Disturbances Of Acid-base Balance Research Articles

The Influence of Acid-Base Balance on Anesthetic Muscle Relaxants: A Comprehensive Review on Clinical Applications and Mechanisms.

Muscle relaxants have broad application in anesthesiology. They can be used for safe intubation, preparing the patient for surgery, or improving mechanical ventilation. Muscle relaxants can be classified based on their mechanism of action into depolarizing and non-depolarizing muscle relaxants and centrally acting muscle relaxants. Non-depolarizing neuromuscular blocking drugs (NMBDs) (eg, tubocurarine, atracurium, pipecuronium, mivacurium, pancuronium, rocuronium, vecuronium) act as competitive antagonists of nicotine receptors. By doing so, these drugs hinder the depolarizing effect of acetylcholine, thereby eliminating the potential stimulation of muscle fibers. Depolarizing drugs like succinylcholine and decamethonium induce an initial activation (depolarization) of the receptor followed by a sustained and steady blockade. These drugs do not act as competitive antagonists; instead, they function as more enduring agonists compared to acetylcholine itself. Many factors can influence the duration of action of these drugs. Among them, electrolyte disturbances and disruptions in acid-base balance can have an impact. Acidosis increases the potency of non-depolarizing muscle relaxants, while alkalosis induces resistance to their effects. In depolarizing drugs, acidosis and alkalosis produce opposite effects. The results of studies on the impact of acid-base balance disturbances on non-depolarizing relaxants have been conflicting. This work is based on the available literature and the authors' experience. This article aimed to review the use of anesthetic muscle relaxants in patients with acid-base disturbances.

The relationship between infection parameters and urine volume in acute kidney injury

Aim: Acute kidney injury (AKI) is a clinical syndrome that can cause disturbances in fluid-electrolyte and acid-base balance, resulting in the accumulation of nitrogen and uremic toxins along with the loss of kidney functions within hours or days. In this study, it was aimed to retrospectively examine patients with acute kidney injury to determine whether there is a relationship between infection parameters and urine volume. Materials and Methods: The study included a total of 144 patients with (n=74) and without infection (n=70) out of 294 patients with AKI who received treatment between 1 January 2020 and 31 December 2021 in the nephrology clinic of a tertiary university hospital. Results: The mean age was 66.4±15.7 (range:19-95) in patients with infection and 63.8±15.2 (range:36- 93) in non-infected patients. 51.4% (n=38) of those with infection and 52.9% (n=37) of those without infection were women. There was no difference between the individuals with and without infection in terms of age and gender (p>0.05). Infection was present in 51.4% (n=74) of the patients included in the study. Urinary tract (31.3%) and respiratory tract infections (13.2%) were the most common in those with infection. A moderate negative correlation was observed between admission CRP and discharge creatinine level in patients with infection. There was no correlation between PCT and sedimentation rate, urine volume and admission/discharge creatinine level. Moderate positive correlations were found between admission/discharge PCT and admission/discharge urine volume in patients without infection. In addition, moderate negative correlations were found between admission/discharge sedimentation rate and admission urine volume. Conclusions: No correlation was found between PCT and sediment (incoming/exit) and outflow urine volume in patients with infection.

Chronic kidney disease in geriatrics

Chronic kidney disease (CKD) affects almost 10% of the world's population, and over 30% of people aged over 70 [1,2]. The overall incidence of treated CKD is stable in France, but continues to rise sharply in people aged over 85 [3]. In its advanced stages, CKD is associated with numerous complications linked to disturbances in water, acid-base and phosphocalcium balance, as well as anemia and increased cardiovascular risk. A better understanding of risk factors, improved practices to promote nephroprotection, and progress in therapeutic education and preparation for suppletive techniques would help reduce this risk.

Renal Tubular Acidosis: Recognition and Treatment Strategies

Renal tubular acidosis (RTA) is a group of kidney disorders characterized by impaired renal acidification, leading to disturbances in acid-base balance. This review article provides a comprehensive overview of RTA, including its epidemiology, pathophysiology, clinical presentation, and diagnosis. Three main types of RTA are discussed: distal RTA (Type 1), proximal RTA (Type 2), and hyperkalemic RTA (Type 4). Each type’s underlying causes and mechanisms are explored, highlighting the importance of accurate diagnosis for appropriate management. Diagnostic approaches involving clinical evaluation, laboratory tests, and specialized renal function studies are described in detail. The treatment strategies for each type of RTA are outlined, emphasizing the importance of correcting the acid-base imbalance and managing associated electrolyte abnormalities. Lifestyle modifications and pharmacological interventions are discussed, including alkali supplementation and potassium regulation. Finally, the need for further research and prospective studies to enhance our understanding of RTA and improve therapeutic interventions is emphasized. Advancements in diagnosis

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.

Characteristics of Acupoint Selection and Therapeutic Effect Analysis of Acupuncture Treatment for Patients with Chronic Kidney Disease.

The therapeutic effect of acupuncture treatment on chronic kidney disease (CKD) was assessed, and the characteristics of acupoint selection in different CKD types were summarised. A total of 100 patients with CKD were enrolled in this retrospective cohort study, of whom 50 received acupuncture treatment for 12 weeks (acupuncture group) and 50 received routine treatment for 12 weeks (control group). Routine treatment included appropriate rest, low-salt and low-protein diet and correction of the disturbance in water, electrolyte and acid-base balance. Hypertensive patients received antihypertensive treatment, and patients with hyperuricaemia received uric acid lowering treatment. Acupuncture acupoints were selected in accordance with traditional Chinese medicine (TCM) theory. Baseline characteristics, therapeutic effects and adverse events were assessed, and kidney function indexes, urine albumin creatine ratios (UACRs) and estimated glomerular filtration rates (eGFRs) were compared at different time points (before acupuncture treatment, T1; Immediately after acupuncture treatment, T2; After 3 months of follow-up, T3). The baseline data were slightly different between the groups (p > 0.05), specifically gender, age, duration time, TCM syndrome, CKD stage, systolic blood pressure (SBP), diastolic blood pressure (DBP), and cholesterol, triglyceride, low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). The acupuncture group presented better therapeutic effects than the control group (82.00% vs. 60.00%, p = 0.015). At T2 or T3, the value of UACR in both groups obviously decreased (p < 0.05), whereas the eGFRs markedly increased (p < 0.05). In addition, at T2 or T3, the UACRs were significantly lower in the acupuncture group than in the control group (p < 0.01), whereas an opposite result was obtained for eGFR (p < 0.05). The adverse event rate barely differed between the groups (8.00% vs. 6.00%, p = 0.695). Acupuncture treatment can effectively treat CKD and can improve kidney function. This study provides a theoretical basis for clinical application.

Hazards of administration of benzodiazepines in patients with adaptive hyperventilation: a case rapport

IntroductionOnly three population-based observational human studies provided evidence that benzodiazepines (BZD) are associated with clinically adverse respiratory outcome. Striking was the finding that BZD drug exposure was associated with a 32% significantly increased adjusted risk of all-cause mortality, including, of note, the subgroup of individuals with no comorbidities. Causation, however, cannot be inferred in observational study design and, highly likely, recipients received BZD’s in these studies to help treating anxiety related to inter alia pre-existing respiratory symptoms.ObjectivesBased on one fatal particular case, authors of current rapport explain what can go wrong when BZD’s are given in patient with respiratory impairment.MethodsAuthors provide a model on how an increase in carbon dioxide can lead to impaired cerebral autoregulation in a person with pre-existing respiratory decompensation. Discussion of integrative metabolic and vascular physiology.ResultsCase rapport of a 18 y.o. otherwise healthy man, who was hospitalized with a novel episode of diabetic ketoacidosis accompanied by profound hypocapnia and anxiety, and who deteriorated and died shortly after airway management because of a clinically important acid-base balance disturbance caused by increased carbon dioxide. All the blood tests and results of respiratory monitoring were collected and carefully assessed.ConclusionsCurrent case suggests that the P(CO(2))--HCO(3) hypothesis is consistent with known data on impaired cerebral autoregulation in diabetic ketoacidosis, driven mainly by increased levels of pCO2. In our opinion, it indicates the recommendation not to administrate BZD’s in patients with pre-existing compensatory hyperventilation as it may counter to the logic of adaptive physiology.DisclosureNo significant relationships.

Acid-Base Balance, Blood Gases Saturation, and Technical Tactical Skills in Kickboxing Bouts According to K1 Rules.

Simple SummaryThe aim of our study was to analyze the changes in ABB after a three-round kickboxing fight and the level of technical and tactical skills presented during the fight. Fighting in kickboxing under K1 rules takes place with a high presence of anaerobic metabolism. Kickboxing athletes must have a good tolerance for metabolic acidosis and the ability to conduct an effective duel despite ABB disorders. Properly developed post-workout regeneration also plays an extremely important role. Background: Acid–base balance (ABB) is a major component of homeostasis, which is determined by the efficient functioning of many organs, including the lungs, kidneys, and liver, and the proper water and electrolyte exchange between these components. The efforts made during competitions by combat sports athletes such as kickboxers require a very good anaerobic capacity, which, as research has shown, can be improved by administering sodium bicarbonate. Combat sports are also characterized by an open task structure, which means that cognitive and executive functions must be maintained at an appropriate level during a fight. The aim of our study was to analyze the changes in ABB in capillary blood, measuring levels of H+, pCO2, pO2, HCO3−, BE and total molar CO2 concentration (TCO2), which were recorded 3 and 20 min after a three-round kickboxing bout, and the level of technical and tactical skills presented during the fight. Methods: The study involved 14 kickboxers with the highest skill level (champion level). Statistical comparison of mentioned variables recorded prior to and after a bout was done with the use of Friedman’s ANOVA. Results: 3 min after a bout, H+ and pO2 were higher by 41% and 11.9%, respectively, while pCO2, HCO3−, BE and TO2 were lower by 14.5%, 39.4%, 45.4% and 34.4%, respectively. Furthermore, 20 min after the bout all variables tended to normalization and they did not differ significantly compared to the baseline values. Scores in activeness of the attack significantly correlated (r = 0.64) with pre–post changes in TCO2. Conclusions: The disturbances in ABB and changes in blood oxygen and carbon dioxide saturation observed immediately after a bout indicate that anaerobic metabolism plays a large part in kickboxing fights. Anaerobic training should be included in strength and conditioning programs for kickboxers to prepare the athletes for the physiological requirements of sports combat.

Predictors of Rehospitalization and Mortality in Diabetes-Related Hospital Admissions.

The risk factors of rehospitalization and death post-discharge in diabetes-related hospital admissions are not fully understood. To determine them, a population-based retrospective epidemiological survey was performed on diabetes-related admissions from the Polish national database. Logistic regression models were used, in which the dependent variables were rehospitalization due to diabetes complications and death within 90 days after the index hospitalization. In 2017, there were 74,248 hospitalizations related to diabetes. A total of 11.3% ended with readmission. Risk factors for rehospitalization were as follows: age < 35 years; male sex; prior hospitalization due to acute diabetic complications; weight loss; peripheral artery disease; iron deficiency anemia; kidney failure; alcohol abuse; heart failure; urgent, emergency, or weekend admission; length of hospitalization; and hospitalization in a teaching hospital with an endocrinology/diabetology unit. Furthermore, 7.3% of hospitalizations resulted in death within 90 days following discharge. Risk factors for death were as follows: age; neoplastic disease with/without metastases; weight loss; coagulopathy; alcohol abuse; acute diabetes complications; heart failure; kidney failure; iron deficiency anemia; peripheral artery disease; fluid, electrolytes, and acid–base balance disturbances; urgent or emergency and weekend admission; and length of hospitalization. We concluded that of all investigated factors, only hospitalization within an experienced specialist center may reduce the frequency of the assessed outcomes.

Prognostic role of perioperative acid-base disturbances on the risk of Clostridioides difficile infection in patients undergoing cardiac surgery.

It is unclear whether acid-base balance disturbances during the perioperative period may impact Clostridium difficile infection (CDI), which is the third most common major infection following cardiac surgery. We hypothesized that perioperative acid-base abnormalities including lactate disturbances may predict the probability of incidence of CDI in patients after cardiac procedures. Of the 12,235 analyzed patients following cardiac surgery, 143 (1.2%) developed CDI. The control group included 200 consecutive patients without diarrhea, who underwent cardiac procedure within the same period of observation. Pre-, intra and post-operative levels of blood gases, as well as lactate and glucose concentrations were determined. Postoperatively, arterial blood was drawn four times: immediately after surgery and successively; 4, 8 and 12 h following the procedure. Baseline pH was lower and PaO2 was higher in CDI patients (p < 0.001 and p = 0.001, respectively). Additionally, these patients had greater base deficiency at each of the analyzed time points (p < 0.001, p = 0.004, p = 0.012, p = 0.001, p = 0.016 and p = 0.001, respectively). Severe hyperlactatemia was also more common in CDI patients; during the cardiac procedure, 4 h and 12 h after surgery (p = 0.027, p = 0.004 and p = 0.001, respectively). Multivariate logistic regression analysis revealed that independent risk factors for CDI following cardiac surgery were as follows: intraoperative severe hyperlactatemia (OR 2.387, 95% CI 1.155-4.933, p = 0.019), decreased lactate clearance between values immediately and 12 h after procedure (OR 0.996, 95% CI 0.994-0.999, p = 0.013), increased age (OR 1.045, 95% CI 1.020-1.070, p < 0.001), emergent surgery (OR 2.755, 95% CI 1.565-4.848, p < 0.001) and use of antibiotics other than periprocedural prophylaxis (OR 2.778, 95% CI 1.690-4.565, p < 0.001). This study is the first to show that perioperative hyperlactatemia and decreased lactate clearance may be predictors for occurrence of CDI after cardiac surgery.

Alterations in Hemolymph Ion Concentrations and pH in Adult Daphnia magna in Response to Elevations in Major Ion Concentrations in Freshwater.

Increases in the concentrations of major ions (Na+ , K+ , Ca2+ , Mg2+ , Cl- ) in freshwater are a growing concern for ecosystem health. These increases may originate from anthropogenic activities such as road deicing, fracking spills, mining, and fertilizer application and have detrimental effects on freshwater organisms through disturbances in ionoregulation and acid-base balance. The cladoceran Daphnia magna is adapted for active ion uptake and reduction of ion loss to maintain osmotic balance, but alterations in ionic composition of the environmental water are associated with toxicity. In the present study, hemolymph ion concentrations were measured using ion-selective microelectrode techniques. Increases in the hemolymph concentrations of Na+ and K+ correspond to elevations in the concentrations of these ions in ambient water. Water concentrations associated with sustained increases in hemolymph ion concentrations correlate well with median lethal concentration values from previous toxicology studies, indicating that Na+ and K+ concentrations in hemolymph may predict toxicity. When water K+ concentration is increased, a simultaneous increase in water Na+ concentration mitigates the increase in hemolymph K+ concentration, a finding which is consistent with the reported mitigation of K+ toxicity by Na+ . When ambient concentrations of K+ , Na+ , and Cl- are increased, not only is there a rise in hemolymph ion concentration but hemolymph pH is altered and pH regulation appears to be prioritized over regulation of hemolymph Na+ , K+ , and Cl- in D. magna. Environ Toxicol Chem 2021;40:366-379. © 2020 SETAC.

Association of Acid-Base Balance in the Renal Proximal Tubule and Blood Pressure Alterations: Potential Role of Local Mediators

Disturbances in acid-base balance leading to the development of hypertension are currently gaining increased attention among researchers. Perturb acid-base balance characterized by metabolic acidosis has been demonstrated in hypertensive animals and humans. Research suggests that acid-base changes are not only the consequences of elevated blood pressure but can precede the development of hypertension. However, no exact mechanism has been identified to link acid-base imbalance with alterations in blood pressure. The kidney proximal tubule is the major site for maintaining normal bicarbonate concentrations which is an important component of acid-base balance. Acid-base transporter proteins in the renal proximal tubule such as Na+/HCO-3 cotransporters, Na+/H+ exchangers, and anion-exchangers play important roles in controlling acid secretion, ammonia production and bicarbonate reabsorption for maintaining acid-base balance. It is well known that sodium retention in the renal tubules leads to increase in blood volume and consequently increases in blood pressure. Therefore, it is the purpose of this review to discuss the role of sodium-coupled acid-base transporters in regulating proximal tubular sodium retention and controlling blood pressure homeostasis. We will also focus on the capacity of local mediators; angiotensin II, cortisol, prosta-glandin and aldosterone, to regulate acid-base and blood pressure homeostasis.

Predictive Elements of Obstructive Urolithiasis in Sheep*

Background: Urolithiasis is an economically important disease that has considerable significance for sheep farming. With the tissue and biochemical changes resulting from the development of this disease, metabolic disorders and immune response are established. Hemogasometric evaluation allows the identification of systemic acid-base imbalances quickly. Acute phase proteins (AFP) have in the last two decades become the biomarkers of choice in human and veterinary medicine. To date, no biomarker studies have been published for sheep with obstructive urolithiasis. Thus, this study aimed to analyze the hemogasometric kinetics in obstructive urolithiasis in sheep and the AFP that can be used as early biomarkers in this disease.Materials, Methods &amp; Results: In this study, 14 healthy male Santa Inês sheep, aged approximately 90 days, fed on calculogenic diet for 120 days. The animals were examined weekly, including observation of clinical signs, and blood and urine analysis were performed. For comparative analysis purposes, at the end of the experiment, sheep that developed obstructive urolithiasis were extracted from the initial experimental group D1 (without urolithiasis) and became part of the second experimental group D2 (with urolithiasis). In the pre-experimental period and on the day of slaughter, venous blood samples were harvested for hemogasometric tests, with a maximum time of 15 minutes between collection and analysis, to ensure the reliability of the results obtained. The pH, pCO2, pO2, EB, tCO2, HCO3-, stHCO3-, tHb, sO2 and Hct, Na+, K+ and Ca2+ ions were quantified. To identify and measure immunoglobulins (A and G) and AFP, samples from sheep that developed obstructive urolithiasis (D2) were analyzed. Blood samples were harvested weekly until the clinical manifestation of the disease, totaling 16 samples, when IgA, IgG, ceruloplasmin, transferrin, albumin, α1-antitrypsin, haptoglobin and α1-acid glycoprotein concentrations were measured. Elevation of pCO2 was observed between D1 and D2, but there was a significant difference (P &lt; 0.05) only in the final moments (FMs). Although EB, tCO2, HCO3-, stHCO3- increased between moments in the same group and between groups at the same time, significant differences were recorded only in the FMs. Higher values were observed for Na+, K+ in the FMs. The AFP of sheep that developed the disease oscillated between moments, however, significant difference (P &lt; 0.05) over time was observed only in haptoglobin and transferrin.Discussion: The disease occurred in five of the 14 animals studied, demonstrating the effectiveness of the formulated diet in inducing the disease. Through the analysis of blood gases, plasma bicarbonate concentration and excess base or deficit it was possible to diagnose disturbances in acid base balance, characterizing a picture of metabolic alkalosis in animals with urolithiasis. Mean pH was not significantly different between groups, but sheep that developed urolithiasis had alkalosis. Final values of tCO2 and HCO3- indicate the compensatory organic response, which, together with the analysis of the averages of HCO3- and EB, reflect the metabolic alkalosis picture. The AFP have different responsiveness among them. Haptoglobin and transferrin were the most reliable biomarkers among the studied AFP to predict obstructive urolithiasis, with transferrin showing atypical behavior, characteristic of positive AFP.

Application of Pontentilla anserine, Polygonum aviculare and Rumex crispus Mixture Extracts in a Rabbit Model with Experimentally Induced E. coli Infection.

Simple SummaryThe beneficial effect of herbs on production parameters, quality of products of animal origin, and animal health was demonstrated in numerous studies. This study aimed to determine an effect of herbal mixture on blood parameters and the anti-colibacteriosis efficacy. The rabbit model used during the experimental infection with E. coli indicates a clear effect of Rumex crispus L., Pontentilla anserine, Polygonum aviculare, whose activity involves the reduction of colonization of basically all sections of the intestines. The use of herbs in rabbits can control the activity of intestinal microbial community. Administration of a mixture of herbs to feed reduced the number of E. coli in cecum more than supplementation into water after experimental infection. The plant extracts may be a good alternative to antibiotic treatment.The study evaluated the anti-colibacteriosis efficacy of herbs in experimental infection by rabbit pathogenic strain of E. coli O103 eae+. It also studied the effects of herbal mixture added to feed or water on blood parameters. This animal model was used since some E. coli strains pathogenic for rabbits are similar to the strains that are pathogenic to humans. The components of herbal extracts were Rumex crispus, Pontentilla anserine, and Polygonum aviculare. Supplementation was carried out in water (ExpW group) or feed (ExpF group), and four weeks later the animals were infected with the E. coli O103 eae+ strain. The administration of herbs increased the mean concentration of total protein and serum albumin (p < 0.01) without causing disturbances of electrolyte and acid-base balance. The highest total antioxidant capacity (TAS) value (p < 0.01) was observed in the ExpF group. The administration of a mixture of herbs and feed caused more reduction in the number of E. coli in cecum than supplementation into water after an experimental infection. The herbs applied in rabbits did not harm the secretory functions of liver, electrolyte, and acid-base balance of the blood. The application of the tested herbal mixtures can control the activity of the intestinal microbial community.

Abstract P2038: A Nobel I551F Mutant of Sodium Handling Transporter NBCe1 Has Cytosolic Retention and Diminishes Transport Activity

The electrogenic Na + /HCO 3 - cotransporter NBCe1 is expressed in many organs and controls sodium handling. NBCe1 homozygous mutation causes not only severe hypotension but also proximal renal tubular acidosis in human and rodents. Here we shows the functional significance of the mutations reported from NCBI database on NBCe1 function. We identified 14 mutations in NBCe1 variant A(kidney type), resulting in the single amino acid substitutions, A425T, F461L, A465S, L494F, N503H, A518T, A518G, I523V, V533D, Y535H, I551F, Y554H, M753V, and L785I. Immunocytological analysis with confocal microscopy revealed only I551F mutant was expressed predominantly in the cytoplasm of HEK 293 cells and MDCK cells. Functional analysis using Xenopus oocytes revealed that I551F mutant had a significantly reduced activity corresponding to 52% of that of wild-type (p&lt;0.01). Whole and biotinylated western blotting in HEK293 cells confirmed that the surface expression of I551F mutant was significantly reduced. Deglycosylation study revealed that I551F has impaired N-glycosylation. To examine the role of I551 in more detail, we also examined the properties of artificial mutants I551A, I551P, I551K, I551R, I551D and I551E in HEK293 and MDCK cells. All of artificial mutants were properly expressed in the plasma membrane. By contrast, only I551F mutant was predominantly expressed in cytoplasmic regions. These results indicate that I551F mutation inactivates the NBCe1 function with cytoplasmic retention. Because NBCe1 plays a major role in renal proximal sodium and bicarbonate reabsorption, I551F mutation may be associated with the disturbance in systemic acid-base balance or the changes in blood pressure.

SAT-151 POSITIVE RENAL OUTCOMES OF LARGE VOLUME PARACENTESIS IN CIRRHOTIC PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS, A NEPHROLOGIST'S PERSPECTIVE

Spontaneous bacterial peritonitis (SBP) occurs in 10-30% of cirrhotic patients and is associated with high mortality rate in this vulnerable population. It is associated with high incidence of acute kidney injury (AKI) and hepatorenal syndrome (HRS), and large number of nephrological input is been sought from our medicine and hepatology section colleagues. In a low to lower middle income country where availability of resources remain a big hurdle, newer therapeutic options with less use of interventions are always been sought. The case is also true for the developed world where healthcare related costs needs to be cut down. Large volume paracentesis (LVP) decreases the burden of infective fluid. Outcomes of LVP in SBP patients has not been clearly addressed in previous studies. Furthermore, in the absence of more viable therapeutic options for preventing kidney impairment in SBP, the management really looms around time and need for renal replacement therapy (RRT). This study will assess the outcome of LVP in patients with SBP, both in terms of mortality, length of stay and effect on renal function This cross-sectional study was conducted in the Medicine Unit of Aga Khan University Hospital. A total of 113 patients with diagnosed SBP were assessed. Among these patients 61 underwent LVP while 51 were managed conservatively. LVP was done as per routine practice of safety and monitoring. All the patients received intravenous Albumin. Baseline and 48 hours clinical outcomes (including creatinine and ascitic fluid total leucocytes (TLC) count) were compared. The development of AKI and post-paracentesis induced circulatory dysfunction (PPCD) were also assessed and model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores were also calculated. Need for renal replacement therapy for the acute disturbances of acid base balance, development of severe and progressive renal failure and continuous renal replacement therapy was also noted. There was statistically significant improvement in post 48 hours creatinine among patients undergoing LVP (p-value <0.001) whereas no significant improvement was seen in patients without LVP (p-value 0.32). Similar improvements were seen for special care unit stay and total length of stay in patients with LVP, need for RRT and incidences of AKI and HRS, as evidenced by the table. LVP in patients with SBP translates into significantly positive outcomes in terms of length of hospital stay, special care unit stay, need for RRT and development of AKI and HRS. Hence as per a nephrologist's perspective, LVP should be considered as a favored therapeutic option in patients with SPB.

Protocolo diagnóstico y despistaje de las acidosis tubulares

Renal tubular acidosis is a group of tubular disorders causing acid-base balance and electrolyte disturbances varying according with tubular segment involved. Etiology can be primary (genetic origin) or secondary to diseases or toxic substances. Overall, they present with hyper-chloremia and a normal plasma anion gap, meanwhile in chronic forms hypercalciuria and nephrolithiasis are detected. They are classified in: type I (characterized by the inability to lower urinary pH), type II (characterized by a decreased renal HCO3− threshold), and type IV (pseudohypoaldosteronism). Bicarbonate replacement and management of ionic disorders are required for their treatment.

Haemadsorption improves intraoperative haemodynamics and metabolic changes during aortic surgery with hypothermic circulatory arrest.

Aortic surgery involving hypothermic circulatory arrest (HCA) results in a systemic inflammatory response that may negatively influence outcome. An extracorporeal haemadsorption (HA) device (CytoSorb®) that removes inflammatory triggers may improve haemodynamic and metabolic reactions due to excessive inflammation and, ultimately, outcome. As a single-centre experience, the data of 336 patients who had undergone aortic surgery with HCA between 2013 and 2017 were retrospectively analysed. Patients with HA were matched to patients receiving standard therapy without HA (Control) by propensity score matching and compared subsequently. During aortic surgery with HCA, HA significantly reduced the requirement of norepinephrine (HA: 0.102 µg/kg/min; Control: 0.113; P = 0.043). Severe disturbances of acid-base balance as reflected by a pH lower than 7.19 (HA: 7.1%; Control: 11.6%; P = 0.139), maximum lactate concentrations (HA: 3.75 mmol/l; Control: 4.23 P = 0.078) and the need for tris-hydroxymethylaminomethane buffer (HA: 6.5%; Control: 13.7%; P = 0.045) were less frequent with HA. Compared to standard therapy, HA decreased the need for transfusion of packed red blood cells (1 unit; P = 0.021) and fresh frozen plasma (3 units; P = 0.001), but increased the requirement of prothrombin complex concentrate (800 IE, P = 0.0036). HA did not affect inflammatory laboratory markers on the first postoperative day. Differences in operative mortality (HA: 4.8%; Control: 8.8%) and the length of hospital stay (HA: 13.5 days; Control: 14) were not statistically significant. HA significantly reduces the need for vasopressors, the amount of transfusion and improves acid-base balance in aortic surgery with HCA. Multicentre prospective trials are required to confirm these results.

Point-of-care laboratory analyses of intraosseous, arterial and central venous samples during experimental cardiopulmonary resuscitation

IntroductionScreening and correcting reversible causes of cardiac arrest (CA) are an essential part of cardiopulmonary resuscitation (CPR). Point-of-care (POC) laboratory analyses are used for screening pre-arrest pathologies, such as electrolyte disorders and acid–base balance disturbances. The aims of this study were to compare the intraosseous (IO), arterial and central venous POC values during CA and CPR and to see how the CPR values reflect the pre-arrest state. MethodsWe performed an experimental study on 23 anaesthetised pigs. After induction of ventricular fibrillation (VF), we obtained POC samples from the IO space, artery and central vein simultaneously at three consecutive time points. We observed the development of the values during CA and CPR and compared the CPR values to the pre-arrest values. ResultsThe IO, arterial and venous values changed differently from one another during the course of CA and CPR. Base excess and pH decreased in the venous and IO samples during untreated VF, but in the arterial samples, this only occurred after the onset of CPR. The IO, arterial and venous potassium values were higher during CPR compared to the pre-arrest arterial values (mean elevations 4.4 mmol/l (SD 0.72), 3.3 mmol/l (0.78) and 2.8 mmol/l (0.94), respectively). ConclusionsA dynamic change occurs in the common laboratory values during CA and CPR. POC analyses of lactate, pH, sodium and calcium within IO samples are not different from analyses of arterial or venous blood. Potassium values in IO, arterial and venous samples during CPR are higher than the pre-arrest arterial values.

Formulating a preoperative risk scoring system for elderly patients with hip fracture

Objective To establish a preoperative risk scoring system for elderly patients with hip fracture on the basis of investigation into the factors influencing their mortality during hospitalization. Methods The data were collected from the database of hospitalization summary reports (HSR) of Beijing Public Health Commission concerning the 14,577 patients who had been 55 years old or older and hospitalized for hip fracture from January 1, 2006 throughout December 31, 2010 at the 35 top-rank hospitals in Beijing. They were divided into a surgery group and a non-surgery group. Two multivariable risk-adjustment models were established for the 2 groups on the basis of an investigation into the factors influencing their mortality during hospitalization. Finally a preoperative risk scoring system for elderly patients with hip fracture was formulated according to the valuation of the least common multiples of β coefficients of the risk factors. Results Besides senior age and male gender, 10 different comorbidities were independently associated with in-hospital mortality, particularly pulmonary embolism, respiratory failure, renal failure and diabetes. The risk for inpatient mortality associated with a specific comorbidity was relatively higher in the surgery group than in the non-surgery group. The risk-adjustment models based on the variables had better accuracy in predicting in-hospital mortality (ROC=0.91 in surgery group versus ROC=0.85 in non-surgery group). In our preoperative risk scoring system for elderly patients with hip fracture, 10 points were for an age of 65 to 74 years old, 14 points for an age of 75 to 84 years old, 18 points for an age beyond 85 years old, 4 points for male gender, 20 points for pulmonary embolism, 18 points for respiratory failure, 10 points for renal insufficiency, 8 points for diabetes, 8 points for heart failure, 7 points for malignant tumor, 7 points for lung infection, 7 points for disturbance of water, electrolyte and acid-base balance, 6 points for arrhythmia, and 6 points for cerebral infarction, totaling 119 points. Conclusions The primary risk factors for in-hospital mortality in the elderly patients with hip fracture seem to be senior age, male gender and 10 different comorbidities. A preoperative risk scoring system has been successfully established for elderly patients with hip fracture. Key words: Hip; Fracture, bone; Aged; Comorbidities; Mortality