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Thuo E, Lyden ER, Peeples ES. Effect of early clinical management on metabolic acidemia in neonates with hypoxic-ischemic encephalopathy. J Perinatol 2024:10.1038/s41372-024-02005-2. [PMID: 38769336 DOI: 10.1038/s41372-024-02005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To determine the safety and effectiveness of sodium bicarbonate administration in the management of metabolic acidemia and short-term outcomes in neonates with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of neonates born at ≥35 weeks of gestation and receiving therapeutic hypothermia. Demographics, pH, lactate, base deficit, treatment, MRI findings, seizure incidence, death prior to discharge were collected. RESULTS There was higher mortality (p = 0.010) and injury on MRI (p = 0.008)-primarily deep gray matter (p < 0.001) and cortical injury (p = 0.003)-in the bicarbonate group compared to controls in univariate analysis. The combined outcome of death or abnormal MRI was not significantly associated (OR 1.97, 95% CI 0.80-4.87, p = 0.141) with bicarbonate administration when adjusting for sex, 5-minute Apgar, and initial base deficit. CONCLUSION This study demonstrated association between bicarbonate use after HIE and negative short-term outcomes. Future prospective trials could overcome the treatment bias limitation demonstrated in this retrospective study.
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Affiliation(s)
- Erastus Thuo
- School of Medicine, Creighton University, Omaha, NE, USA
| | - Elizabeth R Lyden
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
- Child Health Research Institute, Omaha, NE, USA.
- Children's Nebraska, Omaha, NE, USA.
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Nozawa H, Tsuboi N, Oi T, Takezawa Y, Osawa I, Nishimura N, Nakagawa S. Chloride Reduction Therapy with Furosemide: Short-Term Effects in Children with Acute Respiratory Failure. J Pediatr Intensive Care 2023; 12:296-302. [PMID: 37970141 PMCID: PMC10631838 DOI: 10.1055/s-0041-1733942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022] Open
Abstract
From the perspective of the Stewart approach, it is known that expansion of the sodium chloride ion difference (SCD) induces alkalosis. We investigated the role of SCD expansion by furosemide-induced chloride reduction in pediatric patients with acute respiratory failure. We included patients admitted to our pediatric intensive care unit intubated for acute respiratory failure without underlying diseases, and excluded patients receiving extracorporeal circulation therapy (extracorporeal membrane oxygenation and/or renal replacement therapy). We classified eligible patients into the following two groups: case-those intubated who received furosemide within 24 hours, and control-those intubated who did not receive furosemide within 48 hours. Primary outcomes included SCD, partial pressure of carbon dioxide (PaCO 2 ), and pH results from arterial blood gas samples obtained over 48 hours following intubation. Multiple regression analysis was also performed to evaluate the effects of SCD and PaCO 2 changes on pH. Twenty-six patients were included of which 13 patients were assigned to each of the two groups. A total of 215 gas samples were analyzed. SCD (median [mEq/L] [interquartile range]) 48 hours after intubation significantly increased in the case group compared with the control group (37 [33-38] vs. 31 [30-34]; p = 0.005). Although hypercapnia persisted in the case group, the pH (median [interquartile range]) remained unchanged in both groups (7.454 [7.420-7.467] vs. 7.425 [7.421-7.436]; p = 0.089). SCD and PaCO 2 were independently associated with pH ( p < 0.001 for each regression coefficient). As a result, we provide evidence that SCD expansion with furosemide may be useful in maintaining pH within the normal range in pediatric patients with acute respiratory failure complicated by concurrent metabolic acidosis.
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Affiliation(s)
- Hisataka Nozawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Norihiko Tsuboi
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tadashi Oi
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiki Takezawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Osawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
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Spilios M, Bashqoy F, Saad A, Wachtel EV, Tracy J. Incidence of Intracranial Hemorrhage in Patients Younger Than 2 Months Receiving Sodium Bicarbonate 4.2% vs 8.4. J Pediatr Pharmacol Ther 2023; 28:446-451. [PMID: 38130492 PMCID: PMC10731936 DOI: 10.5863/1551-6776-28.5.446] [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: 08/23/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To assess the incidence of intracranial hemorrhage (ICH), including intraventricular hemorrhage, in infants receiving 4.2% or 8.4% sodium bicarbonate. METHODS This is a single-center retrospective chart review of neonates and infants with a gestational age (GA) >32 weeks and a postnatal age <2 months who received sodium bicarbonate in an intensive care unit at an academic tertiary children's hospital. The primary outcome was the incidence of ICH in patients with baseline and follow-up head imaging. The secondary outcome was the incidence of ICH on follow-up head imaging, with or without baseline head imaging. RESULTS There were 351 patients screened, with 135 meeting inclusion criteria. Of these, 84% were born ≥37 weeks GA. Forty-two met the criteria for the primary outcome. Study participants were further subdivided into 3 groups based on the concentration of sodium bicarbonate received: only 4.2%, only 8.4%, or a mixed group that received at least 1 dose each of 4.2% and 8.4%. Intracranial hemorrhage was noted in 1 patient in each group: 8.3%, 5.6%, and 8.3%, respectively (p = 1.00). For the secondary outcome, 11 ICHs were seen on head imaging: 11.3%, 3.8%, and 10%, respectively. There was no statistically significant difference in the incidence of ICH (p = 0.325). CONCLUSIONS The incidence of ICH in term neonates and infants was not significantly different in those receiving 4.2% vs 8.4% sodium bicarbonate. Although additional studies are needed, this study suggests it may be possible to safely expand the use of 8.4% in neonates/infants ≥37 weeks GA. These results should not be applied to preterm neonates (<37 weeks GA and/or <1500 g) or neonates with additional ICH risk factors.
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Affiliation(s)
- Maria Spilios
- Department of Pharmacy (MS, FB, AS, JT), Hassenfeld Children’s Hospital at NYU Langone Health, New York, NY
| | - Ferras Bashqoy
- Department of Pharmacy (MS, FB, AS, JT), Hassenfeld Children’s Hospital at NYU Langone Health, New York, NY
| | - Anasemon Saad
- Department of Pharmacy (MS, FB, AS, JT), Hassenfeld Children’s Hospital at NYU Langone Health, New York, NY
| | - Elena V. Wachtel
- Department of Pediatrics (EW), Bellevue Hospital Center, New York, NY
- Division of Neonatology (EW), Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Joanna Tracy
- Department of Pharmacy (MS, FB, AS, JT), Hassenfeld Children’s Hospital at NYU Langone Health, New York, NY
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Al-Shehri H, Alqahtani R, Alromih AM, Altamimi A, Alshehri K, Almehaideb L, Jabari M, Alzayed A. The practices of intravenous sodium bicarbonate therapy in neonatal intensive care units: A multi-country survey. Medicine (Baltimore) 2023; 102:e34337. [PMID: 37478246 PMCID: PMC10662854 DOI: 10.1097/md.0000000000034337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/23/2023] [Indexed: 07/23/2023] Open
Abstract
A common occurrence in the neonatal intensive care unit (NICU) is metabolic acidosis. Sodium bicarbonate (SB) has been widely used, but there is insufficient evidence on how SB affects neonates in NICUs with metabolic acidosis. The worsening of intracellular acidosis, the impairment of myocardial function, fluctuations in cerebral blood flow, and intracranial hemorrhage are some of the unfavorable effects of SB treatment in neonates that have been documented in the literature. This study aimed to explore neonatologists' practices for using intravenous SB (ISB) in NICUs. A multi-country survey was carried out in 2022 using an online questionnaire sent to neonatologists in various countries in order to gather information about the use of ISB in NICUs. A previously validated questionnaire was adapted and used in this study. The response rate was 67%. The findings show that 91.2% of neonatologists were using SB to correct metabolic acidosis in the NICU; 71.4% did not have written guidelines for using sodium bicarbonate. The majority of them (78.9%) reported that dosage is included in their guidelines for the use of ISB. The findings of this study emphasize the critical importance of providing guidelines in using ISB for managing metabolic acidosis in NICU to standardize procedures and reduce the use of potentially unsuitable and unsafe treatments, as it has been shown that 71.4% of neonatologists worldwide use sodium bicarbonate without guidelines.
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Affiliation(s)
- Hassan Al-Shehri
- Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Renad Alqahtani
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Aroob M. Alromih
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Amal Altamimi
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Khloud Alshehri
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Latifah Almehaideb
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Mosleh Jabari
- Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Abdullah Alzayed
- Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
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Acute Effects of Sodium Bicarbonate in Children with Congenital Heart Disease with Biventricular Circulation in Non-cardiac Arrest Situations. Pediatr Cardiol 2022; 43:1723-1727. [PMID: 35415814 DOI: 10.1007/s00246-022-02905-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
Despite the controversy, sodium bicarbonate is a commonly used medication in critically ill patients of all ages. There is a lack of data on the acute impact on hemodynamic parameters, biomarker indicators of cardiac output, and changes in vasoinotropic support after sodium bicarbonate therapy. In our retrospective study on children with biventricular circulation in pediatric cardiac intensive care unit receiving bicarbonate therapy: we analyzed its effects on arterial blood gases, heart rate, blood pressure (BP), central venous pressures (CVP), cerebral and renal near-infrared spectroscopy (NIRS), changes in vasoinotropic and ventilator changes before and after sodium bicarbonate administration. Thirty-one administrations of sodium bicarbonate in 23 patients with congenital heart disease without residual shunts were analyzed. The average age was 15.4 months, weight 7.7 kg, and the average bicarbonate dose was 1 meq/kg. There was an increase in arterial pH from 7.24 to 7.30 (p = 0.14) and bicarbonate changed from 18 to 20 mEq/L (p = 0.23). No clinically significant changes were found in the following parameters: heart rate (141 ± 20.1 to 136 ± 19), systolic BP (84 ± 17 to 86 ± 14 mmHg), diastolic BP (48 ± 12 to 49 ± 12 mmHg), cerebral NIRS (64 ± 12 to 65 ± 12), renal NIRS (80 ± 10 to 81 ± 7), CVP (9 ± 3 to 10 ± 4 mmHg), paCO2 (45 ± 26 to 42 ± 7 mmHg), paO2 (143 ± 78 to 127 ± 59 mmHg), serum lactate (2.2 ± 2.7 to 3.6 ± 3.8 mmol/L), and vasoinotropic score (7.5 ± 5.0 to 7.7 ± 4.7). Outside of a change in serum pH and bicarbonate levels no other significant changes were noted after sodium bicarbonate administration in children with congenital heart disease with fully septated, biventricular circulation. There was no improvement in systemic oxygen delivery.
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Cashen K, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fink EL, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Meert KL. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatr Crit Care Med 2022; 23:784-792. [PMID: 35880872 PMCID: PMC9529841 DOI: 10.1097/pcc.0000000000003045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). DESIGN Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. SETTING Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621). CONCLUSIONS In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Aisha H Frazier
- Department of Pediatrics, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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Chilakala SK, Parfenova H, Pourcyrous M. The effects of sodium bicarbonate infusion on cerebrovascular function in newborn pigs. Pediatr Res 2022; 92:729-736. [PMID: 34862458 PMCID: PMC9163205 DOI: 10.1038/s41390-021-01876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sodium bicarbonate (NaHCO3) is no longer recommended by the Neonatal Resuscitation Program (NRP), but is still being used by some neonatologists. The effects of NaHCO3 on cerebral hemodynamics are unclear. Therefore, we investigated the effects of NaHCO3 on cerebral blood flow (CBF) and cerebrovascular function using a newborn piglet model. METHODS Newborn pigs were anesthetized, intubated, and ventilated. Cranial windows were implanted to evaluate changes in pial arteriolar diameters (PADs) as a surrogate for CBF during a 4-h intravenous infusion of 3% NaHCO3. Cerebrovascular reactivity to vasodilators and vasoconstrictors was investigated during vehicle control and during NaHCO3 infusion. RESULTS NaHCO3 infusion caused significant and progressive pial arteriolar vasoconstrictions. During NaHCO3 infusion, cerebrovascular reactivity was preserved. Adding vasodilators decreased cerebral vasoconstriction, while adding vasoconstrictors exaggerated cerebral vasoconstriction. CONCLUSIONS Intravenous infusion of NaHCO3 over 4 h caused progressive vasoconstriction of pial arterioles. Cerebrovascular function evaluated by the responses of pial arterioles to physiologically relevant vasoconstrictors and vasodilators was preserved during NaHCO3 infusion. A notable additional reduction of PADs was observed during NaHCO3 infusion in the presence of vasoconstrictors. Extrapolating our findings to human neonates should alarm the clinicians that using NaHCO3 in neonates may cause cerebral hypoperfusion. IMPACT Cerebral vasoconstriction occurs during slow infusion of 3% diluted NaHCO3. Cerebral vasoconstriction is exaggerated when another vasoconstrictor is added during NaHCO3 infusion. Cerebrovascular function is preserved during NaHCO3 infusion. Clinicians should be aware of the risk of cerebral hypoperfusion with NaHCO3 infusion in vulnerable neonates.
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Affiliation(s)
- Sandeep K Chilakala
- Department of Pediatrics, University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee
| | - Helena Parfenova
- Department of Physiology, University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee
| | - Massroor Pourcyrous
- Department of Pediatrics, University of Tennessee Health Science Center (UTHSC), Memphis, TN, USA. .,Department of Physiology, University of Tennessee Health Science Center (UTHSC), Memphis, TN, USA. .,Department of Obstetrics/Gynecology, University of Tennessee Health Science Center (UTHSC), Memphis, TN, USA.
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Mir T, Shafi OM, Uddin M, Nadiger M, Sibghat Tul Llah F, Qureshi WT. Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study. Cureus 2022; 14:e26505. [PMID: 35923483 PMCID: PMC9339595 DOI: 10.7759/cureus.26505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background Knowledge about the causes and outcomes of pediatric cardiac arrest in the emergency department is limited. The aim of our study was to evaluate the characteristics and outcomes of pediatric cardiac arrest in the emergency department (EDCA) and inpatient (IPCA) settings in the United States using a large database designed to provide nationwide estimates. Methods We performed a retrospective cohort study using the Nationwide Emergency Department Sample (NEDS), a database that includes both ED and inpatient encounters. The NEDS was analyzed for episodes of cardiac arrest between 2016-2018 in patients aged ≤18 years. Patients with cardiac arrest were identified using the International Classification of Diseases, 10th revision codes. Results A total of 15,348 pediatric cardiac arrest events with cardiopulmonary resuscitation were recorded, of which 13,239 had EDCA and 2,109 had IPCA. A lower survival rate of 19% was observed for EDCA compared to 40.4% for IPCA. While more than half of the EDCA events had no associated diagnoses, trauma (15.6%), respiratory failure (5%), asphyxiation (2.7%), acidosis (2.4%), and ventricular arrhythmia (1.4%) were associated with the remaining events. In comparison, the most frequently associated diagnoses for IPCA were respiratory failure (75.8%), acidosis (43.9%), acute kidney injury (27.2%), trauma (27.1%), and sepsis (22.5%). Conclusions Survival rates for EDCA were less than half of that for IPCA. The low survival rates along with the distinctive characteristics of EDCA events suggest the need for further research in this area to identify remediable factors and improve survival.
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Barrett-Reis B, Shakeel F, Dennis L, Baggs G, Masor ML. Acidified Feedings in Preterm Infants: A Historical and Physiological Perspective. Am J Perinatol 2022; 40:141-148. [PMID: 35640617 PMCID: PMC9803586 DOI: 10.1055/s-0042-1749166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of acidified milk for feeding infants has a long, interesting history that appears to have developed from the use of buttermilk in Holland as early as the late 19th century for feeding infants with diarrhea. Physicians in the early 20th century assumed that the observed benefits were from buttermilk's acidity leading to the practice of acidifying infant formula. The historical and physiological perspective on the use of acidified infant formula is now especially relevant with the emergence of an acidified liquid human milk fortifier for preterm infants. Here, we review that history, with a deeper dive into the contemporary research on the use of acidified human milk fortifiers, the consequences for preterm infants, and the underlying physiological mechanisms. KEY POINTS: · In the late 19th and early 20th century acidified feedings were in common use for sick infants.. · By the mid-20th century, acidified feedings tested in preterm infants resulted in acidic physiology and poor growth.. · The current practice of acidifying feedings in preterm infants has been associated with metabolic acidosis, poor tolerance, and delayed growth..
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Affiliation(s)
- Bridget Barrett-Reis
- Abbott Nutrition, Columbus, Ohio,Address for correspondence Bridget Barrett-Reis, PhD Associate Research Fellow, Abbott Nutrition R&DBldg ES1 East, 2900 Easton Square Place, Columbus, OH 43219
| | - Fauzia Shakeel
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, Johns Hopkins University School of Medicine, St. Petersburg, Florida
| | - Laura Dennis
- Mercy San Juan Medical Center NICU, Carmichael, California
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10
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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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11
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Man AM, Piffer A, Simonetti GD, Scoglio M, Faré PB, Lava SAG, Bianchetti MG, Milani GP. Ibuprofen-Associated Hypokalemia and Metabolic Acidosis: Systematic Literature Review. Ann Pharmacother 2022; 56:10600280221075362. [PMID: 35135381 DOI: 10.1177/10600280221075362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Ibuprofen is a widely used nonsteroidal anti-inflammatory drug, which has been occasionally associated with hypokalemia and metabolic acidosis. The objective of this report is to analyze the literature on this issue and to address the underlying pathophysiology. DATA SOURCES Excerpta Medica, the National Library of Medicine, and Web of Science were searched from inception to July 16, 2021. STUDY SELECTION AND DATA EXTRACTION Papers reporting individually documented humans on ibuprofen with hypokalemia, acidosis, or both were retained. Data were extracted using a checklist. DATA SYNTHESIS For the final analysis, we evaluated 41 reports describing 50 cases (26 males and 24 females; 36 adults and 14 children) with often profound hypokalemia, acidosis, or both after ingestion of ibuprofen. Twenty-six cases were acute and 24 long term. Hypokalemia and acidosis occurred not only after ingestion of very high doses but also after ingestion of moderately high or even normal doses of ibuprofen. Laboratory values consistent with an excessive urinary potassium excretion or an altered urinary acidification were often disclosed in most cases. Discontinuation of ibuprofen resulted in a resolution of hypokalemia and acidosis within days in 47 cases. The course was lethal in 3 cases. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review highlights potentially fatal side effects of ibuprofen and can help doctors who are confronted with such a situation. CONCLUSIONS These data highlight the potential of ibuprofen to occasionally induce hypokalemia and acidosis of renal origin. Discontinuation of ibuprofen results in a resolution within days.
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Affiliation(s)
- Anca M Man
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Arianna Piffer
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Martin Scoglio
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Pietro B Faré
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Mario G Bianchetti
- Università della Svizzera Italiana, Lugano, Switzerland
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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12
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Wyckoff MH, Sawyer T, Lakshminrusimha S, Collins A, Ohls RK, Leone TA. Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference. World J Pediatr Congenit Heart Surg 2021; 13:77-88. [PMID: 34919486 DOI: 10.1177/21501351211038835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.
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Affiliation(s)
| | - Taylor Sawyer
- 12353University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | | | - Amélie Collins
- 12294Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Robin K Ohls
- 266111University of Utah, Salt Lake City, UT, USA
| | - Tina A Leone
- 12294Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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13
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El-Dib M, Szakmar E, Chakkarapani E, Aly H. Challenges in respiratory management during therapeutic hypothermia for neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101263. [PMID: 34244080 DOI: 10.1016/j.siny.2021.101263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neonatal encephalopathy (NE) is a serious condition with devastating neurological outcomes that can impact oxygenation and ventilation. The currently recommended therapeutic hypothermia (TH) for these infants may also has several respiratory implications. It decreases metabolic rate and oxygen demands; however, it increases oxygen solubility in the blood and impacts its release to peripheral tissue including the brain. Respiratory management of infants treated with TH should aim for minimizing exposure to hypocapnia or hyperoxia. Inspiratory gas should be heated to 37 °C and humidified to prevent airway and alveolar injury. Blood gas values should be corrected to the core temperature during TH and the use of alkaline buffers is discouraged. While mild sedation/analgesia may ameliorate the discomfort related to cooling, paralytic agents/heavy sedation should be used with caution considering their side effects. Finally, the use of caffeine still needs careful investigation in this population.
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Affiliation(s)
- Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., CWN#418, Boston, MA, 02115, USA.
| | - Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., CWN#418, Boston, MA, 02115, USA; 1st Department of Pediatrics, Semmelweis University, 54 Bokay St., HU-1083, Budapest, Hungary.
| | - Ela Chakkarapani
- Translational Health Sciences, Bristol Medical School, University of Bristol, Regional Neonatal Intensive Care Unit, St Michael's Hospital University Hospitals Bristol NHS Trust, Southwell Street, Bristol, BS2 8EG, United Kingdom.
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue # M31-37 Cleveland, OH, 44195, USA.
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14
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Rios DR, Lapointe A, Schmolzer GM, Mohammad K, VanMeurs KP, Keller RL, Sehgal A, Lakshminrusimha S, Giesinger RE. Hemodynamic optimization for neonates with neonatal encephalopathy caused by a hypoxic ischemic event: Physiological and therapeutic considerations. Semin Fetal Neonatal Med 2021; 26:101277. [PMID: 34481738 DOI: 10.1016/j.siny.2021.101277] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Neonatal encephalopathy due to a hypoxic-ischemic event is commonly associated with cardiac dysfunction and acute pulmonary hypertension; both therapeutic hypothermia and rewarming modify loading conditions and blood flow. The pathophysiological contributors to disease are complex with a high degree of clinical overlap and traditional bedside measures used to assess circulatory adequacy have multiple confounders. Comprehensive, quantitative echocardiography may be used to delineate the relative contribution of lung parenchymal, pulmonary vascular, and cardiac disease to hypotension and/or hypoxemic respiratory failure. In this review, we provide a detailed overview of the contributors to hemodynamic instability following perinatal hypoxic-ischemic injury. Our proposed approach to therapy focuses on physiopathological considerations with interventions individualized to this potentially complex condition and considers the pharmacological idiosyncrasies, which may occur among neonates with NE presenting with multiorgan dysfunction while undergoing therapeutic hypothermia.
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Affiliation(s)
- Danielle R Rios
- Department of Pediatrics, Division of Neonatology, University of Iowa, MS 200 Hawkins Drive 8800 JPP, Iowa City, IA, 52242, USA.
| | - Anie Lapointe
- CHU Ste-Justine, Montreal University, CHU Sainte-Justine 3175, chemin Côte Sainte-Catherine Montréal (Québec), H3T 1C5, Canada.
| | - Georg M Schmolzer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, 10240 Kingsway Avenue NW AB, Edmonton, T5H 3V9, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, Calgary, AB, T3B 6A8, Canada.
| | - Krisa P VanMeurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Center for Academic Medicine Division of Neonatology - MC 5660 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Roberta L Keller
- Department of Pediatrics, University of California San Francisco, 550 16th. Street, San Francisco, CA, 94158, USA.
| | - Arvind Sehgal
- Department of Pediatrics, Monash University, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Division of Neonatology, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817, USA.
| | - Regan E Giesinger
- Department of Pediatrics, Division of Neonatology, University of Iowa, MS 200 Hawkins Drive 8800 JPP, Iowa City, IA, 52242, USA.
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15
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Massenzi L, Aufieri R, Donno S, Agostino R, Dotta A. Use of intravenous sodium bicarbonate in neonatal intensive care units in Italy: a nationwide survey. Ital J Pediatr 2021; 47:63. [PMID: 33706798 PMCID: PMC7953611 DOI: 10.1186/s13052-021-00955-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022] Open
Abstract
Background Metabolic Acidosis (MA) is a disturbance of the acid-base balance that can occur in preterm and critically ill term neonates due to different etiologies. Intravenous sodium bicarbonate (SB) has been traditionally used to correct such unbalance, despite the lack of evidence about its safety and efficacy. In literature, reported undesirable effects of treatment with SB in neonates include worsening of intracellular acidosis, impairment of myocardial function, cerebral blood flow fluctuations and intracranial hemorrhage. A national survey was conducted by the Neonatal Pharmacotherapy Study Group of the Italian Society of Neonatology with the aim to assess and describe attitudes and practices concerning the use of SB, particularly for the treatment of MA in Italian NICUs. Methods A questionnaire regarding treatment of MA and SB prescription habits was sent to the directors of 120 Italian NICUs from June 2017 to March 2018. Results The survey response rate was 97.5% (117/120 centers). Findings showed that in 55% of the surveyed NICUs (64/117 units) it is common practice to correct MA with intravenous SB. On the other hand, the remaining 45% of the units try to solve the metabolic disturbances adopting different approaches (improving perfusion, adjusting ventilation parameters or increasing blood volume). Moreover, to prevent the occurrence of MA, 37.6% of the NICUs (44/117) include buffer salts (lactate, acetate or both) in parenteral nutrition prescriptions. SB is also used as a treatment for other conditions, mainly pathologies with bicarbonate loss and tubular acidosis (respectively in 53.8 and 32.5% of the NICUs). Conclusion This survey showed how SB is a commonly used treatment for MA in more than half of Italian NICUs, with indications and prescription criteria that significantly vary across centers. Based on current knowledge, it is reasonable to suggest that the management of neonatal MA should be firstly directed to identify the underlying disorders. Thus, the use of SB should be reserved only for selected cases, also considering the severity of SB adverse effects and the lack of evidence about its efficacy. Guidance for the management of MA is required to harmonize practices and reduce the use of potentially inappropriate and unsafe treatments. Supplementary Information The online version contains supplementary material available at 10.1186/s13052-021-00955-3.
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Affiliation(s)
- Luca Massenzi
- Department of Pediatrics and Neonatology, "S. Giovanni Calibita" Fatebenefratelli Hospital, Via di Ponte Quattro Capi 39, 00186, Rome, Italy.
| | - Roberto Aufieri
- Division of Neonatology and Neonatal Intensive Care Unit, ASL Roma 2 - Ospedale Sant'Eugenio, Rome, Italy
| | - Silvia Donno
- INVALSI - Istituto nazionale per la valutazione del sistema educativo di istruzione e formazione, Rome, Italy
| | - Rocco Agostino
- Division of Neonatology, Villa Margherita Private Nursing Home, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
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16
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Chang CY, Wu PH, Hsiao CT, Chang CP, Chen YC, Wu KH. Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis. Resuscitation 2021; 162:188-197. [PMID: 33662526 DOI: 10.1016/j.resuscitation.2021.02.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/23/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system. RESULTS We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the "before 2010" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the "after 2010" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low. CONCLUSIONS This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations. TRIAL REGISTRATION The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).
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Affiliation(s)
- Chih-Yao Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Po-Han Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan.
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17
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Ma H, Tang Z, Xiao F, Li L, Li Y, Tang W, Chen L, Kang W, Lu Y, Dong X, Cheng G, Wang L, Lu W, Yang L, Ni Q, Peng X, Wang Y, Cao Y, Wu B, Zhou W, Zhuang D, Lin G, Wang H. Neonatal Metabolic Acidosis in the Neonatal Intensive Care Unit: What Are the Genetic Causes? Front Pediatr 2021; 9:727301. [PMID: 34733806 PMCID: PMC8558493 DOI: 10.3389/fped.2021.727301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatal metabolic acidosis (NMA) is a common problem, particularly in critically ill patients in neonatal intensive care units (NICUs). Complex etiologies and atypical clinical signs make diagnosis difficult; thus, it is crucial to investigate the underlying causes of NMA rapidly and provide disorder-specific therapies. Our study aims to provide an overview of the genetic causes of NMA in patients from NICUs. We performed next-generation sequencing (NGS) on neonates with NMA from January 2016 to December 2019. Clinical features, genetic diagnoses, and their effects on clinical interventions were collected for analysis. In the 354 enrolled patients, 131 (37%) received genetic diagnoses; 95 (72.5%) of them were autosomal recessively inherited diseases. Two hundred and fifteen variants spanning 57 genes were classified as pathogenic (P) or likely pathogenic (LP) in 131 patients. The leading cause was metabolic disorders due to 35 genes found in 89 patients (68%). The other 42 NMA patients (32%) with 22 genes had malformations and renal, neuromuscular, and immune-hematological disorders. Seven genes (MMUT, MMACHC, CHD7, NPHS1, OTC, IVD, and PHOX2B) were noted in more than four patients, accounting for 48.9% (64/131) of the identified P/LP variants. Forty-six diagnosed patients with uncorrected NMA died or gave up. In conclusion, 37% of neonates with metabolic acidosis had genetic disorders. Next-generation sequencing should be considered when investigating the etiology of NMA in NICUs. Based on early molecular diagnoses, valuable treatment options can be provided for some genetic diseases to achieve better outcomes.
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Affiliation(s)
- Haiyan Ma
- Department of Neonatology, Zhuhai Women and Children's Hospital, Zhuhai, China
| | - Zezhong Tang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Feifan Xiao
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Long Li
- Department of Neonatology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Yangfang Li
- Department of Neonatology, Kunming Children's Hospital, Kunming, China
| | - Wenyan Tang
- Department of Neonatology, Jiangxi Maternal Hospital, Nanchang, China
| | - Liping Chen
- Department of Neonatology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Wenqing Kang
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yulan Lu
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Xinran Dong
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, Key Laboratory of Neonatal Diseases, Ministry of Health, Shanghai, China
| | - Laishuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, Key Laboratory of Neonatal Diseases, Ministry of Health, Shanghai, China
| | - Wei Lu
- Department of Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Lin Yang
- Department of Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Qi Ni
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaomin Peng
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Yao Wang
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Key Laboratory of Neonatal Diseases, Ministry of Health, Shanghai, China
| | - Bingbing Wu
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Wenhao Zhou
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China.,Department of Neonatology, Children's Hospital of Fudan University, Key Laboratory of Neonatal Diseases, Ministry of Health, Shanghai, China
| | - Deyi Zhuang
- Xiamen Key Laboratory of Neonatal Diseases, Xiamen Children's Hospital, Xiamen, China
| | - Guang Lin
- Department of Neonatology, Zhuhai Women and Children's Hospital, Zhuhai, China
| | - Huijun Wang
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
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18
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Quade BN, Parker MD, Occhipinti R. The therapeutic importance of acid-base balance. Biochem Pharmacol 2021; 183:114278. [PMID: 33039418 PMCID: PMC7544731 DOI: 10.1016/j.bcp.2020.114278] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023]
Abstract
Baking soda and vinegar have been used as home remedies for generations and today we are only a mouse-click away from claims that baking soda, lemon juice, and apple cider vinegar are miracles cures for everything from cancer to COVID-19. Despite these specious claims, the therapeutic value of controlling acid-base balance is indisputable and is the basis of Food and Drug Administration-approved treatments for constipation, epilepsy, metabolic acidosis, and peptic ulcers. In this narrative review, we present evidence in support of the current and potential therapeutic value of countering local and systemic acid-base imbalances, several of which do in fact involve the administration of baking soda (sodium bicarbonate). Furthermore, we discuss the side effects of pharmaceuticals on acid-base balance as well as the influence of acid-base status on the pharmacokinetic properties of drugs. Our review considers all major organ systems as well as information relevant to several clinical specialties such as anesthesiology, infectious disease, oncology, dentistry, and surgery.
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Affiliation(s)
- Bianca N Quade
- Department of Physiology and Biophysics, The State University of New York, The University at Buffalo, Buffalo, NY 14203, USA
| | - Mark D Parker
- Department of Physiology and Biophysics, The State University of New York, The University at Buffalo, Buffalo, NY 14203, USA; Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA; State University of New York Eye Institute, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Rossana Occhipinti
- Department of Physiology and Biophysics, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA.
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19
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Umbilical Cord Unmeasured Anions and Tissue Acid Levels According to Stewart’s Method in Term Newborn Infants and the Impact of Delivery Mode on these parameters. JOURNAL OF CONTEMPORARY MEDICINE 2020. [DOI: 10.16899/jcm.763338] [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] Open
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20
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Cove M, Kellum JA. The End of the Bicarbonate Era? A Therapeutic Application of the Stewart Approach. Am J Respir Crit Care Med 2020; 201:757-758. [PMID: 31658424 PMCID: PMC7124708 DOI: 10.1164/rccm.201910-2003ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Matthew Cove
- Department of MedicineNational University Health SystemSingapore, Singaporeand
| | - John A Kellum
- Department of Critical Care MedicineUniversity of PittsburghPittsburgh, Pennsylvania
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21
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Use of Sodium Bicarbonate During Pediatric Cardiac Admissions with Cardiac Arrest: Who Gets It and What Does It Do? CHILDREN-BASEL 2019; 6:children6120136. [PMID: 31888123 PMCID: PMC6955993 DOI: 10.3390/children6120136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/15/2019] [Accepted: 12/01/2019] [Indexed: 11/16/2022]
Abstract
The objectives of this study were to characterize the use of sodium bicarbonate in pediatric cardiac admissions that experience cardiac arrest, to determine sodium bicarbonate use over the years, and to determine the impact of sodium bicarbonate on length of admissions, billed charges, and inpatient mortality. A cross-sectional study was conducted utilizing the Pediatric Health Information System database. Characteristics of admissions with and without sodium bicarbonate were initially compared by univariate analyses. The frequency by which sodium bicarbonate was used was compared by year. Regression analyses were conducted to determine the impact of sodium bicarbonate on length of stay, billed charges, and inpatient mortality. A total of 3987 (50.3%) of pediatric cardiac intensive care admissions with cardiac arrest utilized sodium bicarbonate; however, frequency changed from 62.1% in 2004 to 43.7% in 2015. Linear regression analysis demonstrated a decrease in length of stay (-27.5 days, p < 0.01) and billed charges (-$470,906, p < 0.01). Logistic regression analysis demonstrated an increase in mortality (odds ratio 1.77, 95% confidence interval 1.56-2.01). In conclusion, sodium bicarbonate is being used with less frequency over the last years in pediatric cardiac admissions with cardiac arrest. After adjustment for cardiac diagnoses, comorbidities, vasoactive medications, and other resuscitation medications, sodium bicarbonate is independently associated with increased mortality.
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Ramachandran S, Wyckoff M. Drugs in the delivery room. Semin Fetal Neonatal Med 2019; 24:101032. [PMID: 31588028 DOI: 10.1016/j.siny.2019.101032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The need for cardiopulmonary resuscitation in newborns is quite rare, as most non-vigorous infants respond well to effective ventilation. For the minority of babies who do not respond to adequate ventilation, chest compressions are necessary using the preferred two thumb technique. Since effective ventilation remains a key component to successful resuscitation, chest compressions are coordinated with ventilations in a 3:1 ratio. If despite adequate ventilation and compressions, the heart rate remains below 60 beats per minute, epinephrine is indicated. The intravenous route is preferred over the endotracheal route and the recommended dose of epinephrine is 0.01-0.03 mg/kg. This can be repeated every 3-5 min until return of spontaneous circulation is achieved. In rare instances, when there is no response to these above measures and in infants who show evidence of significant hypovolemia, volume replacement should be considered.
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Affiliation(s)
- Shalini Ramachandran
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UTSouthwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Myra Wyckoff
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UTSouthwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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Doubova SV, Josefa-García H, Coronado-Zarco IA, Carrera-Muiños S, Cordero-Gonzalez G, Cruz-Reynoso L, Mateos-Sanchez L, Maya-García AJ, Pérez-Cuevas R. Evaluating the quality of the processes of care and clinical outcomes of premature newborns admitted to neonatal intensive care units in Mexico. Int J Qual Health Care 2019; 30:608-617. [PMID: 29722867 DOI: 10.1093/intqhc/mzy061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 03/20/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives To develop quality of care (QoC) indicators, evaluate the quality of the processes of care (QPC) and clinical outcomes, and analyze the association between the QPC and severe clinical outcomes of preterm newborns admitted to neonatal intensive care units (NICUs). Design Mixed methods approach: (1) development of QoC indicators via modified RAND/UCLA method; (2) cross-sectional study of QoC evaluation and (3) multiple logistic regression analysis to ascertain the association between the QPC and severe clinical outcomes. Setting Two NICUs belonged to the Mexican Institute of Social Security in Mexico City. Participants About 489 preterm neonates (<37 weeks of gestation) without severe congenital anomalies. Main Outcome Measure(s) The QoC indicators; ≥60% of recommended QPC and severe clinical outcomes. Results The QoC included 10 QPC indicators across four domains: respiratory, nutrition and metabolism, infectious diseases, and screening, and five outcome indicators. The lower QPC indicators were for the nutrition and metabolism domain (17.8% started enteral feeding with human milk, and 20.7% received sodium bicarbonate appropriately). The higher QPC indicator was for the screening domain (97.6% of neonates <30 weeks gestation underwent early (≤14 days) transfontanelar ultrasound). The mean recommended QPC that neonates received was 47.5%. Only 26.6% of neonates received ≥60% of recommended QPC. About 60.7% of neonates developed severe clinical outcomes including mortality and healthcare-related major morbidity. Receiving ≥60% of recommended QPC was associated with a decrease of nearly half of odds of severe clinical outcomes. Conclusion The evaluation of the QoC in NICUs is essential to address modifiable gaps in quality.
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Affiliation(s)
- Svetlana V Doubova
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Heladia Josefa-García
- Unidad de Cuidados Intensivos Neonatales del Hospital de Pediatría del CMN Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Sandra Carrera-Muiños
- Unidad de Cuidados Intensivos Neonatales, Instituto Nacional de Perinatología, Mexico City, Mexico
| | | | - Leonardo Cruz-Reynoso
- División de pediatría, Hospital Gineco Obstetrica No 3 CMN 'LA RAZA', Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Leovigildo Mateos-Sanchez
- Unidad de Cuidados Intensivos Neonatales, Hospital de Gineco Obstetricia No. 4, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Ana Jesica Maya-García
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Ricardo Pérez-Cuevas
- Health System Research Center, National Institute of Public Health, Cuernavaca City, Mexico
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Muir W. Effect of Intravenously Administered Crystalloid Solutions on Acid-Base Balance in Domestic Animals. J Vet Intern Med 2017; 31:1371-1381. [PMID: 28833697 PMCID: PMC5598900 DOI: 10.1111/jvim.14803] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/30/2017] [Accepted: 07/13/2017] [Indexed: 12/28/2022] Open
Abstract
Intravenous fluid therapy can alter plasma acid-base balance. The Stewart approach to acid-base balance is uniquely suited to identify and quantify the effects of the cationic and anionic constituents of crystalloid solutions on plasma pH. The plasma strong ion difference (SID) and weak acid concentrations are similar to those of the administered fluid, more so at higher administration rates and with larger volumes. A crystalloid's in vivo effects on plasma pH are described by 3 general rules: SID > [HCO3-] increases plasma pH (alkalosis); SID < [HCO3-] decreases plasma pH (alkalosis); and SID = [HCO3-] yields no change in plasma pH. The in vitro pH of commercially prepared crystalloid solutions has little to no effect on plasma pH because of their low titratable acidity. Appreciation of IV fluid composition and an understanding of basic physicochemical principles provide therapeutically valuable insights about how and why fluid therapy can produce and correct alterations of plasma acid-base equilibrium. The ideal balanced crystalloid should (1) contain species-specific concentrations of key electrolytes (Na+ , Cl- , K+ , Ca++ , Mg++ ), particularly Na+ and Cl- ; (2) maintain or normalize acid-base balance (provide an appropriate SID); and (3) be isosmotic and isotonic (not induce inappropriate fluid shifts) with normal plasma.
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Affiliation(s)
- W. Muir
- College of Veterinary MedicineLincoln Memorial UniversityHarrogateTN
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Katheria AC, Brown MK, Hassan K, Poeltler DM, Patel DA, Brown VK, Sauberan JB. Hemodynamic effects of sodium bicarbonate administration. J Perinatol 2017; 37:518-520. [PMID: 28206993 DOI: 10.1038/jp.2016.258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 11/09/2016] [Accepted: 12/13/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the hemodynamic changes that occur with sodium bicarbonate (NaHCO3) administration in premature neonates. STUDY DESIGN This retrospective study included premature neonates 23 to 31+6 weeks of gestational age who underwent continuous cardiac and cerebral monitoring as participants in prospective trials at our institution, and who received NaHCO3 infused over 30 min in the first 24 h of life. Blood pressure (BP), heart rate, cardiac output (CO), SpO2 and cerebral oximetry (StO2) were captured every 2 s. A baseline was established for all continuous data and averaged over the 10 min before NaHCO3 administration. Baseline was compared with measurements over 10 min epochs until 80 min after administration. Arterial blood gases before and within 1 h of administration were also compared. Significance was set at P<0.05. RESULTS A total of 36 subjects received NaHCO3 (1.3±0.3 mEq kg-1) in the first 24 h (14±8.5 h) of life. NaHCO3 administration increased pH (7.23 vs 7.28, P<0.01) and decreased base deficit (-8.9 vs -6.8, P<0.01) and PaCO2 (45 vs 43 mm Hg, P<0.05). There was a transient but significant (P<0.05) decrease in systemic BP coinciding with an increase in cerebral oxygenation without an increase in oxygen extraction. CO did not change. CONCLUSION Early postnatal NaHCO3 administration does not acutely improve CO but does cause transient fluctuations in cerebral and cardiovascular hemodynamics in extremely premature infants.
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Affiliation(s)
- A C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - M K Brown
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - K Hassan
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - D M Poeltler
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - D A Patel
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - V K Brown
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - J B Sauberan
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
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Jetton JG, Sorenson M. Pharmacological management of acute kidney injury and chronic kidney disease in neonates. Semin Fetal Neonatal Med 2017; 22:109-115. [PMID: 27720664 DOI: 10.1016/j.siny.2016.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Both acute kidney injury (AKI) and chronic kidney disease (CKD) are seen more frequently in the neonatal intensive care unit (NICU) as advances in supportive care improve the survival of critically ill infants as well as those with severe, congenital kidney and urinary tract anomalies. Many aspects of the infant's care, including fluid balance, electrolyte and mineral homeostasis, acid-base balance, and growth and nutrition require close monitoring by and collaboration among neonatologists, nephrologists, dieticians, and pharmacologists. This educational review summarizes the therapies widely used for neonates with AKI and CKD. Use of these therapies is extrapolated from data in older children and adults or based on clinical experience and case series. There is a critical need for more research on the use of therapies in infants with kidney disease as well as for the development of drug delivery systems and preparations scaled more appropriately for these small patients.
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Affiliation(s)
- Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA.
| | - Mark Sorenson
- Department of Pharmaceutical Care, University of Iowa Children's Hospital, Iowa City, IA, USA
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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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28
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Bailey SM, Mally PV. Review of splanchnic oximetry in clinical medicine. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:091306. [PMID: 27165703 DOI: 10.1117/1.jbo.21.9.091306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/13/2016] [Indexed: 06/05/2023]
Abstract
Global tissue perfusion and oxygenation are important indicators of physiologic function in humans. The monitoring of splanchnic oximetry through the use of near-infrared spectroscopy (NIRS) is an emerging method used to assess tissue oxygenation status. Splanchnic tissue oxygenation (SrSO2) is thought to be potentially of high value in critically ill patients because gastrointestinal organs can often be the first to suffer ischemic injury. During conditions of hypovolemia, cardiac dysfunction, or decreased oxygen-carrying capacity, blood flow is diverted toward vital organs, such as the brain and the heart at the expense of the splanchnic circulation. While monitoring SrSO2 has great potential benefit, there are limitations to the technology and techniques. SrSO2 has been found to have a relatively high degree of variability that can potentially make it difficult to interpret. In addition, because splanchnic organs only lie near the skin surface in children and infants, and energy from currently available sensors only penetrates a few centimeters deep, it can be difficult to use clinically in a noninvasive manner in adults. Research thus far is showing that splanchnic oximetry holds great promise in the ability to monitor patient oxygenation status and detect disease states in humans, especially in pediatric populations.
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Fost N. Informed Consent Should Be a Required Element for Newborn Screening, Even for Disorders with High Benefit-Risk Ratios. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2016; 44:241-255. [PMID: 27338600 DOI: 10.1177/1073110516654118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Over-enthusiastic newborn screening has often caused substantial harm and has been imposed on the public without adequate information on benefits and risks and without parental consent. This problem will become worse when genomic screening is implemented. For the past 40 years, there has been broad agreement about the criteria for ethically responsible screening, but the criteria have been systematically ignored by policy makers and practitioners. Claims of high benefit and low risk are common, but they require precise definition and documentation, which has often not occurred, undermining claims that involuntary testing is justified. Even when the benefits and risks are well established, it does not automatically follow that involuntary testing is justified, a position supported by the widespread tolerance for parental refusal of immunizations and newborn screening.
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Affiliation(s)
- Norman Fost
- Norman Fost, M.D., M.P.H., Professor Emeritus of Pediatrics at the University of Wisconsin, founded the Bioethics Program and the Child Protection Team at UW in 1973. He was been Chair of the Hospital Ethics Committee since 1984, and, for 31 years, chaired the Health Sciences Institutional Review Board. Dr. Fost has received lifetime achievement awards from the American Academy of Pediatrics and the Office of Human Subjects Protection, and was the first recipient of the Patricia Price Browne Prize in Bioethics. He has served on the FDA Pediatric Advisory Committee and is a member of the NIH Recombinant DNA Advisory Committee
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Axelrod DM, Chock VY, Reddy VM. Management of the Preterm Infant with Congenital Heart Disease. Clin Perinatol 2016; 43:157-71. [PMID: 26876128 DOI: 10.1016/j.clp.2015.11.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The premature neonate with congenital heart disease (CHD) represents a challenging population for clinicians and researchers. The interaction between prematurity and CHD is poorly understood; epidemiologic study suggests that premature newborns are more likely to have CHD and that fetuses with CHD are more likely to be born premature. Understanding the key physiologic features of this special patient population is paramount. Clinicians have debated optimal timing for referral for cardiac surgery, and management in the postoperative period has rapidly advanced. This article summarizes the key concepts and literature in the care of the premature neonate with CHD.
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Affiliation(s)
- David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, 750 Welch Road, Suite 321, Palo Alto, CA 94304, USA.
| | - Valerie Y Chock
- Division of Neonatology, Department of Pediatrics, Stanford University Medical Center, 750 Welch Road, Suite 315, MC 5731, Palo Alto, CA 94304, USA
| | - V Mohan Reddy
- Pediatric Cardiothoracic Surgery, University of California San Francisco Medical Center, 550 16th Street, Floor 5, MH5-745, San Francisco, CA 94143-0117, USA
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Costa ACDO, Schettino RDC, Ferreira SC. [Predictors of extubation failure and reintubation in newborn infants subjected to mechanical ventilation]. Rev Bras Ter Intensiva 2015; 26:51-6. [PMID: 24770689 PMCID: PMC4031885 DOI: 10.5935/0103-507x.20140008] [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: 08/22/2013] [Accepted: 01/14/2014] [Indexed: 11/20/2022] Open
Abstract
Objective To identify risk factors for extubation failure and reintubation in newborn
infants subjected to mechanical ventilation and to establish whether ventilation
parameters and blood gas analysis behave as predictors of those outcomes. Methods Prospective study conducted at a neonatal intensive care unit from May to November
2011. A total of 176 infants of both genders subjected to mechanical ventilation
were assessed after extubation. Extubation failure was defined as the need to
resume mechanical ventilation within less than 72 hours. Reintubation was defined
as the need to reintubate the infants any time after the first 72 hours. Results Based on the univariate analysis, the variables gestational age <28 weeks,
birth weight <1,000g and low Apgar scores were associated with extubation
failure and reintubation. Based on the multivariate analysis, the variables length
of mechanical ventilation (days), potential of hydrogen (pH) and partial pressure
of oxygen (pO2) remained associated with extubation failure, and the
five-minute Apgar score and age at extubation were associated with
reintubation. Conclusion Low five-minute Apgar scores, age at extubation, length of mechanical ventilation,
acid-base disorders and hyperoxia exhibited associations with the investigated
outcomes of extubation failure and reintubation.
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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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Effects of sodium bicarbonate correction of metabolic acidosis on regional tissue oxygenation in very low birth weight neonates. J Perinatol 2015; 35:601-6. [PMID: 25927273 DOI: 10.1038/jp.2015.37] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/20/2015] [Accepted: 02/23/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the effects of sodium bicarbonate (NaHCO3) correction of metabolic acidosis on cardiopulmonary, laboratory, and cerebral, renal and splanchnic regional oxygen saturation (rSO2) and fractional tissue oxygen extraction (FTOE) in extremely premature neonates during the first postnatal week. STUDY DESIGN Observational cohort data were collected from 500 to 1250 g neonates who received NaHCO3 'half' corrections (0.3 * Weight (kg) * Base Deficit (mmol l(-1))) for presumed renal losses. RESULT Twelve subjects with normal blood pressure and heart rate received 17 NaHCO3 corrections. Mean (±s.d.) gestational age was 27±2 week and birth weight was 912±157 g. NaHCO3 corrections provided a mean (±s.d.) 4.5±1.0 ml kg(-1) fluid bolus, shifted mean (±s.d.) base deficit from 7.6±1.8 to 3.4±2.1 mmol l(-1) (P<0.05), and increased median (±s.d.) pH from 7.23±0.06 to 7.31±0.05 (P<0.05). No significant changes in blood pressure, pulse oximetry, PCO2, lactate, sodium, blood urea nitrogen, creatinine or hematocrit were observed. Cerebral, renal and splanchnic rSO2 (74%, 66% and 44%, respectively, at baseline) and FTOE (0.21, 0.29 and 0.52, respectively, at baseline) were unchanged following NaHCO3 correction. CONCLUSION NaHCO3 infusions decreased base deficits and increased pH though produced no discernible effects or benefits on cardiopulmonary parameters including rSO2 and FTOE. These findings warrant further prospective evaluation in larger populations with more significant metabolic acidosis to determine the utility of tissue oxygenation monitoring in differentiating metabolic acidosis due to oxygen delivery/consumption imbalance versus renal bicarbonate losses.
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Extracorporeal Membrane Oxygenation in Pediatric Trisomy 21: 30 Years of Experience from the Extracorporeal Life Support Organization Registry. J Pediatr 2015; 167:403-8. [PMID: 25982140 DOI: 10.1016/j.jpeds.2015.04.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/12/2015] [Accepted: 04/15/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the use of extracorporeal membrane oxygenation (ECMO) in patients with trisomy 21 (T21), to identify risk factors for hospital mortality, and to compare outcomes with those of patients without T21. STUDY DESIGN Children under age 18 years registered in the Extracorporeal Life Support Organization Registry were included. Comparisons between patients with T21 and patients without T21 were performed using the χ(2) or Wilcoxon rank-sum test and multivariable logistic regression. RESULTS The study cohort included 623 patients with T21 and 46 239 patients without T21. The prevalence of T21 was 13.5/1000 patients receiving ECMO. ECMO utilization in patients with T21 increased over time, with 60% of cases occurring in the last decade. There was no significant difference in survival between patients without T21 and those with T21 (63% vs 57%; P = .23). In patients with T21, independent risk factors for mortality before cannulation were a cardiac indication for ECMO support and milrinone use (P ≤ .001 for both). Multivariable risk factors for mortality on ECMO included hemorrhagic, neurologic, renal, and pulmonary complications (P < .04 for all). CONCLUSION The use of ECMO in patients with T21 has increased over time. Patients with a cardiac indication for ECMO have higher mortality compared with those supported for respiratory indications. Despite differences in indications for ECMO, patients with T21 have similar hospital survival as those without T21; thus, by itself, a diagnosis of T21 should not be considered a risk factor for in-hospital mortality when contemplating ECMO cannulation.
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Danhauser K, Smeitink JAM, Freisinger P, Sperl W, Sabir H, Hadzik B, Mayatepek E, Morava E, Distelmaier F. Treatment options for lactic acidosis and metabolic crisis in children with mitochondrial disease. J Inherit Metab Dis 2015; 38:467-75. [PMID: 25687154 DOI: 10.1007/s10545-014-9796-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 10/30/2014] [Accepted: 11/13/2014] [Indexed: 12/15/2022]
Abstract
The mitochondrial pyruvate oxidation route is a tightly regulated process, which is essential for aerobic cellular energy production. Disruption of this pathway may lead to severe neurometabolic disorders with onset in early childhood. A frequent finding in these patients is acute and chronic lactic acidemia, which is caused by increased conversion of pyruvate via the enzyme lactate dehydrogenase. Under stable clinical conditions, this process may remain well compensated and does not require specific therapy. However, especially in situations with altered energy demands, such as febrile infections or longer periods of fasting, children with mitochondrial disorders have a high risk of metabolic decompensation with exacerbation of hyperlactatemia and severe metabolic acidosis. Unfortunately, no controlled studies regarding therapy of this critical condition are available and clinical outcome is often unfavorable. Therefore, the aim of this review was to formulate expert-based suggestions for treatment of these patients, including dietary recommendations, buffering strategies and specific drug therapy. However, it is important to keep in mind that a specific therapy for the underlying metabolic cause in children with mitochondrial diseases is usually not available and symptomatic therapy especially of severe lactic acidosis has its ethical limitations.
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Affiliation(s)
- Katharina Danhauser
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine University, Moorenstr. 5, D-40225, Düsseldorf, Germany
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Metabolic acidosis in the first 14 days of life in infants of gestation less than 26 weeks. Eur J Pediatr 2015; 174:49-54. [PMID: 24969340 DOI: 10.1007/s00431-014-2364-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/31/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Extremely immature newborns develop a self-limiting normal anion gap metabolic acidosis in early life. This study examined the natural history of this acidosis in a population of infants of gestation less than 26 weeks in the first 14 days of life. The acidosis was maximal on day 4 with a mean base deficit of 10.6 mmol/l and had resolved in 90 % of infants by day 11. Dopamine usage was the only independent predictor of the acidosis. Its use was associated with a greater degree of acidosis. CONCLUSION Extremely preterm infants experience a self-limiting normal anion gap metabolic acidosis in the first 2 weeks of life which is consistent with renal tubular immaturity.
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Abstract
Comparative effectiveness research (CER) is a relatively new term for clinical research that directly assists patients, clinicians, and policymakers in making informed decisions to improve health care. In neonatology, there are similarities and differences between CER and existing clinical research and quality improvement literature. This article uses existing examples in neonatal literature to describe CER methodology and list some future directions and challenges in neonatal CER.
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Labenne M, Paut O. Arrêt cardiaque chez l’enfant : définition, épidémiologie, prise en charge et pronostic. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jeurea.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. Sodium bicarbonate therapy in patients with metabolic acidosis. ScientificWorldJournal 2014; 2014:627673. [PMID: 25405229 PMCID: PMC4227445 DOI: 10.1155/2014/627673] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 01/18/2023] Open
Abstract
Metabolic acidosis occurs when a relative accumulation of plasma anions in excess of cations reduces plasma pH. Replacement of sodium bicarbonate to patients with sodium bicarbonate loss due to diarrhea or renal proximal tubular acidosis is useful, but there is no definite evidence that sodium bicarbonate administration to patients with acute metabolic acidosis, including diabetic ketoacidosis, lactic acidosis, septic shock, intraoperative metabolic acidosis, or cardiac arrest, is beneficial regarding clinical outcomes or mortality rate. Patients with advanced chronic kidney disease usually show metabolic acidosis due to increased unmeasured anions and hyperchloremia. It has been suggested that metabolic acidosis might have a negative impact on progression of kidney dysfunction and that sodium bicarbonate administration might attenuate this effect, but further evaluation is required to validate such a renoprotective strategy. Sodium bicarbonate is the predominant buffer used in dialysis fluids and patients on maintenance dialysis are subjected to a load of sodium bicarbonate during the sessions, suffering a transient metabolic alkalosis of variable severity. Side effects associated with sodium bicarbonate therapy include hypercapnia, hypokalemia, ionized hypocalcemia, and QTc interval prolongation. The potential impact of regular sodium bicarbonate therapy on worsening vascular calcifications in patients with chronic kidney disease has been insufficiently investigated.
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Affiliation(s)
- María M. Adeva-Andany
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Carlos Fernández-Fernández
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - David Mouriño-Bayolo
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Elvira Castro-Quintela
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Alberto Domínguez-Montero
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
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Camacho CL, Corral ET, Garcia-Ochoa JMB, Florez IM, de Elias RH, Rey CPP. Acidosis in ventricular fibrillation: Does the administration of sodium bicarbonate (SB) prevent from or delay return of spontaneous circulation (REC)? Resuscitation 2014. [DOI: 10.1016/j.resuscitation.2014.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
The renal system plays a tremendous role in growth and development of infants and children. The kidney itself also undergoes a maturation process as it transitions from the fetal to the extrauterine environment. Renal function continues to undergo further adaptive changes in the neonatal period. It is important for the clinician caring for neonates to be aware of the expected fluid shifts, electrolyte handling, and renal functional capacity as these "normal" changes will become quite relevant when medical or surgical pathology is present. The preterm neonates are especially vulnerable due to their functionally immature kidneys. Renal function in the preterm neonate is not only immature at birth but there is a significant delay in the renal function to achieve its full capacity. This review highlights the physiologic adaptations of the kidney and its effects on the body during the neonatal period.
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Affiliation(s)
- Mustafa Sulemanji
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, Massachusetts 02115
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, Massachusetts 02115.
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Sodium bicarbonate--the swings and roundabouts will not stop without randomized evidence. Crit Care Med 2013; 41:2242-3. [PMID: 23979378 DOI: 10.1097/ccm.0b013e31828e9098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sodium bicarbonate causes dose-dependent increases in cerebral blood flow in infants and children with single-ventricle physiology. Pediatr Res 2013; 73:668-73. [PMID: 23403802 PMCID: PMC3724528 DOI: 10.1038/pr.2013.25] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Sodium bicarbonate (NaHCO3) is a common treatment for metabolic acidemia; however, little definitive information exists regarding its treatment efficacy and cerebral hemodynamic effects. This pilot observational study quantifies relative changes in cerebral blood flow (ΔrCBF) and oxy- and deoxyhemoglobin concentrations (ΔHbO2 and ΔHb) due to bolus administration of NaHCO3 in patients with mild base deficits. METHODS Infants and children with hypoplastic left heart syndrome (HLHS) were enrolled before cardiac surgery. NaHCO3 was given as needed for treatment of base deficit. Diffuse optical spectroscopies were used for 15 min postinjection to noninvasively monitor ΔHb, ΔHbO2, and ΔrCBF relative to baseline before NaHCO3 administration. RESULTS Twenty-two anesthetized and mechanically ventilated patients with HLHS (aged 1 d to 4 y) received a median (interquartile range) dose of 1.1 (0.8, 1.8) mEq/kg NaHCO3 administered intravenously over 10-20 s to treat a median (interquartile range) base deficit of -4 (-6, -3) mEq/l. NaHCO3 caused significant dose-dependent increases in ΔrCBF; however, population-averaged ΔHb and ΔHbO2 as compared with those of controls were not significant. CONCLUSIONS Dose-dependent increases in cerebral blood flow (CBF) caused by bolus administration of NaHCO3 are an important consideration in vulnerable populations wherein risk of rapid CBF fluctuations does not outweigh the benefit of treating a base deficit.
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Noori S, Wu TW, Seri I. pH effects on cardiac function and systemic vascular resistance in preterm infants. J Pediatr 2013; 162:958-63.e1. [PMID: 23164307 DOI: 10.1016/j.jpeds.2012.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/24/2012] [Accepted: 10/08/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the effect of pH on cardiac function and systemic vascular resistance (SVR) in preterm infants. STUDY DESIGN In this prospective observational study, we evaluated hemodynamically stable, ≤ 30 weeks' gestation preterm infants during the first 2 postnatal weeks. Cardiac function was assessed by echocardiography at the time of arterial blood draw for clinically indicated blood gas analysis. Data were separately analyzed for the transitional (days 1-3) and post-transitional (days 4-14) periods. RESULTS We evaluated 147 pairs of arterial blood gases and echocardiograms in 29 preterm neonates (gestational age = 26.2 ± 1.5 weeks). Arterial pH ranged from 7.02-7.46. There was no linear relationship between pH and shortening fraction or stress-velocity index in transitional or post-transitional periods. We found a weak negative linear relationship between pH and left ventricular output and a positive linear relationship between pH and SVR only during the post-transitional period. These relationships were maintained after adjustment for the degree of base deficit. Arterial CO2 had effects similar to pH on myocardial function. CONCLUSIONS Unlike adults, myocardial contractility remains relatively unaffected by acidosis even at pH values close to 7.00 in hemodynamically stable preterm neonates during the first 2 postnatal weeks. However, as in adults, worsening acidosis in preterm neonates after the immediate transitional period is associated with a decrease in SVR along with an increase in left ventricular output. Thus, although myocardial contractility remains unaffected in preterm neonates during the first 2 postnatal weeks, the vascular response to acidosis undergoes a relatively rapid postnatal maturational process.
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Affiliation(s)
- Shahab Noori
- Division of Neonatology and the Center for Fetal and Neonatal Medicine, Department of Pediatrics, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA.
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Abstract
UNLABELLED Acute kidney injury frequently develops following the term perinatal hypoxia-ischaemia. Quantifying the degree of acute kidney injury is difficult, however, as the methods currently in use are suboptimal. Acute kidney injury management is largely supportive with little evidence basis for many interventions. This review discusses management strategies and novel biomarkers that may improve diagnosis and management of renal injury following perinatal hypoxia-ischaemia. CONCLUSION Following perinatal hypoxia-ischaemia, acute kidney injury is common. Management of neonatal acute kidney injury is largely supportive. Novel acute kidney injury biomarkers may play a role in optimizing new categorical definitions of renal injury. Studies are needed to investigate the impact of neonatal acute kidney injury on long-term outcome.
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Pitfield AF, Jamal S, Kissoon N. Updates in Pediatric Resuscitation: Recent Advances and Current Concepts. CURRENT PEDIATRICS REPORTS 2013. [DOI: 10.1007/s40124-012-0002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Neonatal mortality is a major health care concern worldwide. Neonatal resuscitation alone does not address most causes of neonatal mortality; caregivers need to be trained in both neonatal resuscitation and stabilization. Neonatal stabilization requires caregivers to evaluate whether babies are at-risk or unwell, to decide what interventions are required, and to act on those decisions. Several programs address neonatal stabilization in a variety of levels of care in both well-resourced and limited health care environments. This article suggests a shift in clinical, educational, and implementation science from a focus on resuscitation to one on the resuscitation-stabilization continuum.
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Affiliation(s)
- Steven A Ringer
- Department of Newborn Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02492, USA
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Infusing sodium bicarbonate suppresses hydrogen peroxide accumulation and superoxide dismutase activity in hypoxic-reoxygenated newborn piglets. PLoS One 2012; 7:e39081. [PMID: 22761724 PMCID: PMC3382246 DOI: 10.1371/journal.pone.0039081] [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: 03/14/2012] [Accepted: 05/16/2012] [Indexed: 11/19/2022] Open
Abstract
Background The effectiveness of sodium bicarbonate (SB) has recently been questioned although it is often used to correct metabolic acidosis of neonates. The aim of the present study was to examine its effect on hemodynamic changes and hydrogen peroxide (H2O2) generation in the resuscitation of hypoxic newborn animals with severe acidosis. Methods Newborn piglets were block-randomized into a sham-operated control group without hypoxia (n = 6) and two hypoxia-reoxygenation groups (2 h normocapnic alveolar hypoxia followed by 4 h room-air reoxygenation, n = 8/group). At 10 min after reoxygenation, piglets were given either i.v. SB (2 mEq/kg), or saline (hypoxia-reoxygenation controls) in a blinded, randomized fashion. Hemodynamic data and blood gas were collected at specific time points and cerebral cortical H2O2 production was continuously monitored throughout experimental period. Plasma superoxide dismutase and catalase and brain tissue glutathione, superoxide dismutase, catalase, nitrotyrosine and lactate levels were assayed. Results Two hours of normocapnic alveolar hypoxia caused cardiogenic shock with metabolic acidosis (pH: 6.99±0.07, HCO3−: 8.5±1.6 mmol/L). Upon resuscitation, systemic hemodynamics immediately recovered and then gradually deteriorated with normalization of acid-base imbalance over 4 h of reoxygenation. SB administration significantly enhanced the recovery of both pH and HCO3− recovery within the first hour of reoxygenation but did not cause any significant effect in the acid-base at 4 h of reoxygenation and the temporal hemodynamic changes. SB administration significantly suppressed the increase in H2O2 accumulation in the brain with inhibition of superoxide dismutase, but not catalase, activity during hypoxia-reoxygenation as compared to those of saline-treated controls. Conclusions Despite enhancing the normalization of acid-base imbalance, SB administration during resuscitation did not provide any beneficial effects on hemodynamic recovery in asphyxiated newborn piglets. SB treatment also reduced the H2O2 accumulation in the cerebral cortex without significant effects on oxidative stress markers presumably by suppressing superoxide dismutase but not catalase activity.
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Kurt A, Ecevit A, Ozkiraz S, Ince DA, Akcan AB, Tarcan A. The use of chloride-sodium ratio in the evaluation of metabolic acidosis in critically ill neonates. Eur J Pediatr 2012; 171:963-9. [PMID: 22215130 DOI: 10.1007/s00431-011-1666-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 12/19/2011] [Indexed: 11/27/2022]
Abstract
Acid-base disturbances have been usually evaluated with the traditional Henderson-Hasselbach method and Stewart's physiochemical approach by quantifying anions of tissue acids (TA). It is hypothesized that an increase in tissue acids during metabolic acidosis would cause a compensatory decrease in the plasma chloride (Cl) relative to sodium (Cl-Na ratio) in order to preserve electroneutral balance. Therefore, we aimed to investigate the use of Cl-Na ratio as a bedside tool to evaluate the identifying raised TA in neonates as an alternative to complex calculations of Stewart's physiochemical approach. This retrospective study was conducted between January 2008 and December 2009. Infants were included in the study when blood gas analysis reveals a metabolic acidosis; pH <7.25 and sHCO(3) concentration was <22 mEq/L. The Cl-Na ratio, sodium-chloride difference (Diff(NaCl)), anion gap (AG), albumin-corrected AG (AG(corr)), strong ion difference (SID), unmeasured anions (UMA), and TA were calculated at each episode of metabolic acidosis. A total of 105 metabolic acidosis episodes occurred in 59 infants during follow-up. Hypochloremic metabolic acidosis occurred in 17 (16%) of samples, and all had increased TA. The dominant component of TA was UMA rather than lactate. There was a negative correlation between the Cl-Na ratio and SID, AG(corr), UMA, and TA. Also, there was a positive correlation between Diff(NaCl) and SID, AG(corr), UMA, and TA. Base deficit and actual bicarbonate performed poorly in identifying the TA. In conclusion, our study suggested that Diff(NaCl) and Cl-Na ratio are simple and fast, and may be an alternative method to complex Stewart's physiochemical approach in identifying raised UMA and TA in critically ill neonates.
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Affiliation(s)
- Abdullah Kurt
- Department of Pediatrics, Division of Neonatology, Baskent University Faculty of Medicine, Ankara, Turkey
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