Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest

Postoperative hypernatremia is associated with worse brain injuries on EEG and MRI following pediatric cardiac surgery

Objectives

Dysnatremia is a common electrolyte disturbance after cardiopulmonary bypass (CPB) surgery for congenital heart disease (CHD) and a known risk factor for adverse neurological events and clinical outcomes. The objective of this study was to evaluate the association of dysnatremia with worse abnormal EEG patterns, brain injuries detected by magnetic resonance imaging (MRI) and early adverse outcomes.

Methods

We monitored continuous EEG in 340 children during the initial 48 h following cardiac surgery. Demographics and clinical characteristics were recorded. Sodium concentrations were measured in the arterial blood gas analysis every 6 h. Hyponatremia and hypernatremia were classified by the average of sodium concentrations over 48 h. Postoperative cerebral MRI was performed before hospital discharge.

Results

In our patient cohort, dysnatremia was present in 46 (13.5%) patients. Among them, hyponatremia occurred in 21 (6.2%) and hypernatremia in 25 (7.4%). When compared to patients with normonatremia, hyponatremia was not associated with EEG abnormalities and early adverse outcomes (Ps ≥ .14). In hypernatremia group, the CPB time was significantly longer and more frequent use of DHCA (Ps ≤ .049). After adjusting for time, CPB time and the use of DHCA, hypernatremia was significantly associated with worse EEG abnormalities (including background, seizures and pathological delta brushes), more severe brain injuries on MRI (Ps ≤ .04) and trended to be associated with longer postoperative mechanical ventilation time (P = .06).

Conclusion

Hypernatremia and hyponatremia were common in children after cardiac surgery. Hypernatremia, but not hyponatremia, was significantly associated with worse EEG abnormalities and more severe brain injuries on MRI and extended postoperative mechanical ventilation time.

Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest

BACKGROUND

Sodium bicarbonate ("bicarb") administration in out-of-hospital cardiac arrest (OHCA) is intended to counteract acidosis, although there is limited clinical evidence to support its routine administration. We sought to analyze the association of bicarb with resuscitation outcomes in non-traumatic OHCA.

METHODS

Records were obtained from the 2019-2020 ESO Data Collaborative prehospital electronic health record database, spanning 1,322 agencies in 50 states. OHCAs with resuscitations lasting 5-40 minutes were stratified by presenting ECG rhythm (VF/VT, pulseless electrical activity (PEA), asystole) for analysis. The outcomes of any prehospital ROSC and survival to discharge were compared by bicarb status using propensity score matching and logistic regressions with/without adjustment.

RESULTS

We analyzed 23,567 records, 6,663 (28.3 %) of which included bicarb administration. Most patients presented in asystole (67.4 %), followed by PEA (16.6 %), and VF/VT (15.1 %). In the propensity-matched cohort, ROSC was higher in the bicarb group for the asystole group (bicarb 10.6 % vs control 8.8 %; p = 0.013), without differences in the PEA or VF/VT groups. Survival was higher in the bicarb group for asystole (bicarb 3.3 % vs control 2.4 %; p = 0.020) and for PEA (bicarb 8.1 % vs control 5.4 %; p = 0.034), without differences in the VF/VT group. These results were consistent across adjusted/unadjusted logistic regression analyses: bicarb was associated with ROSC and survival in asystole [uOR (95 % CI): ROSC 1.23 (1.04-1.44), survival 1.40 (1.05-1.87)] and with survival in PEA (1.54 (1.03-2.31).

CONCLUSIONS

Bicarb was associated with survival in non-shockable rhythms and ROSC in asystole. Findings from this observational study should be corroborated with prospective randomized work.

Association Between Hypernatremia and Delirium After Cardiac Surgery: A Nested Case-Control Study

Background

The association between hypernatremia and delirium after cardiac surgery has rarely been investigated. This study aimed to determine whether hypernatremia increases the risk of delirium after exposure.

Materials and Methods

From April 2016 to June 2021, 7,831 consecutive patients receiving cardiac surgery were screened for potential enrollment. The primary outcome was postoperative delirium (POD). For the respective case of delirium, 10 controls were matched according to the index date within the nested case-control design. Hypernatremia exposure was defined as serum sodium > 145 mmol/L within 7 days before the index date. A generalized estimation equation was performed to assess excess risks for POD associated with hypernatremia, adjusted for demographics and clinical variables.

Results

About 7,277 patients were included in the final analyses. About 669 (9.2%) patients with POD were assigned to the case group, and 6,690 controls were identified from the whole population. About 66.5% of the cases and 36.3% of the controls had hypernatremia exposure. After being adjusted to certain well-recognized confounding factors, hypernatremia showed a significant correlation with increased risk of delirium after cardiac surgery (adjusted OR, 1.73; 95% CI, 1.41~2.12). An e-value analysis suggested the robustness to unmeasured confounding.

Conclusions

Hypernatremia was associated with an increased risk of delirium after cardiac surgery. This finding could have implications for risk stratification, early detection, and management of delirium in patients receiving cardiac surgery.

Intravesical mitomycin C (MMC) and MMC + cytosine arabinoside for non-muscle-invasive bladder cancer: a randomised clinical trial

Objectives

To compare the urinary pH, recurrence‐free survival (RFS), and safety of adjuvant intravesical therapy in patients with non‐muscle‐invasive bladder cancer (NMIBC) receiving mitomycin C (MMC) therapy and MMC + cytosine arabinoside (Ara‐C) therapy.

Patients and Methods

A total of 165 patients with NMIBC from six hospitals were randomly allocated to two groups: weekly instillation of MMC + Ara‐C (30 mg/30 mL + 200 mg/10 mL) for 6 weeks and the same instillation schedule of MMC (30 mg/40 mL). The primary outcome was RFS, and secondary outcomes were urinary pH and toxicity in the two groups.

Results

A total of 81 and 87 patients were randomised into the MMC and MMC + Ara‐C groups, respectively. Overall, the RFS in the MMC + Ara‐C group was significantly longer (P = 0.018) than that in the MMC group. A similar significant difference was detected in patients with intermediate‐risk NMIBC, but not in those with high‐risk NMIBC. The mean (SD) urinary pH was significantly higher in the MMC + Ara‐C group than in the MMC group, at 6.56 (0.61) vs 5.78 (0.64) (P < 0.001), and the frequency of a urinary pH of >7.0 in the MMC and MMC + Ara‐C groups was 6.3% and 26.7%, respectively (P < 0.001). Multivariate analysis models including clinicopathological features and second transurethral resection demonstrated that increased urinary pH was associated with better outcomes (hazard ratio 0.18, 95% confidential interval 0.18–0.038; P < 0.001). In all, there were 14 and 10 adverse events in the MMC and MMC + Ara‐C groups, respectively, without a significant difference (P = 0.113).

Conclusions

Our randomised clinical trial suggested that intravesical therapy with MMC and Ara‐C is useful and safe for patients with intermediate‐risk NMIBC. Increase in urinary pH with Ara‐C is speculated as a mechanism for increased anti‐cancer effects.

Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review

Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.

Concentration and Volume: Understanding Sodium and Water in the Body

Nurses need to have a firm grasp of normal and pathophysiological mechanisms of sodium and water balance to fully understand assessment findings and establish a rationale for a patient's plan of care. While multiple mechanisms control sodium and water balance, antidiuretic hormone and aldosterone are the most important hormonal influences. This article, the first in a new series designed to improve nurses' understanding of the physiological abnormalities underlying many disorders, reviews the common etiologies and symptoms of hyponatremia and hypernatremia, as well as the role of nursing care in patients with imbalances of sodium and water. Case studies guide the reader through relevant medical history and examination findings to an understanding of both the nursing and medical plans of care.

Sodium homeostasis in the tumour microenvironment

The concentration of sodium ions (Na+) is raised in solid tumours and can be measured at the cellular, tissue and patient levels. At the cellular level, the Na+ gradient across the membrane powers the transport of H+ ions and essential nutrients for normal activity. The maintenance of the Na+ gradient requires a large proportion of the cell's ATP. Na+ is a major contributor to the osmolarity of the tumour microenvironment, which affects cell volume and metabolism as well as immune function. Here, we review evidence indicating that Na+ handling is altered in tumours, explore our current understanding of the mechanisms that may underlie these alterations and consider the potential consequences for cancer progression. Dysregulated Na+ balance in tumours may open opportunities for new imaging biomarkers and re-purposing of drugs for treatment.

Perioperative management of the bleeding patient

Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.