Acid-base Derangements Research Articles

Contaminated well water driving d‐lactic acidosis in child with short bowel syndrome

Abstractd‐lactic acidosis is a rare type of lactic acidosis that typically presents in patients with short bowel syndrome (SBS). Clinical features include a high anion‐gap metabolic acidosis and acute onset of neurological impairment. The underlying pathology is thought to be due to altered gut flora and carbohydrate malabsorption in patients with altered gut anatomy. The treatment centers on correcting acid–base derangements, dietary modifications to decrease carbohydrate intake and antibiotics. We present a case of recurrent d‐lactic acidosis in a patient with SBS. In this unique case, we highlight the importance of considering the home environment when developing a treatment plan.

Demographic and clinical status of the neonates admitted to an intensive care unit in Bangladesh

Background: The neonatal intensive care unit is a fundamental sector for the survival of high-risk newborns. Such a unit involves high-complexity assistance with teams trained in newborn care, reconciling technological advances with proper approaches to humanized care practices. Usually, the outcomes of neonatal intensive care unit patients depend upon the demographic and clinical status of the patients. In Bangladesh, we have very limited research-based information regarding this issue. This study aimed to assess the demographic and clinical status of neonates admitted to an intensive care unit in Bangladesh. Methods: This was an observational cohort study that was conducted in the Neonatal Intensive Care Unit (I.C.U.) of Dhaka Shishu Hospital, Dhaka, Bangladesh during the period from October 2009 to September 2010. In total 230 neonates admitted to the Neonatal Intensive Care Unit, after fulfilling the inclusion criteria were enrolled in this study as study subjects. Properly written consent was taken in favour of all the participants before data collection. All data were processed, analysed and disseminated by using MS Excel and SPSS version 15.0 program as per necessity. Results: Among the total of 230 participants, the male-female ratio was 1.7:1 and gestational age was found as >37 weeks in 60% of neonates. The age of the majority of the neonates (53%) was <7 days. The diaphragmatic hernia was present in the highest number (n=17) of cases as a single congenital anomaly. As the disease pattern, perinatal asphyxia with complications, preterm low birth weight with sepsis and congenital anomalies were found in 24.8%, 20.4% and 23% of cases respectively. Among the total of our patients, in 55% of cases, acid-base derangements were present. Conclusions: The higher frequency of ICU admission of male neonates is alarming for the neonatal care system. The first week of neonatal ICU may be considered the most critical period, especially for preterm babies. Neonates with perinatal asphyxia, preterm low birth weight with sepsis and congenital anomalies are some common features among neonatal ICU care patients.

Frequency of Acid-Base Derangements Among the Neonates Admitted to the Intensive Care Unit

Background: Every year deranged acid-base physiology drives admission to a critical care arena for a vast number of neonates. The neonatal intensive care unit is a fundamental sector for the survival of high-risk newborns. The acid-base disorder must always be considered in the clinical setting. The clinician should, in most cases, be able to predict the type of acid-base imbalance before the blood gas is available. Arterial blood gases (ABG-s) are the gold standard for assessing the adequacy of oxygen delivery, ventilation, and pH. This study aimed to assess the frequency of acid-base derangements among neonates admitted to the intensive care unit. Material & Methods: This was an observational cohort study that was conducted in the Neonatal Intensive Care Unit (I.C.U.) of Dhaka Shishu Hospital, Dhaka, Bangladesh during the period from October 2009 to September 2010. In total 230 neonates admitted to the Neonatal Intensive Care Unit, after fulfilling the inclusion criteria were enrolled in this study as study subjects. For each baby, a detailed history was recorded in a questionnaire form (enclosed herewith) from the mother or other caregiver. It was filled up by the researcher himself containing history (including antenatal history), physical examinations and laboratory findings. Arterial blood gas analysis was done (in a clinical biochemistry laboratory using an automatic analyzer machine) for each neonate at admission and that report was recorded for this study. Results: Among the total study subjects, 127 newborn babies (55.2%) had acid-base imbalances. Mixed acidosis prevailed in the highest frequency (23.9%) Then metabolic acidosis cases were at 17.8% and respiratory acidosis was at 13.9%. Metabolic alkalosis and respiratory alkalosis were absent. Normal blood gas was observed in 44.3% of newborns. All the neonates with pH <7 were dead. After Chi-Square analysis (at df=1), we found a highly significant correlation between mortality outcome with pH <7.35, CO2 >45, HCO3 < 22 mol/l and Base deficit >-10. All modalities of acid-base imbalances were significantly associated with mortality. Conclusion: In this study, a significant number of neonates who were admitted to the intensive care unit, can develop acid-base derangement. Mixed acidosis was found in the highest frequency. Metabolic, respiratory and mixed acidosis all has a significant correlation with death in a NICU. Metabolic alkalosis and respiratory alkalosis were found absent at admission.

Acid trip: Let's retire the terms "disproportionate hyper/hypochloremia" for electrolyte-based acid-base derangements.

Acid trip: Let's retire the terms "disproportionate hyper/hypochloremia" for electrolyte-based acid-base derangements.

Tris-Hydroxymethyl Aminomethane in Critically Ill Adults: A Systematic Review.

Tris-hydroxymethyl aminomethane (THAM) is an amino alcohol used clinically to buffer acid loads and raise pH in acidotic conditions. Unlike sodium bicarbonate, which increases plasma sodium levels with use and produces carbon dioxide (CO 2 ) as part of the buffering process, THAM does neither. Although not widely used in modern critical care and unavailable for clinical use in 2016, THAM has been available in the United States since 2020. Clinical experience and existing literature suggest that THAM may have clinical utility in acid-base management in conditions such as liver transplantation where rising sodium levels during perioperative care may be dangerous, and in managing acid-base derangements during care of patients with acute respiratory distress syndrome (ARDS). To clarify the evidence base supporting the clinical use of THAM, we conducted a systematic review to assess the efficacy and safety of THAM as a buffering agent in critically ill adults using Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection. Randomized-, crossover-, retrospective cohort-, parallel-designed clinical trials, case series, and case reports of adult patients who received THAM in the operative or critical care setting were included. Conference abstracts of qualifying study designs were also included. Two independent reviewers extracted the data regarding the study details, demographics, treatment, and outcomes data. A third reviewer adjudicated discrepancies. A total of 21 studies including 3 randomized controlled trials, 5 observational studies, 4 case series, and 9 case reports met inclusion criteria. Eight studies (38%) were abstracts published in conference proceedings. In total, 417 critically ill patients received THAM to treat acidosis in critically ill surgical and nonsurgical patients, during liver transplantation, and in ARDS. In general, THAM corrected acidosis with an efficacy equivalent to sodium bicarbonate and did so with less hypercarbia and hypernatremia. Adverse effects of THAM included hyperkalemia, hypoglycemia, ventilator depression, and tissue damage with extravasation. We conclude that THAM may have potential advantages in some critical care settings, but that clinical evidence is limited, and high-quality evaluations are necessary.

Orthotopic Transplantation of the Full-length Porcine Intestine After Normothermic Machine Perfusion.

Background.Successful intestinal transplantation is currently hindered by graft injury that occurs during procurement and storage, which contributes to postoperative sepsis and allograft rejection. Improved graft preservation may expand transplantable graft numbers and enhance posttransplant outcomes. Superior transplant outcomes have recently been demonstrated in clinical trials using machine perfusion to preserve the liver. We hypothesized that machine perfusion preservation of intestinal allografts could be achieved and allow for transplantation in a porcine model.Methods.Using a translational porcine model, we developed a device for intestinal perfusion. Intestinal samples were collected at the time of organ procurement, and after 6 h of machine perfusion for gross and histologic evaluation, hourly chemistry panels were performed on the perfusate and were used for protocol optimization. Following transplantation, porcine recipient physical activity, systemic blood parameters, and vital signs were monitored for 2 d before sacrifice.Results.In initial protocol development (generation 1, n = 8 grafts), multiple metabolic, electrolyte, and acid-base derangements were measured. These factors coincided with graft and mesenteric edema and luminal hemorrhage and were addressed with the addition of dialysis. In the subsequent protocol (generation 2, n = 9 grafts), differential jejunum and ileum perfusion were observed resulting in gross evidence of ileal ischemia. Modifications in vasodilating medications enhanced ileal perfusion (generation 3, n = 4 grafts). We report successful transplantation of 2 porcine intestinal allografts after machine perfusion with postoperative clinical and gross evidence of normal gut function.Conclusions.This study reports development and optimization of machine perfusion preservation of small intestine and successful transplantation of intestinal allografts in a porcine model.

Low noncarbonic buffer power amplifies acute respiratory acid-base disorders in patients with sepsis: an in vitro study.

Patients with sepsis have typically reduced concentrations of hemoglobin and albumin, the major components of noncarbonic buffer power (β). This could expose patients to high pH variations during acid-base disorders. The objective of this study is to compare, in vitro, noncarbonic β of patients with sepsis with that of healthy volunteers, and evaluate its distinct components. Whole blood and isolated plasma of 18 patients with sepsis and 18 controls were equilibrated with different CO2 mixtures. Blood gases, pH, and electrolytes were measured. Noncarbonic β and noncarbonic β due to variations in strong ion difference (βSID) were calculated for whole blood. Noncarbonic β and noncarbonic β normalized for albumin concentrations (βNORM) were calculated for isolated plasma. Representative values at pH = 7.40 were compared. Albumin proteoforms were evaluated via two-dimensional electrophoresis. Hemoglobin and albumin concentrations were significantly lower in patients with sepsis. Patients with sepsis had lower noncarbonic β both of whole blood (22.0 ± 1.9 vs. 31.6 ± 2.1 mmol/L, P < 0.01) and plasma (0.5 ± 1.0 vs. 3.7 ± 0.8 mmol/L, P < 0.01). Noncarbonic βSID was lower in patients (16.8 ± 1.9 vs. 24.4 ± 1.9 mmol/L, P < 0.01) and strongly correlated with hemoglobin concentration (r = 0.94, P < 0.01). Noncarbonic βNORM was lower in patients [0.01 (-0.01 to 0.04) vs. 0.08 (0.06-0.09) mmol/g, P < 0.01]. Patients with sepsis and controls showed different amounts of albumin proteoforms. Patients with sepsis are exposed to higher pH variations for any given change in CO2 due to lower concentrations of noncarbonic buffers and, possibly, an altered buffering function of albumin. In both patients with sepsis and healthy controls, electrolyte shifts are the major buffering mechanism during respiratory acid-base disorders.NEW & NOTEWORTHY Patients with sepsis are poorly protected against acute respiratory acid-base derangements due to a lower noncarbonic buffer power, which is caused both by a reduction in the major noncarbonic buffers, i.e. hemoglobin and albumin, and by a reduced buffering capacity of albumin. Electrolyte shifts from and to the red blood cells determining acute variations in strong ion difference are the major buffering mechanism during acute respiratory acid-base disorders.

Acid base disorders in patients with COVID-19.

PurposeAcid–base derangement has been poorly described in patients with coronavirus disease 2019 (COVID-19). Considering the high prevalence of pneumonia and kidneys injury in COVID-19, frequent acid–base alterations are expected in patients admitted with SARS-Cov-2 infection. The study aimed to assess the prevalence of acid–base disorders in symptomatic patients with a diagnosis of COVID-19.MethodsThe retrospective study enrolled COVID-19 patients hospitalized at the University Hospital of Modena from 4 March to 20 June 2020. Baseline arterial blood gas (ABG) analysis was collected in 211 patients. In subjects with multiple ABG analysis, we selected only the first measurement. A pH of less than 7.37 was categorized as acidemia and a pH of more than 7.43 was categorized as alkalemia.ResultsABG analyses revealed a low arterial partial pressure of oxygen (PO2, 70.2 ± 25.1 mmHg), oxygen saturation (SO2, 92%) and a mild reduction of PO2/FiO2 ratio (231 ± 129). Acid–base alterations were found in 79.7% of the patient. Metabolic alkalosis (33.6%) was the main alteration followed by respiratory alkalosis (30.3%), combined alkalosis (9.4%), respiratory acidosis (3.3%), metabolic acidosis (2.8%) and other compensated acid–base disturbances (3.6%). All six patients with metabolic acidosis died at the end of the follow-up.ConclusionVariations of pH occurred in the majority (79.7%) of patients admitted with COVID-19. The patients experienced all the type of acid–base disorders, notably metabolic and respiratory alkalosis were the most common alterations in this group of patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11255-021-02855-1.

FC 025ACID BASE DISORDERS IN COVID-19

Background and AimsAcid-base disorders are common in severely ill patients and reflect the severity of the underlying pathologic process. The incidence and effects of acid-base derangement in COVID-19 patients have been poorly evaluated until now. Tropism of the virus for the lungs and kidneys may theoretically lead to frequent acid-base alterations due to pneumonia and kidney injury, respectively. To verify the derangement of acid-base disorders in COVID-19, we investigated the distribution and the impact of acid-base disorders on the survival of symptomatic patients with a diagnosis of COVID-19.MethodWe retrospectively collected data from electronic charts of all COVID-19 patients hospitalized at the University Hospital of Modena from 4 March to 20 June 2020.Arterial blood gas (ABG) analysis was required to monitor pulmonary gas exchange and acid-base status. A pH of less than 7.37 was categorized as acidemia and a pH of more than 7.42 was categorized as alkalemia.211 patients were included in the study population. In patients with multiple ABG analyses, we selected only the first measurement.ResultsThe estimated mean age of the population was 64.7 ±15,3 years with a high predominance of males (71.6%). Half of the population referred dyspnea and 61.4% at physical examination. Most patients (82.6%) were on oxygen therapy when ABG analysis was performed. Overall, ABG analyses revealed acute respiratory compromise manifesting with a low arterial partial pressure of oxygen (P02, 70.2±25.1 mmHg), oxygen saturation (SO2, 92%) and a mild reduction of PO2/FiO2 ratio (231±129).Acid-base disturbance was found in the 79.7% of the patients, and contrary to our expectation, metabolic alkalosis (33.6%) was the main alteration followed by respiratory alkalosis (30.3%), combined alkalosis (9.4%) respiratory acidosis (3.3%) metabolic acidosis (2.8%) and other compensated acid-base disturbances (3.6%). ANOVA with post hoc Tukey, revealed statistically significant differences in age, sex, serum level of K, Na, bicarbonate, creatinine of PCO2, PO2/FiO2 ratio, CKD, symptoms (caught, diarrhea) and fatality rate among groups.Metabolic acidosis was associated with death (HR=8.2; CI 95%, 1,93-32,39; P<0.004), after adjustment for lung injury (PaO2/FiO2 ratio) tissue hypoperfusion (lactate) and renal involvement (estimated as GFR< 60 ml/min or development of acute kidney injury), Pathological pH (alkalosis or acidosis), variations of PCO2 or hypobicarbonatemia were not associated with mortality in our study population. Metabolic acidosis occurred in patients with a mean creatinine of 4.5±4.5 mg/dl. Notably, 33.3% of patients were on hemodialysis, 33.3% developed COVID-19-associated acute kidney injury and 33.3% had a GFR <60 ml/min. Patients with metabolic acidosis had the highest death-fatality rate (100%) after 7±5.6 days from admission, 50% died of acute respiratory distress syndrome and 50% of septic shock.ConclusionIn conclusion, all kinds of acid-base alterations were found in patients with COVID-19. Metabolic and respiratory alkalosis were the most common acid-base disorders, whereas metabolic acidosis was the only acid-base disturbance associate with poor outcome in our cohort of patients.

Gadolinium-Based Contrast Media Nephrotoxicity in Kidney Impairment: The Physio-Pathological Conditions for the Perfect Murder.

Gadolinium-based contrast media (GBCM) toxicity in patients with kidney disease is a concern for the possible development of systemic nephrogenic fibrosis and possible renal complications. This review focuses on the pathological mechanisms underlying the potential kidney toxicity of gadolinium. Gadolinium, as a free compound (Gd3+), is highly toxic in humans because it competes with divalent calcium (Ca2+) and magnesium (Mg2+) ions, interfering in some relevant biologic processes. Its toxicity is blunted by the complexing of Gd3+ with a carrier, allowing its use in magnetic resonance imaging. The binding reaction between gadolinium and a carrier is thermodynamically reversible. Consequently, under some conditions, gadolinium can be released in the interstitial space as a free Gd3+ compound with the possibility of toxicity. Other metals such as iron, copper, and calcium can interfere with the binding between gadolinium and its carrier because they compete for the same binding site. This process is known as transmetallation. In patients with kidney impairment, conditions such as low clearance of the Gd-carrier complex, acid-base derangements, and high serum phosphorous can increase the presence of free Gd3+, leading to a higher risk for toxicity.

Semiquantitative acid-base analysis in dogs with typical hypoadrenocorticism.

To describe the semiquantitative acid-base status of dogs with untreated naturally occurring typical hypoadrenocorticism and to compare this to the status determined by traditional acid-base analysis. Retrospective study. University teaching hospital. Thirty-three dogs with newly diagnosed typical hypoadrenocorticism between 2000 and 2017. None. Dogs were included if they had newly diagnosed hypoadrenocorticism, post-ACTH stimulation serum cortisol concentration<2μg/dL, and blood collected within 6hours of presentation for acid-base, electrolyte, and serum biochemical assays. Dogs were excluded if the Na+ :K+ ratio was≥28 or the dog had received a mineralocorticoid-containing corticosteroid medication within the preceding month. Traditional acid-base analysis identified normal acid-base status in 1 dog, simple respiratory acid-base abnormalities in 2 of 33 dogs, and simple metabolic acidosis in 14 of 33 dogs. A mixed disorder was most common, noted in 16 of 33 dogs. The semiquantitative approach identified metabolic abnormalities in all cases. All dogs had ≥1 acidifying process, and 29 of 33 had both acidifying and alkalinizing processes. Acidosis attributable to excess free water was present in all dogs, and an acidifying phosphate effect was present in 27 of 33. Hyperlactatemia contributed to the acidosis in 8 of 33 dogs, with a median (range) lactate concentration of 1.5mmol/L (13.5mg/dL) (0.3-4.2mmol/L [2.7-37.8mg/dL]). Dogs with untreated Addison's disease have complex acid-base derangements. The semiquantitative approach to acid-base analysis provides greater insight into the underlying mechanisms of metabolic acid-base abnormalities in these dogs, particularly because lactic acidosis appears to be a minor influence in most cases.

Abstract 14494: Once You 1c It, You Can’t Unsee It: A Case of Flecainide Toxicity

Introduction: Flecainide is a class 1c antiarrhythmic commonly used for the treatment of atrial and ventricular arrhythmias in the absence of underlying structural heart disease. The significant proarrhythmic effects of the drug warrant familiarity with the drug and its toxicity. Flecainide overdose, whether intentional or iatrogenic, is a life threatening emergency with mortality rates as high as 22.5%. We present a case of intentional flecainide overdose and its management. Case: A 78-year-old man with a history of heart failure, paroxysmal atrial fibrillation on flecainide, presented to a local ED after a suicide attempt. He was initially hemodynamically stable and a 12-lead EKG revealed a wide-QRS bradyarrhythmia (See figure 1). Electrolyte panel showed normal potassium and pH. During transport to our tertiary cardiac intensive care unit, the patient declined and was critically ill on arrival. The diagnosis of flecainide toxicity was suspected and therapy was initiated on arrival. Despite therapy with sodium bicarbonate and fat emulsion, the patient continued to decline. Renal replacement therapy was started and the patient was evaluated for mechanical circulatory support. Ultimately, the patient’s family elected for palliative extubation. The patient’s flecainide level returned more than four times above the therapeutic range. Discussion: This case highlights the importance of a high index of suspicion when faced with a wide-QRS arrythmia in a patient with suspected antiarrhythmic overdose. The persistence of these rhythms after correction of acid-base abnormalities and electrolyte derangements should prompt aggressive, empiric treatment of potential overdose. The presence of electromechanical dyssynchrony in this context is an ominous sign and should prompt simultaneous evaluation for biventricular mechanical circulatory support concomitant with medical therapy for suspected overdose. Figure 1

Trimethoprim-associated electrolyte and acid-base abnormalities.

The antimicrobial trimethoprim is structurally related to potassium-sparing diuretics and may consequently lead to derangements in electrolyte and acid-base balance. Since no report so far analyzed the literature documenting individual cases with electrolyte and acid-base derangements induced by trimethoprim, a systematic review was carried out. We retained 53 reports documenting 68 cases (42 males and 26 females 23 to 96 years of age) of electrolyte or acid-base derangements occurring on trimethoprim for about 5 days. One hundred five electrolyte imbalances were detected in the 68 patients: hyperkalemia (>5.0 mmol/L) in 62 (91%), hyponatremia (<135 mmol/L) in 29 (43%) and metabolic acidosis (pH<7.38 and bicarbonate <19 mmol/L) in 14 (21%) cases. Following possible predisposing factors for electrolyte and acid-base abnormalities were found in 54 (79%) patients: high-dose trimethoprim, comedication with drugs that have been associated with electrolyte and acid-base derangements, preexisting kidney disease, age ≥80 years and diabetes mellitus. High-dose trimethoprim, comedicated with drugs that have been associated with electrolyte and acid-base derangements, poor kidney function, age ≥80 years and diabetes mellitus predispose to trimethoprim-associated electrolyte and acid-base abnormalities. Clinicians must recognize patients at risk, possibly avoid drug combinations that may worsen the problem and monitor the laboratory values.

Impact of Acute Kidney Injury on Outcomes of Hospitalizations for Heat Stroke in the United States.

This study aims to evaluate the risk factors and the association of acute kidney injury with treatments, complications, outcomes, and resource utilization in patients hospitalized for heat stroke in the United States. Hospitalized patients from years 2003 to 2014 with a primary diagnosis of heat stroke were identified in the National Inpatient Sample dataset. End stage kidney disease patients were excluded. The occurrence of acute kidney injury during hospitalization was identified using the hospital diagnosis code. The associations between acute kidney injury and clinical characteristics, in-hospital treatments, outcomes, and resource utilization were assessed using multivariable analyses. A total of 3346 hospital admissions were included in the analysis. Acute kidney injury occurred in 1206 (36%) admissions, of which 49 (1.5%) required dialysis. The risk factors for acute kidney injury included age 20–39 years, African American race, obesity, chronic kidney disease, congestive heart failure, and rhabdomyolysis, whereas age <20 or ≥60 years were associated with lower risk of acute kidney injury. The need for mechanical ventilation and blood transfusion was higher when acute kidney injury occurred. Acute kidney injury was associated with electrolyte and acid-base derangements, sepsis, acute myocardial infarction, ventricular arrhythmia or cardiac arrest, respiratory, circulatory, liver, neurological, hematological failure, and in-hospital mortality. Length of hospital stay and hospitalization cost were higher in acute kidney injury patients. Approximately one third of heat stroke patients developed acute kidney injury during hospitalization. Acute kidney injury was associated with several complications, and higher mortality and resource utilization.

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

Introduction: Regional citrate anticoagulation (RCA) is the recommended anticoagulation modality for continuous renal replacement therapy (CRRT). RCA was associated with a low rate of complications in randomized controlled trials. However, little is known about the type and rate of complications in real life. We sought to describe complications associated with RCA in comparison with those associated with heparin anticoagulation. Methods: In our institution, RCA has been the default anticoagulation modality for CRRT in all patients without contraindications since 2013. We have retrospectively reviewed all consecutive patients who received CRRT between January and December 2016 in our institution. For each CRRT session, we have assessed circuit duration, administered dose, as well as therapy-associated complications. Those parameters were compared according to whether the circuit was run in continuous veno-venous hemodialysis (CVVHD) mode with RCA or continuous veno-venous hemofiltration (CVVH) mode with heparin anticoagulation. Results: We analyzed 691 CRRT sessions in 121 patients. Of those 400 (57.9%) were performed in CVVHD-RCA mode and 291 (42.1%) in CVVH-Heparin Mode. Compared with ­CVVH-Heparin mode, CVVHD-RCA mode was associated with a longer circuit lifespan (median duration 54.9 interquartile range [IQR 44.6] vs. 15.3 h [IQR 22.4], p < 0.0001). It was associated with a higher rate of metabolic acidosis 77 (20.2%) vs. 18 (7.2%), (p < 0.0001), alkalosis 186 (48.7%) vs. 43 (17.1%), (p= 0.0001), and hypocalcemia 96 (25.07%) vs. 26 events (10.79%), p < 0.0001. However, the majority of these alterations were of benign or moderate severity. Only one possible citrate intoxication was observed. Conclusions: CVVHD-RCA was associated with a much longer circuit life but an increased rate of minor metabolic complications, in particular acid-base derangements. Some of these complications might have been prevented by therapy adaptation. Medical and nursing staff education is of major importance in the implementation of an RCA protocol.

Bedside Rules for Managing Acid-Base Derangement in Respiratory Failure: Applications to COVID-19

Respiratory failure is typically associated with changes in pCO2leading to respiratory alkalosis (type 1 failure) and respiratory acidosis (type 2). As a compensatory response, plasma HCO3concentration decreases if pCO2decreases and increases conversely. These secondary responses prevent large pH fluctuations. However, metabolic acid-base disorders may still occur as a consequence of dysfunction of other organs and/or medical treatments. To recognize superimposed acid-base disorders, the availability of an accurate prediction of the expected HCO3that corresponds to a given pCO2is crucial. In chronic hypocapnia, the compensatory metabolic response is regulated by the equation ΔHCO3/ΔpCO2=0.4 mEq/L per mm Hg. An easy rule to compute the expected value of HCO3may be 0.4×pCO2+9. In chronic hypercapnia, the equation is ΔHCO3/ΔpCO2=0.48 mEq/L per mm Hg, and the expected value of HCO3becomes 0.48×pCO2+4.74. While this expression is accurate, it seems to be of limited use for simple predictions. In this contribution, we propose the simpler expression: the expected value of HCO3in chronic hypercapnia=½ pCO2+3.5. For values of pCO2not exceeding 70 mm Hg, with the proposed expression, the difference in HCO3prediction in respect to the previous one is <0.5 mEq/L, which is clinically negligible. The root mean square value of the error introduced by the proposed expression is as small as 0.19 mEq/L. Because of its accuracy, we believe that the proposed formula may be useful to identify mixed disorders at the bedside in a simpler way.

Blood acid-base, haematological and haemostatic effects of hydroxyethyl starch (130/0.4) compared to succinylated gelatin colloid infusions in normovolaemic dogs.

Synthetic colloids are commonly administered to dogs to treat absolute or relative hypovolaemia. Voluven® (tetrastarch 130/0.4) and Gelofusine® (succinylated gelatin) are available to veterinarians in South Africa. In humans, use of these products has caused acid–base derangements, changes in haematology and impaired haemostasis. We aimed to investigate these effects in healthy normovolaemic dogs. Eight healthy adult beagle dogs underwent a cross-over study, receiving Voluven® or Gelofusine® (10 mL/kg/h for 120 min) once each with a 14-day washout between treatments. Dogs were premedicated with dexmedetomidine (10 µg/kg intramuscularly). Anaesthesia was induced with propofol and the dogs were maintained with isoflurane-in-oxygen. The anaesthetised dogs were connected to a multi-parameter monitor to monitor physiological parameters throughout. Catheters placed in a jugular vein and dorsal metatarsal artery allowed sampling of venous and arterial blood. Blood was collected immediately prior to commencement of colloid infusion, after 60 min infusion and at the end of infusion (120 min) to allow for arterial blood gas analysis, haematology and coagulation testing (activated partial thromboplastin time [aPTT], prothrombin time [PT] and thromboelastography [TEG]). There was no effect, between treatments or over time, on blood pH. The haemoglobin concentration, erythrocyte count and haematocrit decreased significantly over time (all p < 0.01), with no differences between treatments, and remained within normal clinical ranges. There were no differences between treatments or over time for the TEG, aPTT and PT tests of haemostasis. At the dose studied, Voluven® and Gelofusine® had comparably negligible effects on blood acid–base balance and coagulation in normovolaemic dogs.

Effect of antitubercular treatment on serum electrolyte and bicarbonate among pulmonary tuberculosis patients in tertiary care Hospital: An observational study

Introduction: Tuberculosis is mainly associated with diarrhea, vomiting and profuse sweating leading to dehydration, electrolyte imbalance and acid base derangements. Treatment with anti tubercular drugs reduces the symptoms and balances the electrolytes. Hence, this study was carried out to assess the electrolyte imbalance among tuberculosis patients and to know the effect of anti tubercular treatment. This study was carried out to study the electrolyte imbalance among newly diagnosed tuberculosis patients and to know the effect of treatment with anti tubercular drugs in improving the electrolyte balance at BRIMS teaching Hospital Bidar. Materials and Methods: This was observational study conducted in pulmonary Medicine OPD of Bidar Institute of Medical Sciences teaching hospital Bidar. 50 participants were enrolled in our study and assessed for demographic data, serum electrolytes and bicarbonate levels and compared with Tuberculosis patients before and after treatment. Results: The electrolyte imbalance in terms of decrease in sodium, potassium chloride and bicarbonate values was significantly associate (p Conclusion: In our study, after treatment with antitubercular drugs, electrolyte levels returned to normal. Because of the high incidence of the electrolyte disturbances in tuberculosis patients, close monitoring and aggressive management are mandatory. Keywords: Mycobacterium tuberculosis, Electrolytes, Cytochemical changes, Antitubercular drugs.

Predicting mortality in patients with disseminated intravascular coagulation after cardiopulmonary bypass surgery by utilizing two scoring systems.

: We evaluated clinical and laboratory biomarkers of disseminated intravascular coagulation (DIC) following cardiac surgery in the cardiothoracic surgical ICU (CTICU) to predict mortality. We retrospectively analyzed CTICU patients with suspected DIC identified from the hospital laboratory database, and calculated International Society on Thrombosis and Haemostasis (ISTH) and the Japanese Association for Acute Medicine (JAAM) DIC scores to predict DIC-related mortality. The predictive accuracy of the JAAM and ISTH DIC scoring system were then assessed by logistic regression analysis and receiver operative characteristics analysis, and compared to other potential predictors of mortality (e.g., Acute Physiology and Chronic Health Evaluation II, systemic inflammatory response syndrome criteria, laboratory variables). Our study showed a 30-day mortality rate of 71% in CTICU patients with DIC. The JAAM DIC score offered the best predictive accuracy [area under the curve (AUC): 0.723, 95% % confidence interval (CI): 0.638-0.947, P = 0.021], when compared with ISTH DIC score (AUC: 0.707, 95% CI: 0.491-0.923, P = 0.066) and Acute Physiology and Chronic Health Evaluation II (AUC: 0.687, 95% CI: 0.483-0.891, P = 0.110). A JAAM DIC score at least 6 was reported in 89% of the nonsurvivors and 46% of survivors (P = 0.010), and predicted mortality [odds ratio: 9.33 (1.50-58.20)] with a 73% sensitivity and a 78% specificity. Our results also show a strong relationship between acid-base derangement and mortality. This initial evaluation of DIC-related mortality in the CTICU found the standardized JAAM DIC scoring system in combination with acid-base laboratory values were most useful to predict mortality in postcardiac surgery patients with DIC. Additional prospective studies are needed to further validate our findings.

Correlation of blood gas status with the mortality of neonates admitted in ICU

Background : Blood gas abnormalities are frequently encountered in sick neonates admitted in ICU. They contribute significantly to mortality. Therefore, blood gas status is a helpful indicator of the condition of sick neonate.Objective : To study the correlation between blood gas status and mortality of neonates admitted in ICU.Methods : This observational study was carried out at the ICU of Dhaka Shishu Hospital (DSH) from January 2014 to July 2014. Total 121 neonates were enrolled according to inclusion criteria and analyzed their blood gas status which were correlated with the mortality of neonates.Results : Perinatal asphyxia (PNA) was common disorder with the highest mortality in neonate followed by sepsis and pneumonia. Significant association between mortality with lower pH, PC02 and higher base excess was observed. Metabolic acidosis was the most common acid-base disorder.Conclusion : Low pH, PC02 and more base excess are predictor of mortality in this group of neonate. Initial acid-base derangement significantly correlates with the mortality of critically ill neonates requiring ICU care.Northern International Medical College Journal Vol.9(1) July 2017: 261-263