Early metabolic acidosis in critically ill patients: a binational multicentre study

Fasting in critical illness: the role of ketonuria - a retrospective observational study

BACKGROUND

Metabolic acidosis is a frequent finding in patients admitted to the intensive care unit (ICU). It can be caused by prolonged fasting due to surgical procedures or by medical conditions that lead to starvation ketoacidosis (SKA). Early recognition and treatment of SKA could prevent several life-threatening complications, improving survival and reducing the ICU length of stay.

METHODS

We retrospectively screened all medical records of patients admitted to the ICU (Maggiore Hospital, Bologna, North Italy) from May 2022 to April 2023. We included patients aged 18 years or older who presented ketonuria detected in the urine sample.

RESULTS

We analyzed 190 patients with ketonuria at ICU admission. Postsurgical patients showed lower levels of albumin and a higher rate of shock compared to medical patients. Ketonuric patients with shock had a lower body mass index (BMI) compared to patients without shock (24 versus 26 kg/m2, respectively). There were no differences within groups regarding mortality and ICU readmission rate. Medical patients had a significantly higher ICU length of stay.

CONCLUSIONS

This retrospective observational descriptive study showed that patients with ketonuria, hypoalbuminemia, and low BMI at ICU admission have high risk of hemodynamic instability and shock. Surgical patients compared to medical patients are exposed to a catabolic trigger that could worsen a state of malnutrition and induce anabolic resistance; elective and urgent surgical patients did not differ in terms of risk of shock and mortality, probably due to the activation of this catabolic pathway. Early recognition and treatment of starvation ketoacidosis and perioperative nutritional optimization could reduce incidence of hemodynamic and metabolic complications.

Effect of early clinical management on metabolic acidemia in neonates with hypoxic-ischemic encephalopathy

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.

Fluid Overload Phenotypes in Critical Illness-A Machine Learning Approach

BACKGROUND

The detrimental impact of fluid overload (FO) on intensive care unit (ICU) morbidity and mortality is well known. However, research to identify subgroups of patients particularly prone to fluid overload is scarce. The aim of this cohort study was to derive "FO phenotypes" in the critically ill by using machine learning techniques.

METHODS

Retrospective single center study including adult intensive care patients with a length of stay of ≥3 days and sufficient data to compute FO. Data was analyzed by multivariable logistic regression, fast and frugal trees (FFT), classification decision trees (DT), and a random forest (RF) model.

RESULTS

Out of 1772 included patients, 387 (21.8%) met the FO definition. The random forest model had the highest area under the curve (AUC) (0.84, 95% CI 0.79-0.86), followed by multivariable logistic regression (0.81, 95% CI 0.77-0.86), FFT (0.75, 95% CI 0.69-0.79) and DT (0.73, 95% CI 0.68-0.78) to predict FO. The most important predictors identified in all models were lactate and bicarbonate at admission and postsurgical ICU admission. Sepsis/septic shock was identified as a risk factor in the MV and RF analysis.

CONCLUSION

The FO phenotypes consist of patients admitted after surgery or with sepsis/septic shock with high lactate and low bicarbonate.