0727-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/16/2019] [Accepted: 01/08/2020] [Indexed: 01/04/2023] Open
Abstract
A 47-year-old man with metastatic melanoma presented with refractory hyperlactaemic acidosis following the first dose of the mono-carboxylase transporter 1 inhibitor AZD3965 within a "first time in man" clinical trial. The mechanism of the agent and the temporal relationship suggested that this event was potentially drug related and recruitment was suspended. However, urinary metabolomics showed extensive abnormalities even prior to drug administration, leading to investigations for an underlying metabolic disorder. The lack of clinical symptoms from the elevated lactate and low blood glucose suggested a diagnosis of "hyper-Warburgism", where the high tumour burden was associated with extensive glucose uptake and lactate efflux from malignant cells, and the subsequent impact on blood biochemistry. This was supported by an FDG-PET scan showing extensive glucose uptake in numerous metastases and lack of uptake in the brain. A review of the literature showed 16 case reports of "hyper-Warburgism" in non-haematological malignancies, none of them with melanoma, with most associated with a poor outcome. The patient was treated symptomatically, but died 2 months later. The development of AZD3965 continues with the exclusion of patients with elevated plasma lactate at screening added to the protocol as a safety measure.Trial identification number ClinicalTrials.Gov. NCT01791595.
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Affiliation(s)
- Rosie McNeillis
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alastair Greystoke
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Newcastle University, Newcastle upon Tyne, UK
| | - Jon Walton
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris Bacon
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Newcastle University, Newcastle upon Tyne, UK
| | | | | | - George Petrides
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nicola Leech
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Fiona Jenkinson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ann Bowron
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sarah Halford
- Centre for Drug Development, Cancer Research UK, London, UK
| | - Ruth Plummer
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. .,Newcastle University, Newcastle upon Tyne, UK.
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Rodríguez-Villar S, Do Vale BM, Fletcher HM. The arterial blood gas algorithm: Proposal of a systematic approach to analysis of acid-base disorders. ACTA ACUST UNITED AC 2019; 67:20-34. [PMID: 31826801 DOI: 10.1016/j.redar.2019.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 10/25/2022]
Abstract
Abnormalities in the acid-base balance are common clinical problems and can have deleterious effects on cellular function and be a clue to various disorders. Therefore, it is important for the clinician to make a precise diagnosis of the acid-base disorder(s) present for a proper treatment. Three approaches have been proposed to evaluate acid-base disorders: a bicarbonate-centric approach; the Stewart approach, and the base excess approach. Although the latter two have many adherents, we will only discuss the bicarbonate-centric approach. This approach is simpler to utilize at the bedside, has a physiological evaluation of the acid-base disorder, presents an easily understandable approach to assess severity, and provides a more solid foundation for the development of effective therapies. Therefore, the following discussion will be limited to an examination of this approach. In this case-centric review, important new concepts will be introduced first; their benefits and limitations discussed; and then their utilization to analyze actual cases will be shown. A systematic approach algorithm that incorporates these new concepts has been generated and will be highlighted.
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Affiliation(s)
| | - B M Do Vale
- Critical Care Department,Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal
| | - H M Fletcher
- Critical Care Department, King's College Hospital, London, Reino Unido
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Bicarbonate use and mortality outcome among critically ill patients with metabolic acidosis: A meta analysis. Heart Lung 2019; 49:167-174. [PMID: 31733880 DOI: 10.1016/j.hrtlng.2019.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND The use of sodium bicarbonate in the treatment of metabolic acidosis in critically ill subjects has long been a subject of debate. Despite empiric use in the setting of severe acidemia in critically ill patients, there is little data looking into the role of sodium bicarbonate in the treatment of severe metabolic acidosis in the intensive care unit (ICU) setting. METHODS We conducted a comprehensive search of Pubmed and Cochrane Central Register of Controlled Trials addressing bicarbonate use in the metabolic acidosis in the intensive care unit (ICU) setting. We examined mortality as end point. Pooled odds ratios (OR) and their 95% confidence intervals (CI) were calculated for all outcomes using a random-effect model. RESULTS The final search yielded 202 articles of which all were screened individually. A total of 11 studies were identified but 6 studies were excluded due to irrelevance in mortality outcome and methodology. Analysis was done separately for observational studies and randomized controlled trials. The pooled OR [95% CI] for mortality with bicarbonate use in the observational studies was 1.5 [0.62-3.67] with heterogeneity of 67%, while pooled OR for mortality in the randomized trials was 0.72 [0.49-1.05] (figure 2). In combining all studies, the pooled odds ratio was 0.93 95% [0.69-1.25] but with heterogeneity of 63%. After sensitivity analysis with removing the study done by Kim et al. 2013, heterogeneity was 0% with OR 0.8 [0.59-1.10]. CONCLUSION There is no significant difference in mortality in the use of bicarbonate among critically ill patients with high anion gap metabolic acidosis predominantly driven by lactic acidosis.
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnostic et Prise en Charge de l’Acidose Métabolique Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) – Société française de médecine d’urgence (SFMU). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
L’acidose métabolique est un trouble fréquemment rencontré en médecine d’urgence et en médecine intensive réanimation. La littérature s’étant enrichie de nouvelles données concernant la prise en charge de l’acidose métabolique, la Société de Réanimation de Langue Française (SRLF) et la Société Française de Médecine d’Urgence (SFMU) ont élaboré des recommandations formalisées d’experts selon la méthodologie GRADE. Les champs de la stratégie diagnostique, de l’orientation et de la prise en charge thérapeutique ont été traités et vingt-neuf recommandations ont été formulées : quatre recommandations fortes (Grade 1), dix recommandations faibles (Grade 2) et quinze avis d’experts. Toutes ont obtenu un accord fort. L’application des méthodes d’Henderson-Hasselbalch et de Stewart pour le diagnostic du mécanisme de l’acidose métabolique est discutée et un algorithme diagnostique est proposé. L’utilisation de la cétonémie et des lactatémies veineuse et capillaire est également traitée. L’intérêt du pH, de la lactatémie et de sa cinétique pour l’orientation des patients en pré-hospitalier et aux urgences est envisagé. Enfin, les modalités de l’insulinothérapie au cours de l’acidocétose diabétique, les indications de la perfusion de bicarbonate de sodium et de l’épuration extra-rénale ainsi que les modalités de la ventilation mécanique au cours des acidoses métaboliques sévères sont traitées dans la prise en charge thérapeutique.
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McKenna S, Cheung A, Wolfe A, Coleman BL, Detsky ME, Munshi L, Maze D, Burry L. Clinical Interventions to Prevent Tumour Lysis Syndrome in Hematologic Malignancy: A Multisite Retrospective Chart Review. Can J Hosp Pharm 2019; 72:435-445. [PMID: 31853144 PMCID: PMC6910844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Tumour lysis syndrome (TLS) occurs when lysis of malignant cells causes electrolyte disturbances and potentially organ dysfunction. Guidelines recommending preventive therapy according to TLS risk are based on low-quality evidence. OBJECTIVES The primary objective was to characterize utilization of TLS preventive strategies through comprehensive description of current practice. Secondary objectives were to determine TLS incidence, to compare use of preventive strategies among intermediate- and high-risk patients, and to describe TLS treatment strategies. METHODS This retrospective chart review examined data for patients with newly diagnosed hematologic malignancy who were admitted to an oncology centre and/or affiliated intensive care unit between October 2015 and September 2016 in Toronto, Ontario, Canada. RESULTS Fifty-eight patients (29 at intermediate risk, 29 at high risk) were eligible for inclusion. Use of preventive allopurinol, IV bicarbonate, and furosemide was similar between groups. Rasburicase was more frequently used for high-risk patients (3% [1/29] of intermediate-risk patients versus 36% [9/25] of high-risk patients; p = 0.003). In 4 (14%) of the intermediate-risk patients and 2 (8%) of the high-risk patients, TLS developed during the admission. TLS was observed in 10% (1/10) of patients who received preventive rasburicase and 11% (5/44) of those who did not (p > 0.99), and in 9% (4/45) of patients who received preventive IV bicarbonate and 25% (2/8) of those who did not (p = 0.22). Treatment strategies included rasburicase, IV bicarbonate, furosemide, and renal replacement therapy. CONCLUSIONS In this retrospective chart review, rasburicase was more commonly used for high-risk patients, whereas the use of other agents was similar between risk groups. This pattern of use is inconsistent with guidelines, which recommend that all high-risk patients receive rasburicase. There was no difference in TLS incidence between patients who did and did not receive preventive rasburicase or IV bicarbonate. Further prospective studies are needed to inform management of patients with malignancies who are at intermediate or high risk of TLS.
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Affiliation(s)
- Sarah McKenna
- PharmD, ACPR, is with the Department of Pharmacy, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario
| | - Alexandra Cheung
- , BScPhm, PharmD, is with the Department of Pharmacy, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario
| | - Amanda Wolfe
- (formerly Amanda Jacques), BScPharm, ACPR, was, at the time this study was conducted, with the Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario. She is now with the Department of Pharmacy, Bruyère Continuing Care, Ottawa, Ontario
| | - Brenda L Coleman
- PhD, is with Infectious Disease Research, Mount Sinai Hospital, Sinai Health System, and the Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Michael E Detsky
- MD, MSHP, FRCPC, is with the Interdepartmental Division of Critical Care, University Health Network/Sinai Health System, and the Interdepartmental Division of Critical Care and Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Laveena Munshi
- MD, MSc, FRCPC, is with the Interdepartmental Division of Critical Care, University Health Network/Sinai Health System, Toronto, Ontario
| | - Dawn Maze
- MD, MSc, FRCPC, is with the Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Lisa Burry
- PharmD, is with the Department of Pharmacy, Mount Sinai Hospital, Sinai Health System, and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
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25
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Zhang Z, Mo L, Ho KM, Hong Y. Association Between the Use of Sodium Bicarbonate and Mortality in Acute Kidney Injury Using Marginal Structural Cox Model. Crit Care Med 2019; 47:1402-1408. [PMID: 31356473 DOI: 10.1097/ccm.0000000000003927] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Acute kidney injury with metabolic acidosis is common in critically ill patients. This study assessed the associations between the use of IV sodium bicarbonate and mortality of patients with acute kidney injury and acidosis. DESIGN The study was conducted by using data from Beth Israel Deaconess Medical Center, which included several ICUs such as coronary care unit, cardiac surgery recovery unit, medical ICU, surgical ICU, and trauma-neuro ICU. Marginal structural Cox model was used to assess the relationship between receipt of sodium bicarbonate and hospital mortality, allowing pH, PaCO2, creatinine, and bicarbonate concentration as time-varying predictors of sodium bicarbonate exposure while adjusting for baseline characteristics of age, gender, Sequential Organ Failure Assessment score, acute kidney injury stage, Elixhauser score, quick Sequential Organ Failure Assessment, and Simplified Acute Physiology Score II. SETTING A large U.S.-based critical care database named Medical Information Mart for Intensive Care. PATIENTS Patients with Kidney Disease: Improving Global Outcomes acute kidney injury stage greater than or equal to 1 (> 1.5 (Equation is included in full-text article.)baseline creatinine) and one measurement of acidosis (pH ≤ 7.2). Baseline creatinine was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 3,406 eligible patients, 836 (24.5%) had received sodium bicarbonate treatment. Patients who received sodium bicarbonate treatment had a higher Sequential Organ Failure Assessment (9 vs 7; p < 0.001), lower pH (7.16 vs 7.18; p < 0.001), and bicarbonate concentration (16.51 ± 7.04 vs 20.57 ± 6.29 mmol/L; p < 0.001) compared with those who did not receive sodium bicarbonate. In the marginal structural Cox model by weighing observations with inverse probability of receiving sodium bicarbonate, sodium bicarbonate treatment was not associated with mortality in the overall population (hazard ratio, 1.16; 95% CI, 0.98-1.42; p = 0.132), but it appeared to be beneficial in subgroups of pancreatitis (hazard ratio, 0.53; 95% CI, 0.28-0.98; p = 0.044) and severe acidosis (pH < 7.15; hazard ratio, 0.75; 95% CI, 0.58-0.96; p = 0.024). Furthermore, sodium bicarbonate appeared to be beneficial in patients with severe bicarbonate deficit (< -50 kg·mmol/L). CONCLUSIONS In the analysis by adjusting for potential confounders, there is no evidence that IV sodium bicarbonate is beneficial for patients with acute kidney injury and acidosis. Although the study suggested potential beneficial effects in some highly selected subgroups, the results need to be validated in experimental trials.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lei Mo
- Department of Biostatistics, Lejiu Healthcare Technology, Shanghai, China
| | - Kwok M Ho
- School of Veterinary & Life Sciences, Murdoch University, Perth, WA, Australia
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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26
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Perez Ruiz de Garibay A, Kellum JA, Honigschnabel J, Kreymann B. Respiratory and metabolic acidosis correction with the ADVanced Organ Support system. Intensive Care Med Exp 2019; 7:56. [PMID: 31535309 PMCID: PMC6751235 DOI: 10.1186/s40635-019-0269-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/09/2019] [Indexed: 01/23/2023] Open
Abstract
Background The lung, the kidney, and the liver are major regulators of acid-base balance. Acidosis due to the dysfunction of one or more organs can increase mortality, especially in critically ill patients. Supporting compensation by increasing ventilation or infusing bicarbonate is often ineffective. Therefore, direct removal of acid may represent a novel therapeutic approach. This can be achieved with the ADVanced Organ Support (ADVOS) system, an enhanced renal support therapy based on albumin dialysis. Here, we demonstrate proof of concept for this technology. Methods An ex vivo model of either hypercapnic (i.e., continuous CO2 supply) or lactic acidosis (i.e., lactic acid infusion) using porcine blood was subjected to hemodialysis with ADVOS. A variety of operational parameters including blood and dialysate flows, different dialysate pH settings, and acid and base concentrate compositions were tested. Comparisons with standard continuous veno-venous hemofiltration (CVVH) using high bicarbonate substitution fluid and continuous veno-venous hemodialysis (CVVHD) were also performed. Results Sixty-one milliliters per minute (2.7 mmol/min) of CO2 was removed using a blood flow of 400 ml/min and a dialysate pH of 10 without altering blood pCO2 and HCO3− (36 mmHg and 20 mmol/l, respectively). Up to 142 ml/min (6.3 mmol/min) of CO2 was eliminated if elevated pCO2 (117 mmHg) and HCO3− (63 mmol/l) were allowed. During continuous lactic acid infusion, an acid load of up to 3 mmol/min was compensated. When acidosis was triggered, ADVOS multi normalized pH and bicarbonate levels within 1 h, while neither CVVH nor CVVHD could. The major determinants to correct blood pH were blood flow, dialysate composition, and initial acid-base status. Conclusions In conclusion, ADVOS was able to remove more than 50% of the amount of CO2 typically produced by an adult human. Blood pH was maintained stable within the physiological range through compensation of a metabolic acid load by albumin dialysate. These in vitro results will require confirmation in patients.
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Affiliation(s)
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care 2019; 9:92. [PMID: 31418093 PMCID: PMC6695455 DOI: 10.1186/s13613-019-0563-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023] Open
Abstract
Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new data concerning the management of metabolic acidosis, the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence [SFMU]) have developed formalized recommendations from experts using the GRADE methodology. The fields of diagnostic strategy, patient assessment, and referral and therapeutic management were addressed and 29 recommendations were made: 4 recommendations were strong (Grade 1), 10 were weak (Grade 2), and 15 were experts’ opinions. A strong agreement from voting participants was obtained for all recommendations. The application of Henderson–Hasselbalch and Stewart methods for the diagnosis of the metabolic acidosis mechanism is discussed and a diagnostic algorithm is proposed. The use of ketosis and venous and capillary lactatemia is also treated. The value of pH, lactatemia, and its kinetics for the referral of patients in pre-hospital and emergency departments is considered. Finally, the modalities of insulin therapy during diabetic ketoacidosis, the indications for sodium bicarbonate infusion and extra-renal purification as well as the modalities of mechanical ventilation during severe metabolic acidosis are addressed in therapeutic management.
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Affiliation(s)
- Boris Jung
- Département de Médecine Intensive et Réanimation, CHU Montpellier, 34000, Montpellier, France. .,INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.
| | - Mikaël Martinez
- Pôle Urgence, CH du Forez, 42605, Montbrison, France.,Réseau d'urgence Ligérien Ardèche Nord (REULIAN), Centre Hospitalier Le Corbusier, 42700, Firminy, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse-Grace, Avenue Pasteur, 98012, Monaco, France
| | - Michaël Darmon
- Unité de Médecine Intensive et Réanimation, Hôpital Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Avenue Claude-Vellefaux, 75010, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,France Inserm, ECSTRA Team, UMR 1153, Centre d'Epidémiologie et de Biostatistique, CRESS, Biostatistics and Clinical Epidemiology, Sorbonne-Paris-Cité, Paris, France
| | - Kada Klouche
- INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.,Département de Médecine Intensive-Réanimation, CHU Lapeyronie, 371, Avenue Doyen-Gaston-Giraud, 34295, Montpellier, France
| | - Alexandre Lautrette
- Réanimation, Centre Jean-Perrin, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France.,LMGE, UMR CNRS 6023, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Jacques Levraut
- Département de Médecine d'urgence, CHU de Nice, Hôpital Pasteur-II, 30, Avenue de la Voie Romaine, 06000, Nice, France.,UFR de Médecine, Université de Nice Côte d'Azur, Avenue de Vallombrose, 06000, Nice, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris-VI, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Mathieu Oberlin
- Structure des Urgences, Centre Hospitalier de Cahors, 335, Rue Wilson, 46000, Cahors, France
| | - Nicolas Terzi
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Grenoble, Université de Grenoble, Grenoble, France.,Inserm, U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
| | - Damien Viglino
- Service des Urgences Adultes, CS 10217, CHU Grenoble-Alpes, 38043 Grenoble Cedex 09, Grenoble, France.,Inserm U1042, Laboratoire HP2 Hypoxie-Physiopathologies, Université Grenoble-Alpes, Grenoble, France
| | - Youri Yordanov
- Faculté de Médecine, Sorbonne Universités, 75013, Paris, France.,Inserm, U1153, Université Paris-Descartes, 75006, Paris, France.,Service des Urgences, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Pierre-Géraud Claret
- Pôle Anesthésie Réanimation Douleur Urgences, Centre Hospitalier Universitaire de Nîmes, 4, Rue du Professeur-Robert-Debré, 30029, Nîmes, France
| | - Naïke Bigé
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France
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Kraut JA, Madias NE. Intravenous Sodium Bicarbonate in Treating Patients With Severe Metabolic Acidemia. Am J Kidney Dis 2019; 73:572-575. [DOI: 10.1053/j.ajkd.2018.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/10/2018] [Indexed: 11/11/2022]
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29
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Ghauri SK, Javaeed A, Mustafa KJ, Podlasek A, Khan AS. Bicarbonate Therapy for Critically Ill Patients with Metabolic Acidosis: A Systematic Review. Cureus 2019; 11:e4297. [PMID: 31183278 PMCID: PMC6538112 DOI: 10.7759/cureus.4297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/21/2019] [Indexed: 11/09/2022] Open
Abstract
The management of acid-base disorders always calls for precise diagnosis and treatment of the underlying disease. Sometimes additional means are necessary to combat systemic acidity itself. In this systematic review, we discuss the concept and some specific aspects of bicarbonate therapy for critically ill patients with metabolic acidosis (i.e., patients with blood pH < 7.35). We conducted a systematic literature review of three online databases (PubMed, Google Scholar, and Cochrane) in November 2018 to validate usage of bicarbonate therapy for critically ill patients with metabolic acidosis. Twelve trials and case series were included in the final analysis, from which we assessed population, intervention, comparison, and outcome data. The current literature suggests limited benefit from bicarbonate therapy for patients with severe metabolic acidosis (pH < 7.1 and bicarbonate < 6 mEq/L). However, bicarbonate therapy does yield improvement in survival for patients with accompanying acute kidney injury.
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Affiliation(s)
| | | | | | - Anna Podlasek
- Emergency Medicine, Medical University of Lodz, Lodz, POL
| | - Abdus Salam Khan
- Emergency Medicine, Shifa International Hospital, Islamabad, PAK
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30
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Zhang Z, Zhu C, Mo L, Hong Y. Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis. Intensive Care Med 2018; 44:1888-1895. [PMID: 30255318 DOI: 10.1007/s00134-018-5379-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/15/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Although sodium bicarbonate (SB) solution has been widely used in clinical practice, its effect on mortality when administered to a large population of patients with acidosis is not known. The study aimed to investigate the effectiveness of SB infusion in septic patients with metabolic acidosis. METHODS Septic patients with metabolic acidosis were identified from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score (PS) was used to account for the baseline differences in the probability to receive SB or not. The marginal structural Cox model (MSCM) was employed to adjust for both baseline and time-varying confounding factors. MAIN RESULTS A total of 1718 septic patients with metabolic acidosis were enrolled in the study, including 500 in the SB group and 1218 in the non-SB group. Both pH [7.16 (standard deviation (SD): 0.10) vs. 7.22 (SD: 0.07); p < 0.001] and bicarbonate concentration (BC) [11.84 (SD: 3.63) vs. 14.88 (SD: 3.36) mmol/l; p < 0.001] were significantly lower in the SB than that in the non-SB group. While there was no significant mortality effect in the overall population [hazard ratio (HR): 1.04; 95% CI 0.86-1.26; p = 0.67], SB was observed to be beneficial in patients with acute kidney injury (AKI) stage 2 or 3 and pH < 7.2 (HR 0.74; 95% CI 0.51-0.86; p = 0.021). Similar results were replicated with the MSCM. CONCLUSION Our study observed that SB infusion was not associated with improved outcome in septic patients with metabolic acidosis, but it was associated with improved survival in septic patients with AKI stage 2 or 3 and severe acidosis. The results need to be verified in randomized controlled trials.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3, East Qingchun Road, 310016, Hangzhou, Zhejiang, China.
| | - Carlie Zhu
- Department of Clinical Statistics, 3M China Research and Development Center, Shanghai, China
| | - Lei Mo
- Department of Biostatistics, Lejiu Healthcare Technology Co., Ltd, Shanghai, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3, East Qingchun Road, 310016, Hangzhou, Zhejiang, China
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31
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Rosenstein PG, Tennent-Brown BS, Hughes D. Clinical use of plasma lactate concentration. Part 2: Prognostic and diagnostic utility and the clinical management of hyperlactatemia. J Vet Emerg Crit Care (San Antonio) 2018. [PMID: 29533517 DOI: 10.1111/vec.12706] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To review the current literature pertaining to the use of lactate as a prognostic indicator and therapeutic guide, the utility of measuring lactate concentrations in body fluids other than blood or plasma, and the clinical management of hyperlactatemia in dogs, cats, and horses. DATA SOURCES Articles were retrieved without date restrictions primarily via PubMed, Scopus, and CAB Abstracts as well as by manual selection. HUMAN AND VETERINARY DATA SYNTHESIS Increased plasma lactate concentrations are associated with increased morbidity and mortality. In populations with high mortality, hyperlactatemia is moderately predictive in identifying nonsurvivors. Importantly, eulactatemia predicts survival better than hyperlactatemia predicts death. Consecutive lactate measurements and calculated relative measures appear to outperform single measurements. The use of lactate as a therapeutic guide has shown promising results in people but is relatively uninvestigated in veterinary species. Increased lactate concentrations in body fluids other than blood should raise the index of suspicion for septic or malignant processes. Management of hyperlactatemia should target the underlying cause. CONCLUSION Lactate is a valuable triage and risk stratification tool that can be used to separate patients into higher and lower risk categories. The utility of lactate concentration as a therapeutic target and the measurement of lactate in body fluids shows promise but requires further research.
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Affiliation(s)
- Patricia G Rosenstein
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
| | - Brett S Tennent-Brown
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
| | - Dez Hughes
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
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32
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Jaber S, Paugam C, Futier E, Lefrant JY, Lasocki S, Lescot T, Pottecher J, Demoule A, Ferrandière M, Asehnoune K, Dellamonica J, Velly L, Abback PS, de Jong A, Brunot V, Belafia F, Roquilly A, Chanques G, Muller L, Constantin JM, Bertet H, Klouche K, Molinari N, Jung B. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet 2018; 392:31-40. [PMID: 29910040 DOI: 10.1016/s0140-6736(18)31080-8] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/08/2018] [Accepted: 05/08/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute acidaemia is frequently observed during critical illness. Sodium bicarbonate infusion for the treatment of severe metabolic acidaemia is a possible treatment option but remains controversial, as no studies to date have examined its effect on clinical outcomes. Therefore, we aimed to evaluate whether sodium bicarbonate infusion would improve these outcomes in critically ill patients. METHODS We did a multicentre, open-label, randomised controlled, phase 3 trial. Local investigators screened eligible patients from 26 intensive care units (ICUs) in France. We included adult patients (aged ≥18 years) who were admitted within 48 h to the ICU with severe acidaemia (pH ≤7·20, PaCO2 ≤45 mm Hg, and sodium bicarbonate concentration ≤20 mmol/L) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. We randomly assigned patients (1:1), by stratified randomisation with minimisation via a restricted web platform, to receive either no sodium bicarbonate (control group) or 4·2% of intravenous sodium bicarbonate infusion (bicarbonate group) to maintain the arterial pH above 7·30. Our protocol recommended that the volume of each infusion should be within the range of 125-250 mL in 30 min, with a maximum of 1000 mL within 24 h after inclusion. Randomisation criteria were stratified among three prespecified strata: age, sepsis status, and the Acute Kidney Injury Network (AKIN) score. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. All analyses were done on data from the intention-to-treat population, which included all patients who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02476253. FINDINGS Between May 5, 2015, and May 7, 2017, we enrolled 389 patients into the intention-to-treat analysis in the overall population (194 in the control group and 195 in the bicarbonate group). The primary outcome occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (absolute difference estimate -5·5%, 95% CI -15·2 to 4·2; p=0·24). The Kaplan-Meier method estimate of the probability of survival at day 28 between the control group and bicarbonate group was not significant (46% [95% CI 40-54] vs 55% [49-63]; p=0·09. In the prespecified AKIN stratum of patients with a score of 2 or 3, the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significant (37% [95% CI 28-48] vs 54% [45-65]; p=0·0283). [corrected] Metabolic alkalosis, hypernatraemia, and hypocalcaemia were observed more frequently in the bicarbonate group than in the control group, with no life-threatening complications reported. INTERPRETATION In patients with severe metabolic acidaemia, sodium bicarbonate had no effect on the primary composite outcome. However, sodium bicarbonate decreased the primary composite outcome and day 28 mortality in the a-priori defined stratum of patients with acute kidney injury. FUNDING French Ministry of Health and the Société Française d'Anesthésie Réanimation.
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Affiliation(s)
- Samir Jaber
- Saint Eloi ICU, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France.
| | - Catherine Paugam
- AP-HP, Département Anesthésie et Réanimation, Hôpital Beaujon, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Emmanuel Futier
- CHU de Clermont-Ferrand, Department of Perioperative Medicine, GReD, UMR/CNRS6293, University Clermont Auvergne, INSERM U1103, Clermont-Ferrand, France
| | - Jean-Yves Lefrant
- CHU de Nîmes, Département Anesthésie et Réanimation, University of Montpellier-Nîmes, Nîmes, France
| | | | - Thomas Lescot
- AP-HP, Département Anesthésie et Réanimation, Hôpital Saint Antoine, Paris, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Service d'Anesthésie-Réanimation Chirurgicale-Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Alexandre Demoule
- Service de Pneumologie, Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale du Département R3S, Paris, France
| | | | - Karim Asehnoune
- CHU de Nantes, Département Anesthésie et Réanimation Chirurgicale, Nantes, France
| | - Jean Dellamonica
- CHU de Nice, Département de Réanimation Médicale, INSERM-C3M-Université Cote d'Azur, Nice, France
| | - Lionel Velly
- Aix-Marseille Université, AP-HM, Département Anesthésie et Réanimation Chirurgicale, Groupe Hospitalier Timone, UMR 7289, CNRS, Marseille, France
| | - Paër-Sélim Abback
- AP-HP, Département Anesthésie et Réanimation, Hôpital Beaujon, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Audrey de Jong
- Saint Eloi ICU, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Vincent Brunot
- Département de Médecine Intensive et Réanimation, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Fouad Belafia
- Saint Eloi ICU, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Antoine Roquilly
- CHU de Nantes, Département Anesthésie et Réanimation Chirurgicale, Nantes, France
| | - Gérald Chanques
- Saint Eloi ICU, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Laurent Muller
- CHU de Nîmes, Département Anesthésie et Réanimation, University of Montpellier-Nîmes, Nîmes, France
| | - Jean-Michel Constantin
- CHU de Clermont-Ferrand, Department of Perioperative Medicine, GReD, UMR/CNRS6293, University Clermont Auvergne, INSERM U1103, Clermont-Ferrand, France
| | - Helena Bertet
- CHU de Montpellier, Department of Statistics, Montpellier University, Montpellier, France
| | - Kada Klouche
- Département de Médecine Intensive et Réanimation, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Nicolas Molinari
- CHU de Montpellier, Department of Statistics, Montpellier University, Montpellier, France
| | - Boris Jung
- Département de Médecine Intensive et Réanimation, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
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Affiliation(s)
- Jeffrey A Kraut
- Medical and Research Services and Division of Nephrology, VA Greater Los Angeles Healthcare System, UCLA Membrane Biology Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073, USA.
| | - Nicolaos E Madias
- Department of Medicine, Division of Nephrology, St Elizabeth's Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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34
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Samanta S, Singh RK, Baronia AK, Mishra P, Poddar B, Azim A, Gurjar M. Early pH Change Predicts Intensive Care Unit Mortality. Indian J Crit Care Med 2018; 22:697-705. [PMID: 30405279 PMCID: PMC6201653 DOI: 10.4103/ijccm.ijccm_129_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Aim of the Study: Metabolic acidosis is associated with increased mortality in critically ill patients. We hypothesized that early correction of acidosis of presumed metabolic origin results in improved outcomes. Patients and Methods: We conducted a prospective, observational study from February 2015 to June 2016 in a 12 bed mixed intensive care unit (ICU) of a 1000 bed tertiary care hospital in the north of India. ICU patients aged above 18 years with an admission pH ≥7.0 to <7.35 of presumed metabolic origin were included. Arterial blood gas parameters including pH, PaO2, PaCO2, HCO3−, Na+, K+, Cl−, anion gap (AG), base excess, and lactate at 0, 6, and 24 h along with other standard laboratory investigations were recorded. The primary outcome was to assess the impact of early pH changes on mortality at day 28 of ICU. Results: A total of 104 patients with 60.6% males and 91.3% medical patients were included in the study. Sepsis of lung origin (60.6%) was the predominant etiology. By day 28, 68 (65.4%) patients had died. Median age was 49.5 years, weight 61.7 kg, Sequential Organ Failure Assessment, and Acute Physiologic and Chronic Health Evaluation II scores were 16 and 12, respectively. Nonsurvivors had a higher vasopressor index (P < 0.01), lactate and central venous oxygen saturation (P < 0.05), and lower pH (P < 0.05). A pH correction/change of ≥1.16% during the first 24 h had the best receiver operating characteristic for predicting survival at day 28, with area under the curve (95% confidence interval, 0.72 [0.62–0.82], P < 0.05) compared to HCO3-, BE, lactate, and AG. Conclusions: Metabolic acidosis is associated with higher mortality in ICU. The rate of change in pH may better predict ICU mortality than other metabolic indices.
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Affiliation(s)
- Sujay Samanta
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ratender Kumar Singh
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arvind K Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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van der Mijn JC, Kuiper MJ, Siegert CEH, Wassenaar AE, van Noesel CJM, Ogilvie AC. Lactic Acidosis in Prostate Cancer: Consider the Warburg Effect. Case Rep Oncol 2017. [PMID: 29515400 PMCID: PMC5836159 DOI: 10.1159/000485242] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Lactic acidosis is a commonly observed clinical condition that is associated with a poor prognosis, especially in malignancies. We describe a case of an 81-year-old patient who presented with symptoms of tachypnea and general discomfort. Arterial blood gas analysis showed a high anion gap acidosis with a lactate level of 9.5 mmol/L with respiratory compensation. CT scanning showed no signs of pulmonary embolism or other causes of impaired tissue oxygenation. Despite treatment with sodium bicarbonate, the patient developed an adrenalin-resistant cardiac arrest, most likely caused by the acidosis. Autopsy revealed Gleason score 5 + 5 metastatic prostate cancer as the most probable cause of the lactic acidosis. Next-generation sequencing indicated a nonsense mutation in the TP53 gene (887delA) and an activating mutation in the PIK3CA gene (1634A>G) as candidate molecular drivers. This case demonstrates the prevalence and clinical relevance of metabolic reprogramming, frequently referred to as "the Warburg effect," in patients with prostate cancer.
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Affiliation(s)
- Johannes C van der Mijn
- Department of Internal Medicine, OLVG West Amsterdam, Amsterdam, The Netherlands.,Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Mathijs J Kuiper
- Department of Internal Medicine, OLVG West Amsterdam, Amsterdam, The Netherlands
| | - Carl E H Siegert
- Department of Internal Medicine, OLVG West Amsterdam, Amsterdam, The Netherlands
| | | | | | - Aernout C Ogilvie
- Department of Internal Medicine, OLVG West Amsterdam, Amsterdam, The Netherlands
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Clinical signs, profound acidemia, hypoglycemia, and hypernatremia are predictive of mortality in 1,400 critically ill neonatal calves with diarrhea. PLoS One 2017; 12:e0182938. [PMID: 28817693 PMCID: PMC5560544 DOI: 10.1371/journal.pone.0182938] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/26/2017] [Indexed: 01/09/2023] Open
Abstract
Profound acidemia impairs cellular and organ function and consequently should be associated with an increased risk of mortality in critically ill humans and animals. Neonatal diarrhea in calves can result in potentially serious metabolic derangements including profound acidemia due to strong ion (metabolic) acidosis, hyper-D-lactatemia, hyper-L-lactatemia, azotemia, hypoglycemia, hyperkalemia and hyponatremia. The aim of this retrospective study was to assess the prognostic relevance of clinical and laboratory findings in 1,400 critically ill neonatal calves with diarrhea admitted to a veterinary teaching hospital. The mortality rate was 22%. Classification tree analysis indicated that mortality was associated with clinical signs of neurologic disease, abdominal emergencies, cachexia, orthopedic problems such as septic arthritis, and profound acidemia (jugular venous blood pH < 6.85). When exclusively considering laboratory parameters, classification tree analysis identified plasma glucose concentrations < 3.2 mmol/L, plasma sodium concentrations ≥ 151 mmol/L, serum GGT activity < 31 U/L and a thrombocyte count < 535 G/L as predictors of mortality. However, multivariable logistic regression models based on these laboratory parameters did not have a sufficiently high enough sensitivity (59%) and specificity (79%) to reliably predict treatment outcome. The sensitivity and specificity of jugular venous blood pH < 6.85 were 11% and 97%, respectively, for predicting non-survival in this study population. We conclude that laboratory values (except jugular venous blood pH < 6.85) are of limited value for predicting outcome in critically ill neonatal calves with diarrhea. In contrast, the presence of specific clinical abnormalities provides valuable prognostic information.
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Kim EB, Kim KS, Lee SM, Son YK, Kim SE, An WS. A Case of Lactate Containing Peritoneal Dialysis Solution Induced Lactic Acidosis Corrected by Changing to Hemodialysis. KOSIN MEDICAL JOURNAL 2017. [DOI: 10.7180/kmj.2017.32.1.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Elevated lactate levels are associated with acute illnesses, and the mortality is high. Here, we report a case of lactate-containing peritoneal dialysis (PD) solution inducing lactic acidosis corrected by changing to hemodialysis (HD). This 70-year-old female patient was treated with PD 8 months previously for end-stage renal disease caused by diabetes mellitus. She was admitted complaining of general weakness. Initial lactate level was 22.1 mg/dL and increased to 62.4 mg/dL showing high anion gap metabolic acidosis and compensatory hyperventilation. There are no definite causes of lactic acidosis besides the use of PD solutions containing a lactate component. The patient's lactate level was decreased after temporarily changing the dialysis modality to HD. Her lactate level was increased again after restarting PD, and decreased to normal after restarting HD. We report this case because physicians should consider lactate-containing PD solution as a possible cause of lactic acidosis.
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Vitin AA, Azamfirei L, Tomescu D, Lang JD. Perioperative Management of Lactic Acidosis in End-Stage Liver Disease Patient. ACTA ACUST UNITED AC 2017; 3:55-62. [PMID: 29967872 PMCID: PMC5769918 DOI: 10.1515/jccm-2017-0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/28/2017] [Indexed: 12/13/2022]
Abstract
Lactic acidosis (LA) in end-stage liver disease (ESLD) patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.
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Affiliation(s)
- Alexander A Vitin
- Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA
| | - Leonard Azamfirei
- University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Dana Tomescu
- "Carol Davila" University of Medicine and Pharmacy, Anesthesiology and Intensive Care Department 3, Fundeni Clinical Institute, Bucharest, Romania
| | - John D Lang
- Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA
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Affiliation(s)
- Myra F Ellis
- Myra F. Ellis is a clinical nurse in the cardiothoracic intensive care unit at Duke University Hospital in Durham, North Carolina.
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Abstract
Despite concerns about the negative effects of metabolic acidosis, there is minimal evidence that sodium bicarbonate administration is an effective treatment. In addition, sodium bicarbonate therapy is associated with many adverse effects, including paradoxic intracellular acidosis, hypokalemia, hypocalcemia, hypernatremia, and hyperosmolality. Definitive recommendations regarding bicarbonate therapy are challenging as there is little high-quality evidence available. In most clinical scenarios of metabolic acidosis, treatment efforts should focus on resolution of the underlying cause, and sodium bicarbonate therapy should be used with caution, if at all. An exception to this is kidney disease, wherein sodium bicarbonate therapy may have a valuable role.
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Affiliation(s)
- Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, University of California, Davis, Room 2112, Tupper Hall, Davis, CA 95616, USA.
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41
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Kraut JA, Madias NE. Lactic Acidosis: Current Treatments and Future Directions. Am J Kidney Dis 2016; 68:473-82. [DOI: 10.1053/j.ajkd.2016.04.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/01/2016] [Indexed: 11/11/2022]
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Abstract
Lactic acidosis is the most common metabolic acidosis in hospitalized patients-the result from an underlying pathogenic process. To successfully manage lactic acid production, its cause needs to be eliminated. Patients with cancer have many risk factors for developing lactic acidosis, including the cancer diagnosis itself. Patients with lactic acidosis are critically ill, requiring an intense level of nursing care with accompanying frequent cardiopulmonary and renal assessments. The mortality rate from lactic acidosis is high. Therefore, appropriate nursing interventions may include end-of-life and palliative care.
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Lee SM, An WS. New clinical criteria for septic shock: serum lactate level as new emerging vital sign. J Thorac Dis 2016; 8:1388-90. [PMID: 27501243 DOI: 10.21037/jtd.2016.05.55] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Su Mi Lee
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University, Busan, Korea
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Lee SM, Kim SE, Kim EB, Jeong HJ, Son YK, An WS. Lactate Clearance and Vasopressor Seem to Be Predictors for Mortality in Severe Sepsis Patients with Lactic Acidosis Supplementing Sodium Bicarbonate: A Retrospective Analysis. PLoS One 2015; 10:e0145181. [PMID: 26692209 PMCID: PMC4686961 DOI: 10.1371/journal.pone.0145181] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/30/2015] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Initial lactate level, lactate clearance, C-reactive protein, and procalcitonin in critically ill patients with sepsis are associated with hospital mortality. However, no study has yet discovered which factor is most important for mortality in severe sepsis patients with lactic acidosis. We sought to clarify this issue in patients with lactic acidosis who were supplementing with sodium bicarbonate. MATERIALS AND METHODS Data were collected from a single center between May 2011 and April 2014. One hundred nine patients with severe sepsis and lactic acidosis who were supplementing with sodium bicarbonate were included. RESULTS The 7-day mortality rate was 71.6%. The survivors had higher albumin levels and lower SOFA, APACHE II scores, vasopressor use, and follow-up lactate levels at an elapsed time after their initial lactate levels were checked. In particular, a decrement in lactate clearance of at least 10% for the first 6 hours, 24 hours, and 48 hours of treatment was more dominant among survivors than non-survivors. Although the patients who were treated with broad-spectrum antibiotics showed higher illness severity than those who received conventional antibiotics, there was no significant mortality difference. 6-hour, 24-hour, and 48-hour lactate clearance (HR: 4.000, 95% CI: 1.309-12.219, P = 0.015) and vasopressor use (HR: 4.156, 95% CI: 1.461-11.824, P = 0.008) were significantly associated with mortality after adjusting for confounding variables. CONCLUSIONS Lactate clearance at a discrete time point seems to be a more reliable prognostic index than initial lactate value in severe sepsis patients with lactic acidosis who were supplementing with sodium bicarbonate. Careful consideration of vasopressor use and the initial application of broad-spectrum antibiotics within the first 48 hours may be helpful for improving survival, and further study is warranted.
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Affiliation(s)
- Su Mi Lee
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Seong Eun Kim
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Eun Bin Kim
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Hyo Jin Jeong
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Young Ki Son
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University, Busan, Korea
- Institute of Medical Science, Dong-A University College of Medicine, Busan, Korea
- * E-mail:
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Tischner C, Wenz T. Keep the fire burning: Current avenues in the quest of treating mitochondrial disorders. Mitochondrion 2015; 24:32-49. [DOI: 10.1016/j.mito.2015.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/18/2015] [Accepted: 06/24/2015] [Indexed: 12/18/2022]
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The Use of Sodium Bicarbonate in the Treatment of Acidosis in Sepsis: A Literature Update on a Long Term Debate. Crit Care Res Pract 2015; 2015:605830. [PMID: 26294968 PMCID: PMC4534594 DOI: 10.1155/2015/605830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 06/29/2015] [Accepted: 07/01/2015] [Indexed: 12/29/2022] Open
Abstract
Introduction. Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods. We conducted a PubMed literature search in order to identify published literature related to the effects of sodium bicarbonate treatment on metabolic acidosis due to sepsis. The search included all articles published in English in the last 35 years. Results. There is ongoing debate regarding the use of bicarbonates for the treatment of acidosis in sepsis, but there is a trend towards not using bicarbonate in sepsis patients with arterial blood gas pH > 7.15. Conclusions. Routine use of bicarbonate for treatment of severe acidemia and lactic acidosis due to sepsis is subject of controversy, and current opinion does not favor routine use of bicarbonates. However, available evidence is inconclusive, and more studies are required to determine the potential benefit, if any, of bicarbonate therapy in the sepsis patient with acidosis.
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Orientation diagnostique et conduite à tenir devant une acidose métabolique. Arch Pediatr 2015; 22:52-3. [DOI: 10.1016/s0929-693x(15)30027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kimmoun A, Novy E, Auchet T, Ducrocq N, Levy B. Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:175. [PMID: 25887061 PMCID: PMC4391479 DOI: 10.1186/s13054-015-0896-7] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Lactic acidosis is a very common biological issue for shock patients. Experimental data clearly demonstrate that metabolic acidosis, including lactic acidosis, participates in the reduction of cardiac contractility and in the vascular hyporesponsiveness to vasopressors through various mechanisms. However, the contributions of each mechanism responsible for these deleterious effects have not been fully determined and their respective consequences on organ failure are still poorly defined, particularly in humans. Despite some convincing experimental data, no clinical trial has established the level at which pH becomes deleterious for hemodynamics. Consequently, the essential treatment for lactic acidosis in shock patients is to correct the cause. It is unknown, however, whether symptomatic pH correction is beneficial in shock patients. The latest Surviving Sepsis Campaign guidelines recommend against the use of buffer therapy with pH ≥7.15 and issue no recommendation for pH levels <7.15. Furthermore, based on strong experimental and clinical evidence, sodium bicarbonate infusion alone is not recommended for restoring pH. Indeed, bicarbonate induces carbon dioxide generation and hypocalcemia, both cardiovascular depressant factors. This review addresses the principal hemodynamic consequences of shock-associated lactic acidosis. Despite the lack of formal evidence, this review also highlights the various adapted supportive therapy options that could be putatively added to causal treatment in attempting to reverse the hemodynamic consequences of shock-associated lactic acidosis.
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Affiliation(s)
- Antoine Kimmoun
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France. .,Université de Lorraine, Nancy, 54000, France. .,INSERM U1116, Groupe Choc, Faculté de Médecine, Vandoeuvre-les-Nancy, 54511, France.
| | - Emmanuel Novy
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France. .,Université de Lorraine, Nancy, 54000, France.
| | - Thomas Auchet
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France.
| | - Nicolas Ducrocq
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France.
| | - Bruno Levy
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital de Brabois, Vandoeuvre-les-Nancy, 54511, France. .,Université de Lorraine, Nancy, 54000, France. .,INSERM U1116, Groupe Choc, Faculté de Médecine, Vandoeuvre-les-Nancy, 54511, France.
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Yu W, Hu S, Xie ZY, He ZJ, Luo HM, Lin HY, Zhou FQ, Sheng ZY. Pyruvate oral rehydration solution improved visceral function and survival in shock rats. J Surg Res 2015; 193:344-54. [DOI: 10.1016/j.jss.2014.06.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/16/2014] [Accepted: 06/19/2014] [Indexed: 10/25/2022]
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50
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Zou Y, Liu J, Liao Y, Pei W, Kong G. Temporary hyperlactataemia during partial hepatectomy: Report of two cases. Int J Surg Case Rep 2014; 6C:285-8. [PMID: 25560056 PMCID: PMC4347905 DOI: 10.1016/j.ijscr.2014.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 09/15/2014] [Accepted: 09/18/2014] [Indexed: 11/20/2022] Open
Abstract
Lactic acidosis (LA) is characterized by accumulation of lactate in the body, and it may detrimentally affect homeostasis. Perioperative LA is rarely seen, here we presented 2 cases of patients suffered with temporary hyperlactataemia during partial hepatectomy, intended to emphasize that prolonged hypovolemia condition caused by controlled low central venous pressure, and overused hepatic vascular occlusion technique during parenchymal resection of hepatic surgery may seriously impact on the internal environment of patients. And we also discussed how to well manage long-time hepatectomy to prevent LA from occurring and to treat it appropriately.
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Affiliation(s)
- Yi Zou
- Department of Anesthesiology, Hunan Provincial People's Hospital, Jiefang West Road No. 61, Changsha City, Hunan Province, PR China
| | - Jitong Liu
- Department of Anesthesiology, Hunan Provincial People's Hospital, Jiefang West Road No. 61, Changsha City, Hunan Province, PR China
| | - Yongqiong Liao
- Department of Anesthesiology, Hunan Provincial People's Hospital, Jiefang West Road No. 61, Changsha City, Hunan Province, PR China
| | - Wanmin Pei
- Department of Anesthesiology, Hunan Provincial People's Hospital, Jiefang West Road No. 61, Changsha City, Hunan Province, PR China
| | - Gaoyin Kong
- Department of Anesthesiology, Hunan Provincial People's Hospital, Jiefang West Road No. 61, Changsha City, Hunan Province, PR China.
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