Acid-base Disturbances Research Articles

Effect of Glycemic Control on Sepsis in Critically Ill Diabetic Patients: A Prospective Cohort Study

Abstract Background Hyperglycemia is common and often multifactorial in critically ill patients. Severe hyperglycemia can result in endothelial dysfunction, cytokine release, platelet activation, mitochondrial dysfunction and electrolyte and acid base disturbances and has been associated with an adverse outcome in a variety of settings in patients without a history of diabetes; this association has not been demonstrated in diabetes patients. Aim of the Work Aim is to evaluate the outcome of glycemic control in critically ill diabetic patients. Patients and Methods This Prospective Cohort study was performed at Ain Shams University Hospitals - El – Zaitoun Specialized Hospital. 60 patients that are known diabetic and admitted to ICU suffering from sepsis aging over 18 years. Patients have been divided equally into two groups: 1st group RBG measurements less than or equal 150 mg/dl while the 2nd group RBG measurements above 150 mg/dl. So there was highly statistically significant difference between the two studied groups and glucose level on admission. Results There was statistically insignificant difference between the two studied groups and Sex or Age. Also there is no significant difference in special habits (smoking) between the two groups. Considering ICU stay, in our study, there was statistically significant higher mean of ICU stay in 2nd group, in comparison to 1st group. The calculated Acute Physiology and Chronic Health Evaluation (APACHEII) in our study showed no significant difference between two groups Considering complications, our study reported insignificant increase in complicated cases the 2nd group in comparison to 1st group. This may be due to the small number of patients in our study. Further observational and randomized control studies are suggested to further evaluate the variability of complications. Conclusion Glycemic control in the ICU continues to be challenging at best. Glucose control in the intensive care unit adds yet another facet to the routine care of a highly complex patient profile. Although observational studies and certain interventional trials have suggested that intensive glucose control can reduce mortality in this setting, recent studies have failed to confirm these findings. Like that is our study, hyperglycemia was associated with increased duration of total days in the intensive care unit. There was insignificant increase in complicated cases in hyperglycemic group in comparison to the other group. This may be due to the small number of patients in our study. So further observational and randomized control studies are suggested to further evaluate the variability of complications.

Acid-base and electrolyte evaluation in dogs with upper GI obstruction: 115 dogs (2015-2021).

Metabolic alkalosis, although uncommon in small animals, has been previously associated with gastrointestinal obstructions. Depending on the population and disease process evaluated, previous prevalence of metabolic alkalosis is reported as ranging from 2% to 45% in canine patients. The objective of this study was to determine the prevalence of metabolic alkalosis and other acid-base and electrolyte disorders in a cohort of dogs with a confirmed upper gastrointestinal obstruction. Electronic medical records were reviewed to identify dogs who presented for vomiting with evidence of an upper gastrointestinal obstruction from January 2015 to October 2021. Patients were enrolled only if a preoperative venous blood gas was obtained and analysed in house. Traditional acid-base analysis was utilised to determine an acid-base status before relieving the obstruction. When available, post-operative venous acid-base status was determined within 24 hours after surgery, and compared to preoperative results. A total of 115 dogs were included in the study. Twenty-five out of 115 (22%) dogs displayed either a simple metabolic alkalosis or a mixed acid-base disturbance before surgery. Twenty-seven out of 115 dogs (37%) had a normal acid-base status at entry. Seventy-one dogs had pre- and post-operative venous blood gas results available. Metabolic alkalosis was resolved in nearly all patients post-operatively, with no patients displaying a simple metabolic alkalosis. A mixed metabolic acidosis and respiratory alkalosis was the most common condition post-operatively, found in 25 of 71 (35%) dogs. Severe derangements of electrolytes were infrequent preoperatively (3/115; 2.6%). A majority of patients in this study exhibited hypokalaemia (64.4%), hypochloraemia (72.8%) and hyponatraemia (77.4%) on preoperative venous blood gases. Venous pH, Pv CO2 , bicarbonate and base excess were significantly higher preoperatively when compared to the post-operative results. This study found the prevalence of pre-operative metabolic alkalosis in dogs with a documented upper gastrointestinal obstruction to be lower than previously reported. Surgical or endoscopic alleviation of the upper gastrointestinal obstruction resulted in resolution of metabolic alkalosis in nearly all patients.

Anti- N-MethyL-D-Aspartate Receptor Encephalitis in Children Infected with Herpes Simplex

Herpes Simplex Virus (HSV) is a common cause of infectious encephalitis in children, which can lead to severe neurological sequels. There is a new perspective suggesting that herpes simplex encephalitis plays an important role in triggering the synthesis of NMDA receptor antibodies. There have been no data on the incidence of anti-NMDA receptor encephalitis in Indonesia. Herpes simplex encephalitis was found in these patients as a risk factor for anti-NMDA receptor encephalitis. A 9-year-old male patient complained of seizures such as jerking of the right hand and smacking of the lips along with fever for 4 days before being admitted to the hospital. Complaints began with slurred speech and t inability of fingers to hold objects for the previous 8 days. From the physical examination, it was reported that the patient looked seriously ill, blood pressure was 110/80 mmHg, pulse was 117 beats per minute, the temperature was 38.5 C, and respiratory rate was 24 times per minute. Another physical examination was within normal limits. The results of a complete blood count at the time of initial treatment of patients showed mild leukocytosis due to a mild increase in monocytes, whereas blood gas and electrolyte analysis showed hypoventilation at the beginning of hospitalization in which mixed acid-base disturbance, respiratory acidosis, and metabolic alkalosis occurred. Analysis of cerebrospinal fluid in these patients showed mononuclear pleocytosis and the results of immunoserological test in serum indicated HSV1 and HSV2 infection and detected anti-NMDA receptor. Both clinical and laboratory findings in this study supported encephalitis. Herpes simplex virus infection can be a risk factor for patients suffering from anti-NMDA receptor encephalitis.

Biochemical Approach of Acid-Base Disturbances

Background: The current paradigms in arterial blood gas analysis are based on mathematical or physicochemical models that require complex algorithms for interpretation. This leads to avoidance or dislike from health care professionals. Purpose: To formulate a new approach to the analysis and classification of acid base disturbances. Methodology: we conducted a systematic review of the related literature and a paradigm shift for data interpretation. Results: Acid-base disorders can be grouped and managed according to the underlying biochemical processes. Conclusions: This proposal represents a new classification, which groups acid base disorders according to the underlying causal biochemical process. Disorders with an elevated anion gap relate to alterations in cellular respiration (energy/ATP production)- All disturbances with normal anion gap relate to transmembrane ion exchange.

Comparison of Acid Base Status and Electrolytes in Individuals with Prediabetes, Diabetes and Normoglycemia

Objective: To determine the acid-base status and electrolytes in individuals with pre-diabetes, diabetes and normoglycemia. Study Design: Cross-sectional study. Place and Duration of Study: Department of Chemical Pathology, Combined Military Hospital, Quetta Pakistan, from Jan2020 to Jun 2020. Methodology: Two hundred study participants were part of this cross-sectional study. Study participants were divided into 3 groups based on plasma glucose levels normoglycemics, prediabetics, and patients with diabetes. Sample for serum electrolytes, plasma glucose, and venous blood gases was taken and analyzed. Results were calculated statistically by using SPSS 21. Results: Mean age of study participants as 40.11+/-13.93 years. Out of these, 130(65%) study participants were males and 70(35%) were females. Out of these 200study participants, 105(52.5%) had sodium level <135mmol/L and serum potassium <3.5mmol/L, 90(45%) had serum sodium level between 135-145mmol/L and serum potassium level between 3.5-5.5mmol/L and only 5(2.5%) had serum sodium level >145mmol/Land serum potassium >5.5mmol/L. Similarly, 5(2.5%) study participants had serum chloride level <98mmol/L, 84(42%) between 98-108 mmol/L and 111(55.5%) ad >108mmol/L with a mean of 106±5 mmol/L. Regarding acid base disturbance, metabolic acidosis was observed in patients with diabetes as compared to normoglycemic and prediabetics. Conclusion: Patients with different stages of hyperglycemia have a different pattern of electrolytes and acid-base status which can be used as surrogate markers of normoglycemia, prediabetes, and diabetes.

Predictive performance of multiple organ dysfunction in asphyxiated newborns treated with therapeutic hypothermia on 24-month outcome: a cohort study

BackgroundPerinatal asphyxia may be followed by multiple organ dysfunction (MOD) and is often included in prognostication of the individual patient, but evidence of discriminating accuracy is lacking. The aim of...

Phenotyping cardiogenic shock that showed different clinical outcomes and responses to vasopressor use: a latent profile analysis from MIMIC-IV database.

Cardiogenic shock (CS) is increasingly recognized as heterogeneous in its severity and response to therapies. This study aimed to identify CS phenotypes and their responses to the use of vasopressors. The current study included patients with CS complicating acute myocardial infarction (AMI) at the time of admission from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Laboratory and clinical variables were collected and used to conduct latent profile (LPA) analysis. Furthermore, we used a multivariable logistic regression (LR) model to explore the independent association between the use of vasopressors and endpoints. A total of 630 eligible patients with CS after AMI were enrolled in the study. The LPA identified three profiles of CS: profile 1 (n = 259, 37.5%) was considered as the baseline group; profile 2 (n = 261, 37.8%) was characterized by advanced age, more comorbidities, and worse renal function; and profile 3 (n = 170, 24.6%) was characterized by systemic inflammatory response syndrome (SIRS)-related indexes and acid-base balance disturbance. Profile 3 showed the highest all-cause in-hospital mortality rate (45.9%), followed by profile 2 (43.3%), and profile 1 (16.6%). The LR analyses showed that the phenotype of CS was an independent prognostic factor for outcomes, and profiles 2 and 3 were significantly associated with a higher risk of in-hospital mortality (profile 2: odds ratio [OR] 3.95, 95% confidence interval [CI] 2.61-5.97, p < 0.001; profile 3: OR 3.90, 95%CI 2.48-6.13, p < 0.001) compared with profile 1. Vasopressor use was associated with an improved risk of in-hospital mortality for profile 2 (OR: 2.03, 95% CI: 1.15-3.60, p = 0.015) and profile 3 (OR: 2.91, 95% CI: 1.02-8.32, p = 0.047), respectively. The results of vasopressor use showed no significance for profile 1. Three phenotypes of CS were identified, which showed different outcomes and responses to vasopressor use.

Low-solute hyponatremia in a kidney transplant recipient.

Electrolyte and acid-base disturbances are common in kidney transplant recipients, but there are few reports of low-solute hyponatremia or beer potomania in this population. We report herein a case of low-solute hyponatremia in a kidney transplant recipient with impaired graft function, highlighting key issues in diagnosis and management of low-solute hyponatremia, as well as exploring the pathophysiology of hyponatremia after kidney transplantation. A 51-year-old man who had received a cadaveric renal transplant 18 years before presented with symptomatic hyponatremia and seizure. Workup for an underlying intracranial pathology was negative, and subsequent biochemical workup suggested low-solute hyponatremia with potomania, arising from dietary modifications taken by the patient while self-isolating during the COVID-19 pandemic. Correction of hyponatremia was successful with conservative management with close monitoring. This case illustrates key points in the diagnosis and management of low-solute hyponatremia and highlights the pathophysiology of hyponatremia after kidney transplantation.

The AE4 transporter mediates kidney acid-base sensing

The kidney plays a key role in the correction of systemic acid-base imbalances. Central for this regulation are the intercalated cells in the distal nephron, which secrete acid or base into the urine. How these cells sense acid-base disturbances is a long-standing question. Intercalated cells exclusively express the Na+-dependent Cl−/HCO3− exchanger AE4 (Slc4a9). Here we show that AE4-deficient mice exhibit a major dysregulation of acid-base balance. By combining molecular, imaging, biochemical and integrative approaches, we demonstrate that AE4-deficient mice are unable to sense and appropriately correct metabolic alkalosis and acidosis. Mechanistically, a lack of adaptive base secretion via the Cl−/HCO3− exchanger pendrin (Slc26a4) is the key cellular cause of this derailment. Our findings identify AE4 as an essential part of the renal sensing mechanism for changes in acid-base status.

Identification of RhBG Mutations that Impair NH3/NH4+ Transport in Patients with Chronic Kidney Disease

Background: Acid-base disturbances are common in many illnesses, and metabolic acidosis is a major complication in patients with chronic kidney disease (CKD). The kidneys respond to acidosis by increasing urinary excretion of total ammonia (NH 3 /NH 4 + ) and to a lesser extent titratable acids. In the collecting duct, total ammonia is secreted by the NH 3 /NH 4 + transporters, RhBG and RhCG. RhBG transports NH 3 and NH 4 + at the basolateral membrane of intercalated cells. In CKD patients, the increase in ammonium excretion in response to acidosis is markedly impaired. Recent studies suggest that the reduced ability of the kidney to excrete ammonium is likely a cause of detrimental renal outcome in CKD and faster progression towards end-stage renal disease. Hypothesis: This study aims to identify loss of function mutations of RhBG (nsSNPs) that impair NH 3 /NH 4 + transport which may contribute to the deleterious effect of acidosis in CKD. Methods: We used Chronic Renal Insufficiency Cohort (CRIC) study to select SNPs of RhBG that are present in CKD patients but not in controls, or have a significant odds ratio (OR). Transport studies were conducted on Xenopus oocytes expressing Rh proteins or mutants. Wild-type RhBG (RhBG-WT) or RhBG-mutants were expressed by microinjecting oocytes with respective mRNA. H 2 O-injected oocytes served as negative controls. Each oocyte was perfused with solutions containing 5 mM NH 3 /NH 4 + or 5 mM MA/MA + (methylamine/methylammonium, a surrogate of NH 3 /NH 4 + ) to test RhBG function. Using ion-selective microelectrodes, we measured changes in intracellular pH, whole cell currents or surface pH to assess transport of NH 3 or NH 4 + . Results: Two RhBG mutations, G148R and G148W, which are only present in the patient group from CRIC cohort, significantly inhibited transport of NH 3 and NH 4 + (and MA/MA + ) compared with RhBG-WT (p&lt;0.05) in Xenopus oocytes. Two other mutations, G86S and G86C, positively associated with CKD patients (OR=4.65, p&lt;0.05), showed different inhibition patterns: G86S maintained the ability to transport NH 4 + , NH 3 and MA + while G86C inhibited NH 3 and NH 4 + transport but MA + transport was less affected compared with RhBG-WT. Both G86S and G86C showed a 50% decrease in MA transport (p&lt;0.05) that was still significantly higher than negative control. Conclusions: We discovered two RhBG mutations, G148R and G148W, in CKD patients that completely inhibited the transport of NH 3 /NH 4 + . The other two mutations, G86S and G86C, partially inhibited transport, and G86C was more deleterious than G86S in its inhibitory effect on NH 4 + and NH 3 transport. Significance: This study is the first to identify, in a cohort of CKD patients, 4 mutations with functional effects on NH 3 /NH 4 + transport. This work provides the foundation to further investigate whether naturally occurring genetic variations that impair ammonia secretion are associated with fast CKD progression under acidosis conditions. Funding grants: NIH-U54 GM104940, Paul Teschan Research, NIH-R01, Carol Lavin Bernick, Tulane institutional This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

A Systematic Approach to Understanding Acid-Base Disorders in the Critically Ill.

The objective of this review is to discuss acid-base physiology, describe the essential steps for interpreting an arterial blood gas and relevant laboratory tests, and review the 4 distinct types of acid-base disorders. A comprehensive literature search and resultant bibliography review of PubMed from inception through March 7, 2023. Relevant English-language articles were extracted and evaluated. Critically ill patients are prone to significant acid-base disorders that can adversely affect clinical outcomes. Assessing these acid-base abnormalities can be complex because of dynamic aberrations in plasma proteins, electrolytes, extracellular volume, concomitant therapies, and use of mechanical ventilation. This article provides a systematic approach to acid-base abnormalities which is necessary to facilitate prompt identification of acid-base disturbances and prevent untoward morbidity and mortality. Many acid-base disorders result from medication therapy or are treated with medications. Pharmacists are uniquely poised as the medication experts on the multidisciplinary team to assist with acid-base assessments in the context of pharmacotherapy. The use of a systematic approach to address acid-base disorders can be performed by all pharmacists to improve pharmacotherapy and optimize patient outcomes.

Correlation Between Serum and Arterial Blood Gas Bicarbonate in Patients Admitted to the Intensive Care Unit.

Objective Clinicians use two modalities to determine acid-base disturbances: calculated bicarbonate on arterial blood gas (ABG) and measured bicarbonate on basic metabolic panels (BMP).The primary objective was to investigate the discrepancy between the two values for diagnosing acidemia in the intensive care unit (ICU). Our secondary objective was to discern the threshold to treat acidemia within various clinical settings. Materials and methods We performed a multi-center study using a retrospective patient chart review consisting of ABG and BMP bicarbonate levels at various pH ranges; 584 adult patients were included in this study. SAS software (SAS Institute Inc., Cary, NC) was used for analysis. Results Strong positive correlations were found between calculated ABG and measured BMP bicarbonate, with the group of pH 6.9-7.0 being the strongest. Based on odds ratio analysis, patients were more likely to not receive bicarbonate treatment if pH was greater than 7.1 based on calculated ABG bicarbonate. Patients also did not receive bicarbonate treatment when pH was greater than 7.2 based on BMP bicarbonate levels. Our study found that patients with higher pH (pH > 7.1) were less likely to receive bicarbonate treatment. Patients with pH 6.9-7.0 were more likely to receive bicarbonate treatment. Based on receiver operator curve(ROC)model curves, neither ABG nor BMP bicarbonate values have strong accuracy for diagnosing acidemia. Conclusion We found no significant difference in CO2 levels and ICU types regardless of if ABG or BMP was used.

SIGNIFICANCE OF ACID BASE STATUS AT ADMISSION IN ACUTE ORGANOPHOSPHORUS POISONING AND ITS IMPACT ON OUTCOMEHOSPITAL BASED OBSERVATIONAL STUDY FROM NORTH EAST INDIA

BACKGROUND: Organophosphorus compounds (OPCs) are being used worldwide as an insecticide, herbicide, fungicide in agriculture field and household garden. Acute respiratory failure has been found to be the most common cause of death in OPC poisoning due to increased secretions and decreased ventilation leading to acid base disturbances. This study was undertaken to assess acid base status in patients with acute OPCs poisoning and to determine its association with the clinical outcome in patients with acute OPCs poisoning. MATERIALS AND METHODS This was a prospective observational study conducted in Dept of General Medicine, Silchar Medical College and Hospital from 1st June 2021 to 31st May 2022 for a period of one year. It was a hospital based observational study. A total of 100 patients were evaluated, with history of ingestion of OP compound and clinical features suggestive of acute OPCs poisoning after fulfillment of inclusion and exclusion criteria. RESULTS Total 100 patients were studied and majority were in the age group of 21-30 years. On Arterial Blood Gas Study,88% had acid base imbalance and 12% had normal acid base balance. Majority of the patient had respiratory alkalosis (49%), followed by respiratory acidosis (16%),metabolic acidosis (15%),metabolic alkalosis (8%).The overall mortality in our study was 19%.The mortality rate in metabolic acidosis group was 46.66%, respiratory acidosis group was 37.5%, metabolic alkalosis group was 12.5 % and respiratory alkalosis group was 10.2 %. CONCLUSION Acid -base imbalances are present in majority of the patients presenting with acute OPC poisoning. The assessment of the initial acid base status can help in determining the prognosis of the patients, help to intensify management and reduce the overall mortality in patients with acute OPC poisoning.

Features of respiratory syncytial virus infection in children in the post-COVID-19 era

Respiratory syncytial virus (RSV) infection in children is a major public health problem, especially in the 0-1 year age group where clinical forms of the disease can evolve severely with life-threatening complications. In the period 2020 – 2022, as a result of epidemiological measures specific to the COVI-19 pandemic (protective mask, online teaching activity, social distancing) we have witnessed a considerable decrease in the number of cases of RSV infection in children. With the lifting of prophylactic measures and the onset of the cold season, we have seen an increase in the number of admissions with a diagnosis of respiratory virus in pediatric wards. In this article, we aim to analyze the clinical, evolutionary and epidemiological features of respiratory syncytial virus infection in children in the 2022 - 2023 season. We conducted a retrospective clinical study of RSV infection cases admitted to the Pediatric Infectious Diseases Clinical Departments of the National Institute of Infectious Diseases “Prof. Dr. Matei Bals” in the period October 2022 - March 2023. During this period, we registered 195 cases of RSV infection in children, which represents 6.47% of the total number of hospitalized virologic illnesses in children (195/3012). All pediatric RSV infection cases admitted to our wards have progressed favorably; we have not recorded any deaths. From an epidemiological point of view, the peak incidence of RSV infection in children occurred in December (98 cases). The most frequent clinical form of the disease was the medium form, but severe forms represented 31.8%. Among the complications, the most common were respiratory (acute respiratory failure, pneumonia/bronchopneumonia), hematological (intrainfectious and deficiency anemia, leukopenia, thrombocytopenia), digestive (diarrheal disease, hepatic cytolysis syndrome) and acute dehydration syndrome associated with hydro electrolytic and acid-base disturbances. Severe complications were more frequent than in previous seasons, being associated with a risk of an unfavorable outcome: acute respiratory failure and neurological complications (convulsions, encephalitis). We also observed that acute RSV infection in the 2022 - 2023 season is characterized by the association of co-infections (viral, bacterial and fungal) more frequent than in previous years (22.5%). The most frequent co-infections were bacterial (superinfections - pneumonia/bronchopneumonia) probably due to the immunosuppression of the hosts as a result of repeated recent episodes of viral infections. Of note, RSV infection associated with other coinfections evolved more severely, with prolonged hospitalization and more complications. In conclusion we can say that RSV infection in the 2022 - 2023 season evolved more severely in children compared to previous seasons because in the last 3 years during the COVID-19 pandemic there were very few cases of respiratory viroids, thus the population was not naturally immunized, especially the age group 0 - 4 years. In addition, the abandonment of specific protective measures for respiratory diseases has “exploded” the number of respiratory illnesses in the pediatric population, especially in children.

Midline catheters for blood gas and acid/base monitoring in critical patients: A prospective observational study.

Arterial lines and central venous catheter (CVC) allow to monitor patients' acid-base status and gas exchange. Their placement and maintenance may however be burdened by severe complications. Midline Catheters (MC) are peripheral venous accesses that are less invasive and easier to insert compared to CVC and arterial lines. A prospective observational study was performed including stabilized critical patients with clinical indication to midline positioning before intensive care unit (ICU) discharge. The primary aim was to assess if venous sampling from MCs can be a reliable alternative to CVC for pH and CO2 monitoring. The secondary aim was to evaluate the correlation between samplings from MC, CVC and arterial line with regards to pH, carbon dioxide tension (pCO2), lactates and electrolytes. Three samples from CVC, arterial line and MC were collected simultaneously. Agreement and correlation of the studied parameters between different sampling sites were explored. 40 patients were included in the analysis. A good agreement for pH and pCO2 was recorded between MC and CVC: mean differences were 0.001 (95% CI -0.006 to 0.007) and 0.7 (-0.1 to 1.5), percentage error 0.4% and 11.2%, respectively. Correlation between MC and both central venous and arterial samples for pH, pCO2, lactates and electrolytes was found to be moderate-to-strong (Pearson's R coefficient range 0.59-0.99, p < 0.001 for all these parameters). In stabilized critical patients, midline catheters represent a reliable alternative to CVC and arterial lines to monitor acid-base disturbances, CO2 levels and electrolytes. The present findings add to the known advantages of MC, which might be considered a first-line vascular access for non-critical or stabilized patients who do not require infusion of vesicant or irritant drugs.

Therapeutic management in chronic renal failure in PKD

The therapeutic management in chronic renal failure, determined by polycystic kidney disease (PKD), is dynamically adapted depending on the evolutionary type of the condition and the progression of the cysts. The objectives of nutritional therapy consist in providing adequate nutritional support, reducing the clinical expression and effects of uremic intoxication, reducing hydroelectrolytic changes, vitamin-mineral and acid-base disturbances, along with limiting the progression of renal disease. Drug therapy aims at the management of the physiopathological consequences related to each stage of chronic kidney disease (CKD), represented by the decrease of the functional force, the reduction of the symptoms and the effects of uremic intoxication, the reduction of the hydroelectrolytic changes and disturbances of the vitamin, mineral metabolism and acidosis and the limitation of the morbid process progression.

A Severe Case of Hypokalemic Metabolic Alkalosis: A Quiz

A Severe Case of Hypokalemic Metabolic Alkalosis: A Quiz

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid–base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong (“we recommend”) or weak/conditional (“we suggest”), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8–12 mmol/L or anion gap 23–27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.

Proportion of hyperemesis gravidarum and associated factors among pregnant women admitted into the obstetrics ward at Akesta general hospital, North East Ethiopia.

Hyperemesis gravidarum is a condition of intractable vomiting during pregnancy that leads to fluid and electrolyte imbalance, nutrition deficiency and weight loss often requiring hospital admission. Approximately 0.3%-10.8% of pregnant women experience nausea and vomiting during the first trimester of pregnancy. It has been associated with both maternal and fetal morbidity. There is limited evidence about the proportion of hyperemesis gravidarum and associated factors in the study area. The aim of this study was to determine the proportion of hyperemesis gravidarum and associated factors among pregnant women admitted into the obstetric ward at Akesta General Hospital, South Wollo Zone, Ethiopia. This is hospital-based cross-sectional study of 355 pregnant mothers in Akesta general hospital in northeast Ethiopia from September 1/2018- to August 30 /2020. A simple random sampling technique was used to select the patient card from the whole admission of pregnant women cards during the study period. The diagnosis of hyperemesis gravidarum include persistent vomiting not related to other causes, an objective measure of acute starvation, electrolyte abnormalities and acid-base disturbances, as well as weight loss. The data analysis was done using SPSS version 25. Bivariable and multivariable binary logistic regression analysis was conducted to identify factors associated with hyperemesis gravidarum. Adjusted odds ratio (AOR) with 95% confidence intervals (CI) was reported to show the strength of the association. Statistical significance was stated at P-value < 0.05. The proportion of hyperemesis gravidarum was 11.3%. Women with previous history of hyperemesis gravidarum AOR (95%CI) = 10.9[2.46, 48.44], previous history of urinary tract infection AOR (95%CI) = 4.32[1.58, 11.86], previous history of gastrointestinal disease AOR (95% CI) = 4.12[1.40, 12.65], history of abortion AOR (95% CI) = 6.23[2.24, 17.52] were factors significantly associated with hyperemesis gravidarum. In this study, the overall hospital proportion of hyperemesis gravidarum was high. History of gastrointestinal disease, previous history of urinary tract infection, history of hyperemesis gravidarum, and history of abortion were the major risk factors.

Alactic base excess is an independent predictor of death in sepsis: A propensity score analysis

PurposeAlactic base excess (ABE) is a novel biomarker defined as the sum of lactate and standard base excess and estimates the renal capability of handling acid-base disturbances in sepsis. The objective of this study is to see if ABE is an independent predictor of mortality in septic patients with and without renal dysfunction. Materials and methodsWe retrospectively studied 1178 patients with sepsis and septic shock. Patients were divided according to ABE values: 1) negative ABE (<−3 mmol/L); 2) neutral ABE (≥ − 3 and < 4 mmol/L); and 3) positive ABE (≥4 mmol/L). The effect of ABE on mortality was evaluated using Cox regression weight by inverse probability weighting (IPWT) analysis after propensity score assessment. Additionally, we performed a stratified analysis in patients with GFR > 60 mL/min/1.73 m2. ResultsNegative ABE patients had higher mortality than patients with neutral ABE (adjusted HR 1.43; 95%CI 1.02–2.01). Also, in patients with GFR > 60 mL/min/1.73 m2 (n = 493), we observed higher mortality in patients with negative ABE (adjusted HR 2.43; 95%CI 1.07–5.53). ConclusionsNegative ABE is an independent predictor of in-hospital mortality in septic patients with and without renal dysfunction.