Electrolyte imbalances in an unselected population in an emergency department: A retrospective cohort study

Beneficial Effect of Calcium Treatment for Hyperkalemia Is Not Due to "Membrane Stabilization"

OBJECTIVES

Hyperkalemia is a common life-threatening condition causing severe electrophysiologic derangements and arrhythmias. The beneficial effects of calcium (Ca2+) treatment for hyperkalemia have been attributed to "membrane stabilization," by restoration of resting membrane potential (RMP). However, the underlying mechanisms remain poorly understood. Our objective was to investigate the mechanisms underlying adverse electrophysiologic effects of hyperkalemia and the therapeutic effects of Ca2+ treatment.

DESIGN

Controlled experimental trial.

SETTING

Laboratory investigation.

SUBJECTS

Canine myocytes and tissue preparations.

INTERVENTIONS AND MEASUREMENTS

Optical action potentials and volume averaged electrocardiograms were recorded from the transmural wall of ventricular wedge preparations (n = 7) at baseline (4 mM potassium), hyperkalemia (8-12 mM), and hyperkalemia + Ca2+ (3.6 mM). Isolated myocytes were studied during hyperkalemia (8 mM) and after Ca2+ treatment (6 mM) to determine cellular RMP.

MAIN RESULTS

Hyperkalemia markedly slowed conduction velocity (CV, by 67% ± 7%; p < 0.001) and homogeneously shortened action potential duration (APD, by 20% ± 10%; p < 0.002). In all preparations, this resulted in QRS widening and the "sine wave" pattern observed in severe hyperkalemia. Ca2+ treatment restored CV (increase by 44% ± 18%; p < 0.02), resulting in narrowing of the QRS and normalization of the electrocardiogram, but did not restore APD. RMP was significantly elevated by hyperkalemia; however, it was not restored with Ca2+ treatment suggesting a mechanism unrelated to "membrane stabilization." In addition, the effect of Ca2+ was attenuated during L-type Ca2+ channel blockade, suggesting a mechanism related to Ca2+-dependent (rather than normally sodium-dependent) conduction.

CONCLUSIONS

These data suggest that Ca2+ treatment for hyperkalemia restores conduction through Ca2+-dependent propagation, rather than restoration of membrane potential or "membrane stabilization." Our findings provide a mechanistic rationale for Ca2+ treatment when hyperkalemia produces abnormalities of conduction (i.e., QRS prolongation).

The influence of undetected hemolysis on POCT potassium results in the emergency department

OBJECTIVES

This study aimed to evaluate discrepancies in potassium measurements between point-of-care testing (POCT) and central laboratory (CL) methods, focusing on the impact of hemolysis on these measurements and its impact in the clinical practice in the emergency department (ED).

METHODS

A retrospective analysis was conducted using data from three European university hospitals: Technische Universitat Munchen (Germany), Hospital Universitario La Paz (Spain), and Erasmus University Medical Center (The Netherlands). The study compared POCT potassium measurements in EDs with CL measurements. Data normalization was performed in categories for potassium levels (kalemia) and hemolysis. The severity of discrepancies between POCT and CL potassium measurements was assessed using the reference change value (RCV).

RESULTS

The study identified significant discrepancies in potassium between POCT and CL methods. In comparing POCT normo- and mild hypokalemia against CL results, differences of -4.20 % and +4.88 % were noted respectively. The largest variance in the CL was a +4.14 % difference in the mild hyperkalemia category. Additionally, the RCV was calculated to quantify the severity of discrepancies between paired potassium measurements from POCT and CL methods. The overall hemolysis characteristics, as defined by the hemolysis gradient, showed considerable variation between the testing sites, significantly affecting the reliability of potassium measurements in POCT.

CONCLUSIONS

The study highlighted the challenges in achieving consistent potassium measurement results between POCT and CL methods, particularly in the presence of hemolysis. It emphasised the need for integrated hemolysis detection systems in future blood gas analysis devices to minimise discrepancies and ensure accurate POCT results.

Association between hypomagnesemia and serum lactate levels in patients with sepsis: a retrospective observational study

BACKGROUND

Sepsis-3 emphasizes the recognition of sepsis-induced cellular metabolic abnormalities, and utilizes serum lactate level as a biomarker of cellular metabolic abnormalities. Magnesium plays an important role as a cofactor in glucose metabolism, although it is not well known that magnesium deficiency causes elevated serum lactate levels. Additionally, it remains unclear how magnesium status affects the role of serum lactate levels as a marker of metabolic abnormalities in sepsis. Thus, this study aimed to investigate the association between serum magnesium and lactate levels in patients with sepsis and explore this relationship from the perspectives of time course and circulatory abnormalities.

METHODS

This retrospective observational study of adult patients with sepsis was performed at the 16-bed intensive care unit of Jichi Medical University Hospital between June 2011 and December 2017. The relationship between serum magnesium and lactate levels for 5 days from intensive care unit admission was investigated along the time course. Multivariate logistic regression analysis was performed to evaluate the association between serum magnesium and lactate levels during intensive care unit admission.

RESULTS

Among 759 patients included, 105 had hypomagnesemia (magnesium level < 1.6 mg/dL), 558 had normal serum magnesium levels (1.6-2.4 mg/dL), and 96 had hypermagnesemia (magnesium level > 2.4 mg/dL) at intensive care unit admission. From intensive care unit admission to day 5, the hypomagnesemia group had higher serum lactate levels and a higher frequency of lactic acidosis than the normal magnesium level and hypermagnesemia groups (70% vs. 51.6% vs. 50%; P < 0.001). Hypomagnesemia at intensive care unit admission was independently associated with lactic acidosis, i.e., lactic acid level > 2 mmol/L (odds ratio, 2.76; 95% confidence interval, 1.60-4.76; P < 0.001).

CONCLUSIONS

Hypomagnesemia was associated with serum lactate levels in the early and post-resuscitation phases of sepsis. Further studies are needed to elucidate whether the magnesium status is associated with sepsis-induced cellular and metabolic abnormalities.

An Evaluation of the National Early Warning Score 2 and the Laboratory Data Decision Tree Early Warning Score in Predicting Mortality in Geriatric Patients

BACKGROUND

Due to the high rate of geriatric patient visits, scoring systems are needed to predict increasing mortality rates.

OBJECTIVE

In this study, we aimed to investigate the in-hospital mortality prediction power of the National Early Warning Score 2 (NEWS2) and the Laboratory Data Decision Tree Early Warning Score (LDT-EWS), which consists of frequently performed laboratory parameters.

METHODS

We retrospectively analyzed 651 geriatric patients who visited the emergency department (ED), were not discharged on the same day from ED, and were hospitalized. The patients were categorized according to their in-hospital mortality status. The NEWS2 and LDT-EWS values of these patients were calculated and compared on the basis of deceased and living patients.

RESULTS

Median (interquartile range [IQR]) NEWS2 and LDT-EWS values of the 127 patients who died were found to be statistically significantly higher than those of the patients who survived (NEWS2: 5 [3-8] vs. 3 [1-5]; p < 0.001; LDT-EWS: 8 [7-10] vs. 6 [5-8]; p < 0.001). In the receiver operating characteristic curve analysis, the NEWS2, LDT-EWS, and NEWS2+LDT-EWS-formed by the sum of the two scoring systems-resulted in 0.717, 0.705, and 0.775 area under curve values, respectively.

CONCLUSIONS

The NEWS2 and LDT-EWS were found to be valuable for predicting in-hospital mortality in geriatric patients. The power of the NEWS2 to predict in-hospital mortality increased when used with the LDT-EWS.

Serum calcium is associated with sudden cardiac arrest in stroke patients from ICU: a multicenter retrospective study based on the eICU collaborative research database

This primary objective of our study was to investigate the relationship between serum calcium levels and the occurrence of sudden cardiac arrest (SCA) in stroke patients. We analyzed the clinical data of 10,423 acute stroke patients admitted to the intensive care unit. The association between serum calcium and SCA following an acute stroke was assessed through multivariate logistic regression. We explored the non-linear connection between serum calcium levels and SCA in stroke patients using a generalized additive model and smooth curve fitting. Our study uncovered that serum calcium serves as an independent risk factor for sudden cardiac arrest in stroke patients. Notably, we observed that the relationship between serum calcium levels upon admission and the occurrence of SCA in stroke patients within the hospital was non-linear. Furthermore, we identified inflection points in serum calcium levels at 8.2 and 10.4 mg/dL. These findings emphasize a non-linear relationship between serum calcium levels and the risk of SCA in stroke patients. Maintaining serum calcium within the range of 8.2-10.4 mg/dL could lead to a significant reduction in the incidence of cardiac arrest among stroke patients.

Admission plasma potassium and length of hospital stay: a meta-analysis

OBJECTIVE

Hypokalaemia and hyperkalaemia ('dyskalaemia') are commonly seen in patients requiring emergency hospital admission. The adverse effect of dyskalaemia on mortality is well described but there are few data for the effect on hospital length of stay. We sought to determine the association of serum potassium concentration with in-hospital length of stay.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A structured search of MEDLINE, PubMed and SCOPUS databases to 19 March 2021.

ELIGIBILITY CRITERIA

Observational cohort studies defining exposure of interest as serum potassium levels (at admission or within the first 72 hours) and with outcome of interest as length of hospital stay. Studies had to provide estimates of length of stay as a comparison between normokalaemia and defined ranges of hyperkalaemia or hypokalaemia.

DATA EXTRACTION AND SYNTHESIS

We identified 39 articles published to March 2021 that met the inclusion and exclusion criteria. Study selection, data extraction and quality assessment were carried out by two reviewers working independently and in duplicate, to assessed eligibility and risk of bias, and extract data from eligible studies. Random effects models were used to pool estimates across the included studies. Meta-analyses were performed using Cochrane-RevMan.

RESULTS

Five studies were included in the meta-analysis. Compared with the reference group (3.5-5.0 mmol/L), the pooled raw differences of medians were 4.45 (95% CI 2.71 to 6.91), 1.99 (95% CI 0.03 to 3.94), 0.98 (95% CI 0.91 to 1.05), 1.51 (95% CI 1.03 to 2.0), 1 (95% CI 0.75 to 1.25) and 2.76 (95% CI 1.24 to 4.29) for patients with potassium levels of <2.5, 2.5 to <3.0, 3.0 to <3.5, <5 to 5.5, <5.5 to 6 and >6.0 mmol/L, respectively.

CONCLUSION

Hospital length of stay follows a U-shaped distribution, with duration of admission being twofold greater at the extremes of the potassium range.

Traditional uses, chemical compounds, pharmacological activities and clinical studies on the traditional Chinese prescription Yi-Gan San

ETHNOPHARMACOLOGICAL RELEVANCE

A widely used traditional prescription, Yi-Gan San (YGS) is a remedy for neurodegenerative disorders. The formulation consists of seven Chinese medicinal materials in specific proportions, namely Uncariae Ramulus cum Uncis (Uncaria rhynchophylla (Miq.) Miq. ex Havil.), Bupleuri Radix (Bupleurum chinense DC.), Angelicae Sinensis Radix (Angelica sinensis (Oliv.) Diels), Chuanxiong Rhizoma (Ligusticum wallichii Franch.), Poria (Poria cocos (Schw.) Wolf), Atractylodis Macrocephalae Rhizoma (Atractylodes macrocephala Koidz.) and Glycyrrhizae Radix et Rhizoma (Glycyrrhiza uralensis Fisch.). Using YGS has been shown to alleviate various behavioural and psychological symptoms of dementia (BPSD).

AIM OF THIS REVIEW

The goal of this review is to give up-to-date information about the traditional uses, chemistry, pharmacology and clinical efficacy of YGS based on the scientific literature and to learn the current focus and provide references in the next step.

MATERIALS AND METHODS

The database search room was accessed using the search terms "Yi-Gan San" and "Yokukansan" to obtain results from resources such as Web of Science, PubMed, Google Scholar and Sci Finder Scholar. We not only consulted the literature of fellow authors for this review but also explored classical medical books.

RESULTS

YGS has been used to cure neurosis, sleeplessness, night weeping and restlessness in infants. Its chemical components primarily consist of triterpenes, flavonoids, phenolics, lactones, alkaloids and other types of compounds. These active ingredients displayed diverse pharmacological activities to ameliorate BPSD by regulating serotonergic, glutamatergic, cholinergic, dopaminergic, adrenergic, and GABAergic neurotransmission. In addition, YGS showed neuroprotective, antistress, and anti-inflammatory effects. The majority of cases of neurodegenerative disorders are treated with YGS, including Alzheimer's disease and dementia with Lewy bodies.

CONCLUSIONS

Based on previous studies, YGS has been used as a traditional prescription in East Asia, such as Japan, Korea and China, and it has diverse chemical compounds and multiple pharmacological activities. Nevertheless, few experimental studies have focused on chemical and quantitative YGS studies, suggesting that further comprehensive research on its chemicals and quality assessments is critical for future evaluations of drug efficacy.

Electrolyte Imbalance Among Bangladeshi Patients With COVID-19

Introduction Infection with SARS-CoV-2 begins in the lower respiratory tract, but COVID-19 often involves the renal system, resulting in serum electrolyte imbalance. Monitoring serum electrolyte levels and parameters of liver and kidney function is essential to understand disease prognosis. Objectives This study aimed to determine the effect of imbalances in serum electrolytes and other parameters on COVID-19 severity. Material and method This retrospective study comprised 241 patients, ages 14 years and older, including 186 patients who were moderately affected and 55 who were categorized as severely affected by COVID-19. Serum electrolytes (sodium (Na⁺), potassium (K⁺), and chloride (Cl^-)) and biomarkers of kidney and liver function (creatinine and alanine aminotransferase (ALT)) were measured and correlated with disease severity. This research was conducted among admitted patients of Holy Family Red Crescent Medical College Hospital designated into two groups based on retrospective hospital records. Individuals with moderate illness had evidence of lower respiratory tract infection (cough, cold, breathless, etc.) during clinical assessment or imaging (chest X-ray and computed tomography (CT) scan of the lungs) and have an oxygen saturation by pulse oximetry (SpO₂) ≥ 94% on room air at sea level. The severely ill group involved individuals with SpO₂ ≤94% on room air at sea level and respiratory rate ≥ 30 breaths/minute, and critically ill patients are those who needed mechanical ventilation or required intensive care unit (ICU) care. This categorization was based on the Coronavirus Disease 2019 (COVID-19) Treatment Guidelines (https://www.covid19treatmentguidelines.nih.gov/about-the-guidelines/whats-new/). Results Average Na⁺ and creatinine increased by 2.30 parts (95% confidence interval (CI) = 0.20, 4.81, P = 0.041) and 0.35 units (95% CI = 0.03, 0.68, P = 0.043) in severe cases compared with moderate cases. Older participants had relatively Na⁺ lowered to -0.06 parts (95% CI = -0.12, -0.001, P = 0.045), significant Cl^- reduction by 0.09 units (95% CI = -0.14, -0.04, P = 0.001), and ALT by 0.47 units (95% CI = -0.88, -0.06, P = 0.024), whereas serum creatinine was increased by 0.01 parts (95% CI = 0.001, 0.02, P = 0.024). The creatinine and ALT of COVID-19 participants were significantly higher in males by 0.34 units and 23.2 units, respectively, compared with females. In severe COVID-19 cases compared with moderate cases, the risks of hypernatremia, elevated chloride levels, and elevated serum creatinine levels were increased by 2.83-fold (95% CI = 1.26, 6.36, P = 0.012), 5.37-fold (95% CI = 1.90, 15.3, P = 0.002), and 2.00-fold (95% CI = 1.08, 4.31, P = 0.039), respectively. Conclusion Serum electrolyte and biomarker levels can serve as good indicators of the condition and disease prognosis of patients with COVID-19. Our purpose in this study was to determine the association between serum electrolyte imbalance and disease severity. We collected data from ex post facto hospital records and did not intend to assess the mortality rate. Consequently, this study expects that the prompt diagnosis of electrolyte disparity or disturbance possibly minimizes COVID-19-related morbidity and mortality.

Baseline electrolyte disorders predict disease severity and mortality in patients with COVID-19

Distinguishing critical laboratory biomarkers for disease severity at the time of hospital presentation is important for early identification of patients who are most likely to have poor outcomes and effective use of health resources. This study aimed to evaluate whether electrolyte imbalances on hospital admission predict severe disease and mortality in patients with coronavirus disease 2019 (COVID-19). We retrospectively collected data on the blood electrolyte concentrations of 286 COVID-19 patients at admission. The correlations between electrolyte imbalances, inflammation, and thrombosis markers in COVID-19 patients were also evaluated. We assessed the predictive performance of baseline blood electrolyte concentrations for severe disease and death using receiver operating characteristic curve analysis and multivariate logistic regression methods. Abnormalities in serum sodium, calcium, and potassium levels at admission were found at 20.6%, 14%, and 4.2%, respectively in this study. In the receiver operating characteristic curve analyses, hypocalcemia and hyponatremia effectively predicted disease progression to hospitalization (area under the curve 0.82, P < .001 and 0.81, P < .001, respectively) and 30-day mortality (area under the curve 0.85, P < .001 and 0.91, P < .001, respectively). In the multivariate logistic regression analysis, baseline hypocalcemia was identified as an independent risk factor associated with the risk of hospitalization (β = 2.019, P = .01; odds ratio: 7.53). Baseline hypocalcemia and hyponatremia effectively predicted disease progression toward hospitalization and 30-day mortality in patients with COVID-19. Clinicians should closely follow up or reevaluate COVID-19 patients with baseline electrolyte disorders.

Association between hypomagnesemia and coagulopathy in sepsis: a retrospective observational study

BACKGROUND

Hypomagnesemia reportedly has significant associations with poor clinical outcomes such as increased mortality and septic shock in patients with sepsis. Although the mechanism underlying these outcomes mostly remains unclear, some experimental data suggest that magnesium deficiency could potentiate coagulation activation in sepsis. However, in sepsis, the association between serum magnesium levels and coagulopathy, including disseminated intravascular coagulation (DIC), remains unknown. Thus, we aimed to investigate the relationship between serum magnesium levels and coagulation status and the association between hypomagnesemia and DIC in patients with sepsis.

METHODS

This retrospective observational study was conducted at the intensive care unit (ICU) of a university hospital from June 2011 to December 2017. Patients older than 19 years who met the Sepsis-3 definition were included. We categorized patients into three groups according to their serum magnesium levels: hypomagnesemia (< 1.6 mg/dL), normal serum magnesium level (1.6-2.4 mg/dL), and hypermagnesemia (> 2.4 mg/dL). We investigated the association between serum magnesium levels and overt DIC at the time of ICU admission according to the criteria of the International Society on Thrombosis and Haemostasis.

RESULTS

Among 753 patients included in this study, 181 had DIC, 105 had hypomagnesemia, 552 had normal serum magnesium levels, and 96 had hypermagnesemia. Patients with hypomagnesemia had a more activated coagulation status indicated by lower platelet counts, lower fibrinogen levels, higher prothrombin time-international normalized ratios, higher thrombin-antithrombin complex, and more frequent DIC than those with normal serum magnesium levels and hypermagnesemia (DIC: 41.9% vs. 20.6% vs. 24.0%, P < 0.001). The coagulation status in patients with hypomagnesemia was more augmented toward suppressed fibrinolysis than that in patients with normal serum magnesium levels and hypermagnesemia. Multivariate logistic regression revealed that hypomagnesemia was independently associated with DIC (odds ratio, 1.69; 95% confidence interval, 1.00-2.84; P = 0.048) after adjusting for several confounding variables.

CONCLUSIONS

Patients with hypomagnesemia had a significantly activated coagulation status and suppressed fibrinolysis. Hypomagnesemia was independently associated with DIC in patients with sepsis. Therefore, the treatment of hypomagnesemia may be a potential therapeutic strategy for the treatment of coagulopathy in sepsis.

A Medical Conundrum in a Surgical Setting: Lessons Learned From an Atypical Case of Hyponatremia

In the world of medicine and specifically endocrinology, hyponatremia is one of the commonest electrolyte abnormalities that result in a varied spectrum of presentations. Patients can incur symptoms ranging from lethargy, light-headedness, and confusion to much more severe symptoms such as vomiting, abdominal pain, deterioration in consciousness, and, in critical cases, even seizures. In elderly patients, hyponatremia is a major cause of Delirium and if not treated appropriately, can result in adverse outcomes and complications. In severe cases of hyponatremia, the opinion of an endocrinologist must be sought early for a conscientious investigation of the underlying etiology, as this prevents the need for unnecessary interventions, and thus reduces the risk of potential harm. Despite being a common electrolyte abnormality, hyponatremia can be associated with rare and uncommon etiologies, one of them being acute intermittent porphyria (AIP) as seen in our case. Due to the non-specific presentation of AIP, medical and healthcare professionals must be cautious of this condition, since it can mimic an acute abdomen. Symptoms of AIP usually overlap with other conditions, thus resulting in a diagnostic dilemma. Triggers and factors leading to acute attacks of AIP must be explored and rationalized appropriately, involving a thorough review of a patient's medication and social history. Moreover, discussion in a multidisciplinary team (MDT) setting for such complex presentations has a positive impact on patient care and is therefore recommended.

Admission Serum Calcium Level and Short-Term Mortality After Acute Ischemic Stroke: A Secondary Analysis Based on a Norwegian Retrospective Cohort

Background

Disturbed serum calcium levels are related to the risk of stroke. However, previous studies exploring the correlation between serum calcium and the clinical outcome of ischemic stroke (IS) have shown inconsistent results.

Object

The study aimed to investigate the relationship between admission serum calcium and 30-day mortality in patients with IS.

Methods

A total of 876 IS patients from a Norwegian retrospective cohort were included for secondary analysis. The exposure variable and the primary outcome were albumin-corrected serum calcium (ACSC) at baseline and all-cause mortality within 30 days after the first admission, respectively. Multivariable logistic regression analysis was used to estimate the risk of 30-day mortality according to ACSC levels. Moreover, the potential presence of a non-linear relationship was evaluated using two-piecewise linear regression with a smoothing function and threshold level analysis. The stability of the results was evaluated by unadjusted and adjusted models.

Results

The result of multiple regression analysis showed that ACSC at baseline was positively associated with the incidence of 30-day mortality after adjusting for the potential confounders (age, gender, serum glucose, hypertension, atrial fibrillation/atrial flutter, renal insufficiency, heart failure, chronic obstructive pulmonary disease, pneumonia, paralysis, and aphasia) (OR = 2.43, 95% CI 1.43–4.12). When ACSC was translated into a categorical variable, the ORs and 95% CIs in the second to the fourth quartile vs. the first quartile were 1.23 (0.56, 2.69), 1.16 (0.51, 2.65), and 2.13 (1.04, 4.38), respectively (P for trend = 0.03). Moreover, the results of two-piecewise linear regression and curve-fitting revealed a linear relationship between ACSC and 30-day mortality.

Conclusion

ACSC is positively associated with 30-day mortality in IS patients, and the relationship between them is linear.

The association between serum glucose to potassium ratio on admission and short-term mortality in ischemic stroke patients

High serum glucose to potassium ratio (GPR) at admission is implicated for a poor outcome in acute brain injury, acute intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage. However, the relationship between GPR and the outcome of ischemic stroke (IS) remains unknown. In all, 784 IS patients from a large emergency Norwegian cohort were included for secondary analysis. The exposure and outcome were GPR at baseline and all-cause mortality within 30 days after the first admission. Multivariable logistic regression analysis was performed to estimate the risk of 30-day mortality based on GPR levels. In addition, we examined whether there was a nonlinear relationship between admission GPR and 30-day mortality using two-piecewise linear regression with a smoothing function and threshold level analysis. The results of multivariable regression analysis showed that GPR at baseline was positively associated with the 30-day mortality (OR 2.01, 95% CI 1.12, 3.61) after adjusting for potential confounders (age, gender, department, serum sodium, serum albumin, serum-magnesium, hypertension, heart failure, chronic renal failure, and pneumonia). When GPR was translated to a categorical variable, the ORs and 95% CIs in the tertiles 2 to 3 versus the tertile 1 were 1.24 (0.60, 2.56) and 2.15 (1.09, 4.24), respectively (P for trend = 0.0188). Moreover, the results of the two-piecewise linear regression and curve fitting revealed a linear relationship between GPR and 30-day mortality. In IS patients, GPR is positively correlated with 30-day mortality, and the relationship between them is linear. The GPR at admission may be a promising predictor for the short-term outcome in IS patients.

Does 3D Printing-Assisted Acetabular or Pelvic Fracture Surgery Shorten Hospitalization Durations among Older Adults?

Acetabular or anterior pelvic ring fractures are rare but extremely complicated and challenging injuries for orthopedic trauma surgeons. Three-dimensional (3D) printing technology is widely used in the management of these two fracture types for surgical benefits. Our study aimed to explore whether 3D printing-assisted acetabular or pelvic surgery is beneficial in terms of shortening the length of hospital stay (LHS) and intensive care unit (ICU) stay (ICU LS) for older patients. This retrospective study included two groups of 76 participants over 60 years old who underwent operations with (n = 41) or without (n = 35) guidance by 3D printing. The Mann–Whitney U test was used to analyze continuous variables. Chi-square analysis was applied for categorical variables. Univariable and multivariable linear regression models were used to analyze the factors associated with LHS. The median LHS in the group without 3D printing assistance was 16 (12–21) days, and the median ICU LS was 0 (0–2) days. The median LHS in the group with 3D printing assistance was 17 (12.5–22.5) days, and the median ICU LS was 0 (0–3) days. There was no significant difference in LHS associated with 3D printing assistance vs. that without 3D printing among patients who underwent open reduction and internal fixation for pelvic or acetabular fractures. The LHS positively correlated with the ICU LS whether the operation was 3D printing assisted or not. For fracture surgery in older patients, in addition to the advancement of surgical treatment and techniques, medical teams require more detailed preoperative evaluations, and more personalized medical plans regarding postoperative care to achieve the goals of shortening LHS, reducing healthcare costs, and reducing complication rates.

Early prognostic impact of serum sodium level among out-of-hospital cardiac arrest patients: a nationwide multicentre observational study in Japan (the JAAM-OHCA registry)

Dysnatremia is an electrolytic disorder commonly associated with mortality in various diseases. However, little is known about dysnatremia in out-of-hospital cardiac arrest (OHCA) cases. Here, we investigated the association between serum sodium level on hospital arrival and neurological outcomes after OHCA. This nationwide hospital-based observational study (The Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry) enrolled patients with OHCA between 2014 and 2017. We included adult patients aged ≥ 18 years with non-traumatic OHCA who achieved return of spontaneous circulation (ROSC) and whose serum sodium level on hospital arrival was available. Based on the serum sodium level, patients were divided into three levels: hyponatremia (Na < 135 mEq/L), normal sodium level (Na ≥ 135 or ≤ 145 mEq/L), and hypernatremia (Na > 145 mEq/L). The primary outcome was 1-month survival with favourable neurological outcomes. Altogether, 34 754 patients with OHCA were documented, and 5160 patients with non-traumatic OHCA and who achieved ROSC were eligible for our analyses. The proportion of favourable neurological outcomes was highest in patients with normal sodium levels at 17.6% (677/3854), followed by patients with hyponatremia at 8.2% (57/696) and patients with hypernatremia at 5.7% (35/610). Moreover, hyponatremia and hypernatremia were associated with a decreased probability of favourable neurological outcomes compared with normal sodium level (vs. hyponatremia, adjusted odds ratio [AOR] 0.97, 95% confidence interval [CI] 0.95-0.99; vs. hypernatremia, AOR 0.96, 95% CI 0.94-0.98). Hypo- and hypernatremia on hospital arrival were associated with a decreased probability of favourable neurological outcomes in patients with non-traumatic OHCA who achieved ROSC.

Predictors of Rehospitalization and Mortality in Diabetes-Related Hospital Admissions

The risk factors of rehospitalization and death post-discharge in diabetes-related hospital admissions are not fully understood. To determine them, a population-based retrospective epidemiological survey was performed on diabetes-related admissions from the Polish national database. Logistic regression models were used, in which the dependent variables were rehospitalization due to diabetes complications and death within 90 days after the index hospitalization. In 2017, there were 74,248 hospitalizations related to diabetes. A total of 11.3% ended with readmission. Risk factors for rehospitalization were as follows: age < 35 years; male sex; prior hospitalization due to acute diabetic complications; weight loss; peripheral artery disease; iron deficiency anemia; kidney failure; alcohol abuse; heart failure; urgent, emergency, or weekend admission; length of hospitalization; and hospitalization in a teaching hospital with an endocrinology/diabetology unit. Furthermore, 7.3% of hospitalizations resulted in death within 90 days following discharge. Risk factors for death were as follows: age; neoplastic disease with/without metastases; weight loss; coagulopathy; alcohol abuse; acute diabetes complications; heart failure; kidney failure; iron deficiency anemia; peripheral artery disease; fluid, electrolytes, and acid–base balance disturbances; urgent or emergency and weekend admission; and length of hospitalization. We concluded that of all investigated factors, only hospitalization within an experienced specialist center may reduce the frequency of the assessed outcomes.

Why hemolysis detection should be an integral part of any near-patient blood gas analysis

Blood gas analysis at or near the patient’s bedside is a common practice in acute medicine and plays a crucial role in the diagnosis and management of patient’s respiratory status, metabolites, electrolytes, co-oximetry and acid–base balance. Pre-analytical quality aspects of the specimens are getting more and more attention, including the presence of potential interferences. Central laboratories have implemented technologies to detect interferences such as hemolysis, lipidemia or hyperbilirubinemia in blood samples to ensure the highest possible quality in results provided to routine care. However, systematic detection for interference due to hemolysis is currently not in place for blood gas analysis at the point-of-care (POC). To apply hemolysis detection solutions at the central laboratory, but not at the POC for blood gas analysis, is a clear contradiction when novel hemolysis detecting technologies are available. The introduction of a system that systematically detects hemolysis in connection to POC blood gas analysis would be imperative to patient safety and costs associated with potential clinical malpractice (leading to wrong, missing and/or delayed treatment) and would also ensure better compliance to CLSI guidelines and ISO standards, and be beneficial for patient and staff.

Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis

BACKGROUND

Sepsis is the leading cause of hospitalization and death in the intensive care unit. It is vital to identify high-risk patients with poor prognosis in the early stages of sepsis. We aimed to investigate the prognostic value of serum phosphorus levels for sepsis.

METHODS

The data of 4767 patients with sepsis were collected from the Multiparameter Intelligent Monitoring in Intensive Care III database. The Locally Weighted Scatterplot Smoothing technique and Kaplan-Meier analysis were used to test the crude relationship between serum phosphorus levels and mortality or overall survival. The multivariable logistic regression was used to further analyze the relationship between serum phosphorus levels and in-hospital mortality. The subgroup analysis was performed according to renal failure, use of vasopressin and the Sequential Organ Failure Assessment (SOFA) score.

RESULTS

Only hyperphosphatemia significantly correlated with in-hospital mortality [odds ratio (OR) 1.48; 95% confidence interval (CI) 1.19-1.85], while the correlation between hypophosphatemia and in-hospital mortality was not significant (OR 0.91; 95% CI 0.70-1.19). The interactions between serum phosphorus and renal failure, use of vasopressin or the SOFA score were not significant.

CONCLUSIONS

Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis.

Development and implementation of an electrolyte replacement protocol in the outpatient oncology infusion centers of a large academic healthcare system

Background

Patients receiving chemotherapy frequently experience electrolyte imbalances. Electrolyte replacement is, therefore, a necessity as patients may experience life-threatening symptoms. Study objective: The objective of this study was to evaluate the occurrence of low serum potassium and magnesium, and identify the rate of replacement for patients with low serum potassium and magnesium levels. Based on our findings, we developed and implemented a nursing-driven electrolyte replacement protocol.

Methods

Preimplementation phase – A retrospective review for serum potassium and magnesium values obtained during infusion clinic visit between 1 August and 31 October 2016 was conducted. Implementation phase – A nursing-driven electrolyte replacement protocol with medication order “smart-set” and order selection intelligence within EPIC Beacon was developed and implemented in May 2017. Postimplementation phase – The postimplementation phase data were collected from 1 August to 30 November 2017 using a similar approach as the preimplementation phase.

Results

Preimplementation phase – During the preimplementation phase of the study, a total of 1495 serum potassium levels and 1193 serum magnesium levels were obtained. Among the 152 patients who needed potassium replacement, 34% ( n = 52) were replaced and among the 118 serum magnesium levels that needed replacement, 30% ( n = 35) were replaced. Postimplementation phase – 3979 serum potassium and 2707 magnesium levels were obtained. Among the 170 patients who needed potassium replacement, 75% ( n = 127) were replaced. Among the 142 patients who needed magnesium replacement, 73% ( n = 104) were replaced.

Conclusion

A 121% increase in potassium replacement and a 143% increase in magnesium replacement were identified after implementing this protocol.

Hypophosphatemia in critically ill adults and children - A systematic review

BACKGROUND & AIMS

Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments.

METHODS

A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies.

RESULTS

For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak.

CONCLUSIONS

Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.

Fluid-electrolyte homeostasis requires histone deacetylase function

Histone deacetylase (HDAC) enzymes regulate transcription through epigenetic modification of chromatin structure, but their specific functions in the kidney remain elusive. We discovered that the human kidney expresses class I HDACs. Kidney medulla-specific inhibition of class I HDACs in the rat during high-salt feeding results in hypertension, polyuria, hypokalemia, and nitric oxide deficiency. Three new inducible murine models were used to determine that HDAC1 and HDAC2 in the kidney epithelium are necessary for maintaining epithelial integrity and maintaining fluid-electrolyte balance during increased dietary sodium intake. Moreover, single-nucleus RNA-sequencing determined that epithelial HDAC1 and HDAC2 are necessary for expression of many sodium or water transporters and channels. In performing a systematic review and meta-analysis of serious adverse events associated with clinical HDAC inhibitor use, we found that HDAC inhibitors increased the odds ratio of experiencing fluid-electrolyte disorders, such as hypokalemia. This study provides insight on the mechanisms of potential serious adverse events with HDAC inhibitors, which may be fatal to critically ill patients. In conclusion, kidney tubular HDACs provide a link between the environment, such as consumption of high-salt diets, and regulation of homeostatic mechanisms to remain in fluid-electrolyte balance.

Variations in Magnesium Concentration Are Associated with Increased Mortality: Study in an Unselected Population of Hospitalized Patients

Dysmagnesemia is a serious disturbance of microelement homeostasis. The aim of this study was to analyze the distribution of serum magnesium concentrations in hospitalized patients according to gender, age, and result of hospitalization. The study was conducted from February 2018 to January 2019 at the Central Clinical Hospital in Warsaw. Laboratory test results from 20,438 patients were included in this retrospective analysis. When a lower reference value 0.65 mmol/L was applied, hypermagnesemia occurred in 196 patients (1%), hypomagnesemia in 1505 patients (7%), and normomagnesemia in 18,711 patients (92%). At a lower reference value of 0.75 mmol/L, hypomagnesemia was found in 25% and normomagnesemia in 74% of patients. At a lower reference value of 0.85 mmol/L, hypomagnesemia was found in 60% and normomagnesemia in 39% of patients. Either hypo- or hyper-magnesemia was associated with increased risk of in-hospital mortality. This risk is the highest in patients with hypermagnesemia (40.1% of deaths), but also increases inversely with magnesium concentration below 0.85 mmol/L. Serum magnesium concentration was not gender-dependent, and there was a slight positive correlation with age (p < 0.0001, r = 0.07). Large fluctuations in serum magnesium level were associated with increased mortality (p = 0.0017). The results indicate that dysmagnesemia is associated with severe diseases and generally severe conditions. To avoid misdiagnosis, an increase of a lower cut-off for serum magnesium concentration to at least 0.75 mmol/L is suggested.

Risk Factors for 90-day Readmissions With Fluid and Electrolyte Disorders Following Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study of the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database.

OBJECTIVE

To identify risk factors for 30- and 90-day readmission due to fluid and electrolyte disorders following posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

Thirty- and 90-day readmission rates are important quality and outcome measures for hospitals and physicians. These measures have been tied to financial penalties for abnormally high rates of readmission. Furthermore, complex and high cost surgeries have been increasingly reimbursed in the form of bundled disease resource group payments, where any treatment within 90-day postdischarge is covered within the original bundled payment scheme.

METHODS

A total of 65,121 patients in the Healthcare Cost and Utilization Project Nationwide Readmissions Database met our inclusion criteria, of which 1128 patients (1.7%) were readmitted within 30 days, and 1669 patients (2.6%) were readmitted within 90 days due to fluid and electrolyte abnormalities. A bivariate analysis was performed to compare baseline characteristics between patients readmitted with fluid and electrolyte disorders and the remainder of the cohort. A multivariate regression analysis was then performed to identify independent risk factors for readmission due to fluid and electrolyte disorders at 30 and 90 days.

RESULTS

The strongest independent predictors of 30-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and drug use disorder. The five strongest predictors of 90-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and fluid and electrolyte disorders.

CONCLUSION

Patients with baseline liver disease, previously diagnosed fluid and electrolyte disorders, age older than 55 years, or drug use disorders are at higher risk for readmissions with fluid and electrolyte disorders following posterior lumbar fusion. Close monitoring of fluid and electrolyte balance in the perioperative period is essential to decrease complications and reduce unplanned readmissions.

LEVEL OF EVIDENCE

3.

Assessment of Selected Serum Electrolyte and Associated Risk Factors in Diabetic Patients

PURPOSE

The objective of this study was to assess selected serum electrolytes imbalance and associated factors in diabetic patients attending their follow up appointments in Jimma University Medical Center (JUMC) from February 1 to April 1, 2019.

PATIENTS AND METHODS

A cross sectional study design was used to assess the selected serum electrolytes in diabetic patients attending their follow up appointments at Jimma University Medical Center (JUMC) chronic illness clinic. A convenience sampling technique was used to include 279 diabetic patients in the study and an interviewer based questionnaire was used to include all necessary data from each diabetic patient. Five milliliters of blood were collected from each subject and processed and analyzed for blood glucose and serum electrolyte determination by ABX Pentra400 and Humalyte plus5 ion-selective electrode (ISE) system  clinical chemistry analyzers. Pearson's correlation coefficient model and multivariate logistic regression were used respectively to assess the correlation and significant association between abnormal serum electrolytes and independent variables.

RESULTS

A high prevalence of one or more serum electrolyte abnormalities was determined in diabetic patients. The overall prevalence was 42.0% (n=116/276) in which hyponatremia was the highest followed by hypochloremia and hypercalcemia, 40.6%, 14.9% and 10.9% respectively. Age, type of medication, and high body mass index (BMI) had strong positive correlations with abnormal serum concentration levels of sodium (r=0.611, P=0.731), potassium (r=0.752, P=0.812) and chloride (r=0.645, P=0.459). Being employed (AOR: 3.933, 95% C.I: 1.057-14.637, P value: 0.041), treated with mixed medications (AOR: 2.9, 95% C.I: 1.292-6.441, P value: 0.010) and being unable to control blood glucose level or being hyperglycemic (AOR: 3.2, 95% C.I: 2.179-5.721, P value: 0.000) were statistically identified as risk factors for serum electrolyte abnormalities in diabetic patients.

CONCLUSION

The serum electrolyte concentration level was highly abnormal in diabetic patients. The prevalence of abnormal concentration was more common in diabetic patients with advanced age, and some variables had strong positive correlation with abnormal serum electrolyte level in diabetic patients.