Higher Base Deficit Research Articles

The accuracy of the Thompson score in predicting early outcome in neonates with hypoxic ischaemic encephalopathy treated with therapeutic cooling in a tertiary hospital.

Hypoxic ischaemic encephalopathy (HIE) is one of the major contributors to neonatal mortality and morbidity in developing countries. Scarcity of resources limits clinicians in optimally caring for these patients. Optimal utilisation of clinical tools such as the Thompson score (TS) can assist in improving care by classifying the severity of HIE followed by appropriate treatment. The primary objective was to study the correlation of the TS and early neonatal outcomes in infants with HIE who received therapeutic hypothermia (TH). Secondary objectives were to investigate the correlation of blood gas values with the TS, need for resuscitation with TS, target organ damage (TOD) with TS and the most common risk factors associated with HIE in Tembisa Provincial Tertiary Hospital (TPTH). This was a retrospective record review of infants admitted with HIE from January 2018 to August 2019 at the TPTH neonatal unit. Infants had to have successfully completed TH. Ninety-three infants met the inclusion criteria, with 32, 48 and 13 being classified into the mild, moderate and severe categories by TS, respectively. The median length of stay (LOS) was noted to rise with a rising TS, recorded to be 7, 8 and 9 days in the mild, moderate and severe groups, respectively. The mortality rate in the study was calculated to be 2.1%, and there was no significant difference across the groups (p=0.231). A need for antiseizure medication (ASM) on discharge was significantly associated with severe HIE (p=0.028). Hypertension was a frequent chronic illness, noted in 11.3% of the mothers. The most frequent perinatal risk factor was meconium aspiration (50.5%), followed by prolonged second stage of labour (PSSL) (17.2%). A higher TS (severe group) was associated with prolonged resuscitation for >10 minutes (p=0.001) and a need for adrenaline (p=0.008). The frequency of cardiac impairment, liver impairment and clinical seizures increased with a higher TS category (p=0.23, p=0.35 and p=0.51, respectively). On blood gas analysis, a low pH and a high base deficit were associated with severe HIE (p=0.027, p=0.061 respectively). The TS is still a useful clinical tool in the era of TH as it is able to predict some early neonatal outcomes such as LOS and a need for ASM at discharge. It is also able to demonstrate increased frequency of duration of resuscitation and a need for adrenaline in severely encephalopathic infants compared with mild. A high TS is also associated with severe metabolic acidosis and increased frequency of TOD. Maternal hypertension, meconium-stained liquor and PSSL are the common risk factors for HIE at TPTH.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing.

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality. a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing. data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05). age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Life over limb: Arterial access-related limb ischemic complications in 48-hour REBOA survivors.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used in some trauma settings. Arterial access-related limb ischemic complications (ARLICs) resulting from the femoral arterial access required for REBOA are largely under reported. We sought to describe the incidence of these complications and the clinical, technical, and device factors associated with their development. This was a retrospective cohort study of records of adult trauma patients from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between October 2013 and September 2020 who had REBOA and survived at least 48 hours. The primary outcome was ARLIC, defined as clinically relevant extremity ischemia or distal embolization. Relevant factors associated with ARLIC were also analyzed. Of 418 identified patients, 36 (8.6%) sustained at least one ARLIC; 22 with extremity ischemia, 25 with distal embolism, 11 with both. Patient demographics and injury characteristics were similar between ARLIC and no ARLIC groups. Access-related limb ischemic complication was associated with larger profile devices (p = 0.009), cutdown access technique (p = 0.02), and the presence of a pelvic external fixator/binder (p = 0.01). Patients with ARLIC had higher base deficit (p = 0.03) and lactate (p = 0.006). One hundred fifty-six patients received tranexamic acid (TXA), with 22 (14%) ARLICs. The rate of TXA use among ARLIC patients was 61% (vs. 35% TXA for non-ARLIC patients, p = 0.002). Access-related limb ischemic complication did not result in additional in-hospital mortality, however, ARLIC had prolonged hospital LOS (31 vs. 24 days, p = 0.02). Five ARLIC required surgical intervention, three patch angioplasty (and two with associated bypass), and four ARLIC limbs were amputated. Femoral artery REBOA access carries a risk of ARLIC, which is associated with unstable pelvis fractures, severe shock, and strongly with the administration of TXA. Use of lower-profile devices and close surveillance for these complications is warranted in these settings and caution should be exercised when using TXA in conjunction with REBOA. Prognostic and Epidemiologic, Level III.

Bloodstream Infections in Preterm Neonates and Mortality-Associated Risk Factors

To investigate the association of early (±4hours after onset of bloodstream infection) clinical and laboratory variables with episode-related mortality (<7days). This 2-site retrospective study included 142 neonates born at <35weeks of gestational age with positive blood/cerebrospinal fluid (CSF) culture at >72hours of age from organisms other than coagulase-negative Staphylococcus. Early variables were compared between those with bloodstream infection-related mortality and survivors. Multivariable analysis was conducted for the primary outcome, and the area under the curve (AUC) was estimated for relevant variables. The neonates who died were of lower gestational age at disease onset. After adjusting for relevant variables, lowest mean blood pressure (MBP) (aOR, 0.10; 95% CI, 1.02-1.19) and highest base deficit (aOR, 1.18; 95% CI, 1.06-1.32) were independently associated with mortality. The AUC was 0.87 (95% CI, 0.78-0.96) for base deficit, increasing to 0.91 (95% CI, 0.83-0.99) with the addition of MBP. Low MBP and high base deficit within ±4hours of bloodstream infection onset identify preterm neonates at risk of mortality.

Maternal arterial blood gas values during delivery: Effect of mode of delivery, maternal characteristics, obstetric interventions and correlation to fetal umbilical cord blood

Obstetricians routinely use biochemical parameters from non-pregnant women to assess the condition of the laboring mother. However, it is well known that pregnancy leads to significant physiological changes in most organ systems. The aim of this study was to determine normal values for maternal arterial blood gases during vaginal deliveries as compared with control values from planned cesarean sections. We also wanted to elucidate the effect of various maternal characteristics, mode of delivery and obstetric interventions on blood gas values. We carried out a randomly selected, prospective-observational cohort study of 250 women undergoing vaginal delivery and 58 women undergoing planned cesarean section at the Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden. We found significant differences for gestational age, parity, umbilical venous blood pH, pCO2 and lactate values between the two study groups (P<.005). Significantly lower pH, pCO2 , pO2 and sO2 were found in mothers delivering vaginally. Higher base deficit, hemoglobin, bilirubin, potassium, glucose and lactate were found in vaginal deliveries than in planned cesarean sections (P<.02). Maternal body mass index (BMI), smoking and hypertension were not significantly correlated to acid base parameters in women with vaginal deliveries. On the other hand, multiple regression showed significant associations for the use of epidural anesthesia on maternal pH (P<.05) and pO2 (P<.01); and synthetic oxytocin on pCO2 (P=.08), glucose (P<.00) and lactate (P<.02) levels in maternal arterial blood. Maternal arterial pH, pCO2 and lactate values correlated significantly to values in venous umbilical cord blood (P<.000). Maternal arterial blood gas parameters varied significantly according to mode of delivery, the use of epidural anesthesia and synthetic oxytocin.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Glucose Levels during the First 24 Hours following Perinatal Hypoxia.

Hypoglycemia is a significant risk factor for perinatal brain injury and adverse outcomes, particularly in infants requiring resuscitation following hypoxic ischemic (HI) insult. We aimed to study blood glucose (BG) levels in physiologically stressed infants in the presence or absence of epinephrine (Epi) administration at resuscitation in the first 24 hours after birth. A retrospective chart review of all infants with heart rate (HR) < 100/min at 1 minute requiring positive pressure ventilation (PPV) at birth was performed. Infants were classified into two groups as follows: (1) PPV group: infants' HR improved with PPV only at resuscitation, and Epi group: infants received Epi at resuscitation for persistent bradycardia. Serial measurements of BG levels collected and glucose infusion rate (GIR) calculated at 24 hours. By design, infants in the Epi group had lower cord pH and higher base deficit. BG was significantly lower overtime in premature infants ≤32 weeks of gestation in the Epi group. The BG was markedly higher in near-term and term infants in the Epi group compared with the PPV group. Hypoglycemia was more common despite administration of higher GIR in premature infants ≤32 weeks of gestation. In the presence of physiological stress, premature infants are more at risk for hypoglycemia than term infants.

Base Deficit as a Predictor of Mortality in Sepsis and Septic Shock

Introduction: Sepsis is a common problem encountered in emergency room which needs to be intervened early. It is always difficult to have quick prognostic marker of sepsis in busy emergency. So this study was conducted to determine whether base deficit can be used as an indicator of mortality among septic patients in emergency room setup like ours.&#x0D; Methods: It was a hospital based descriptive cross sectional study done at Tribhuvan University Teaching Hospital, Kathmandu from March 2018 to December 2018. Acute physiology and chronic health Evaluation II score (APACHE II), Base deficit, Sequential Organ Failure Assessment (SOFA) score on first day of arrival in emergency room was calculated. The association of 28-day outcome with acute physiology and chronic Health Evaluation II score, Base deficit value and SOFA score were derived.&#x0D; Results: Out of 229 patients with septic shock 62 died (27%) and among 71 patients without septic shock, 12 died (16.9%).Overall mortality was 24.66 % (n= 74).The area under the ROC curve for Base deficit(0.864;95% C.I.=0.822-0.906), APACHE II (0.782; 95% C.I=0.718-0.848, SOFA (0.689;95% C.I=0.620-0.757) were greater than 0.7 except for SOFA which signifies these test to have fair efficacy to predict mortality.&#x0D; Conclusions: High base deficit value predicts mortality in patients with sepsis and septic shock. The base deficit could be used as an alternate marker to predict mortality in septic patient. We recommend for large multicenter study with randomization so that the findings can be applied to general population and of different geographical situations.

Anion gap and base deficit are predictors of mortality in acute pesticide poisoning.

Acute pesticide poisoning has long been a serious problem as a method of suicide worldwide. This poisoning is a highly fatal condition that requires a rapid and precise diagnosis for adequate treatment. However, various studies on mortality predictor factors have been insufficient for whole pesticide treatments. We hypothesized that the initial plasma anion gap (AG) and base deficit (BD) are reliable prognostic factors. A retrospective study analyzed 561 patients with a diagnosis of acute pesticide poisoning between January 1, 2014 and June 30, 2017. The initial AG and BD values were divided into quartiles according to the number of patients. Survival at 30 days from admission was estimated using the Kaplan-Meier survival analysis. Receiver-operator characteristic (ROC) curves were drawn, and the areas under the curve for AG and BD for mortality were calculated. Fifty-eight (10.3%) of 561 patients died within 30 days. The highest AG quartile (>22 mEq/L) was associated with an increased risk of 30-day hospital mortality. Compared to patients with an AG less than 14.7 mEq/L, these patients had a 4.18-fold higher risk of 30-day hospital mortality and the highest BD quartile (>7.9 mEq/L) was associated with an increased risk of 30-day hospital mortality. Compared to patients with a BD less than 1.4 mEq/L, these patients had 2.23-fold higher risk of 30-day hospital mortality. The areas under the ROC for AG and BD curve were 0.699 and 0.744, respectively. Initial high AG and BD values could predict mortality and require precise intensive care.

Evaluation of capillary leakage after vasopressin resuscitation in a hemorrhagic shock model

BackgroundHemorrhagic shock (HS) is a major threat to patients with trauma and spontaneous bleeding. The aim of the study was to investigate early effects of vasopressin on metabolic and hemodynamic parameters and endothelium permeability by measuring capillary leakage compared to those of other resuscitation strategies in a HS model.MethodsForty-five Sprague-Dawley rats were randomized into five groups: S group (n = 5), sham-operated rats without shock or resuscitation; HS group (n = 10), HS and no resuscitation; RL group (n = 10), HS and resuscitation with Ringer’s lactate (RL); RLB group (n = 10), HS and resuscitation with two-third shed blood plus RL; and vasopressin group (n = 10), HS and resuscitation with RL, followed by continuous infusion of 0.04 U/kg/min vasopressin. The effects of resuscitation on hemodynamic parameters [mean arterial pressure (MAP), superior mesenteric artery blood flow (MBF), and mesenteric vascular resistances (MVR)], arterial blood gases, bicarbonate, base deficit, and lactate levels as well as on capillary leakage in the lung, ileum, and kidney were investigated. Capillary leakage was evaluated with Evans blue dye extravasation.ResultsIn the vasopressin group, the MAP was higher than in the RL and RLB groups (p < 0.001), while MBF was decreased (p < 0.001). MVR were increased only in the vasopressin group (p < 0.001). Capillary leakage was increased in the lungs of the animals in the vasopressin group compared to that in the lungs of animals in the RLB group (p < 0.05); this increase was associated with the lowest partial pressure of oxygen (p < 0.05). Conversely, decreased capillary leakage was observed with vasopressin in the ileum (p < 0.05). Increased capillary leakage was observed in the kidney in the RLB and vasopressin groups (p < 0.05). Lastly, vasopressin use was associated with higher base deficit and lactate levels when compared to the RL and RLB groups (p < 0.001).ConclusionAlthough vasopressin was proposed as a vasoactive drug for provisional hemodynamic optimization in the early phase of HS resuscitation, the overall findings of this experimental study focus on the possible critical side effects of vasopressin on metabolic parameters and endothelium permeability.

A study of arterial pH, bicarbonate levels, and base deficit at presentation as markers of predicting morbidity and mortality in acute pancreatitis

Background: The development of metabolic acidosis can occur commonly during critical illness. It is a clinical disturbance characterized by a low arterial pH, a reduced plasma HCO3− concentration, and compensatory hyperventilation. An extensive search for objective tools that predict severity and outcome at the time of hospital admission remains a major challenge. Patients and Methods: Patients with acute pancreatitis presenting to our unit between January 2012 and November 2013 were prospectively studied. Arterial blood gas (ABG) analysis was done at admission, and development of organ failure, any need for intervention, and mortality were noted. The association between various parameters of ABG analysis and the development of organ failure or local complications, need for interventions (endoscopic/radiological/surgical), and mortality were analyzed. Results: In all, 100 patients (mean age: 36.25 ± 12.86 years; 47.0% males and 53.0% females) were studied. The etiology of acute pancreatitis was Gall stone disease in 52 (52.0%), Alcoholism in 35 (35%), and others in 13 patients (13%). Of the 100 patients, acute fluid collections developed in 84 patients (84%). Multiple organ failure developed in 18 patients (18%). Respiratory failure developed in 68 patients (68%) and renal failure developed in 15 patients (15%), whereas 13 patients (13%) developed shock. Seven of the 19 patients (36.84%) with pH ≤7.35 died when compared with 1 of 81 patients (1.23%) with pH >7.35 (P = 0.001). Seven of the 58 patients (13.79%) with bicarbonate ≤24 mEq/L died when compared with 1 of 42 patients (2.38%) with bicarbonate >24 mEq/L (P = 0.05). Seven of 36 patients (19.4%) with base deficit ≥−4.0 died when compared with 1 of 64 patients (1.56%) with base deficit >4.0 (P = 0.002). Conclusion: Low arterial pH, low bicarbonate levels, and higher base deficit at presentation predict an adverse outcome with more frequency of organ failure, need for intervention, and mortality.

Outcome of very-low-birth-weight babies managed with nasal continuous positive airway pressure, with or without surfactant, in a high-care nursery

Background. Very-low-birth-weight (VLBW) infants who require nasal continuous positive airway pressure (NCPAP) are managed in neonatal intensive care units (NICUs) in developed countries, while in low-resource settings this is not always possible. The failure rate of NCPAP provided outside NICUs is not well known. Objectives. To determine the failure rate, assessed as the need for invasive medical ventilation (iMV) and mortality on NCPAP in VLBW infants managed in a high-care nursery (HCN) within the first 72 hours of life. Methods. Records of VLBW infants managed with NCPAP, at Chris Hani Baragwanath Hospital, were reviewed for infant characteristics, need for iMV and mortality on NCPAP. Clinical risk index for babies (CRIB) was calculated for each infant. Comparisons were made between those who needed iMV and those who did not, and between survivors and non-survivors on NCPAP. Results. A total of 325 VLBW infants were managed with NCPAP in the HCN. Mean (standard deviation) birth weight was 1 120 (184)g, 98.5% were of gestational age (GA) <34 weeks and 14.9% were small for GA (SGA). Thirteen percent died while on NCPAP and 33% of survivors required iMV – an overall failure rate of 43%. Factors associated with iMV were high CRIB score ( p <0.001), lower Apgar score ( p =0.013), lower PaO2 ( p =0.022) and high base deficit ( p =0.034). Those who died were more likely to have extremely low birth weight ( p <0.001), lower GA ( p <0.001), high CRIB score ( p <0.001) and base deficit ( p <0.001). On multivariate analysis, the predictors for need of iMV were low Apgar score ( p =0.033), SGA ( p =0.042) and CRIB score ( p =0.005), while that of mortality on NCPAP was birth weight. Conclusion. Although failure rate of NCPAP in VLBW infants managed in HCN is high, a significant proportion of VLBW infants benefit from this intervention.

Parasympathetic tone variations according to umbilical cord pH at birth: a computerized fetal heart rate variability analysis.

Non-reassuring fetal heart rate tracings reflect an imbalance between the parasympathetic and sympathetic nervous systems. In this situation, fetal asphyxia can be suspected and may be confirmed by metabolic measurements at birth like low pH or high base deficit values. The objective of this study was to determine whether fetal asphyxia during labor is related to parasympathetic nervous system activity. This is a retrospective study of a database collected in 5 centers. Two hundred and ninety-nine fetal heart rate tracings collected during labor were analyzed. Autonomic nervous system, especially the parasympathetic nervous system, was analyzed using an original index: the FSI (Fetal Stress Index). The FSI is a parasympathetic activity evaluation based on fetal heart rate variability analysis. Infants were grouped based on normal or low pH value at birth. FSI was measured during the last 30min of labor before birth and compared between groups. The minimum value of the FSI during the last 30min before delivery was significantly lower in the group with the lower umbilical cord arterial pH value. In this pilot study during labor, FSI was lower in the group of infants with low arterial pH at birth.

Acute Methanol Poisoning: Prevalence and Predisposing Factors of Haemorrhagic and Non-Haemorrhagic Brain Lesions.

The purpose was to study the prevalence and predisposing factors of brain lesions in survivors of acute methanol poisoning. Clinical data on 106 patients with methanol poisoning were collected during the Czech mass poisoning outbreak. Of 83 survivors, in 46 (55%) patients, follow-up examinations including magnetic resonance imaging of brain (MR) were performed 3-8 and 24-28 months after discharge from the hospital. Of 46 patients with a median age of 49 (interquartile range, 35-57) years, 24 (52%) patients had a total of 40 abnormal brain findings with haemorrhagic lesions detected in 15 (33%) and non-haemorrhagic lesions found in 9 (19%) patients. The patients with haemorrhagic brain lesions were more acidemic (lower arterial blood pH, higher base deficit) and had higher glycaemia and lactacidaemia on admission than those without haemorrhages (all p < 0.05). Thirteen of 32 (41%) of patients with systemic anticoagulation and 2 of 14 (14%) of patients without it had haemorrhagic lesions (p = 0.080). Bleeding complications during the treatment occurred in 4 of 15 (27%) patients, and 5 of 15 (33%) patients had conditions predisposing to haemorrhage in the group with haemorrhagic lesions. In three cases with a series of computer tomography (CT)/MR performed during hospitalization, the necrotic lesions in the brain remained non-haemorrhagic during hospitalization and haemorrhagic lesions were detected on the follow-up MR examinations only. No association between brain haemorrhages and systemic anticoagulation during dialysis was found: brain haemorrhages might occur in severely poisoned patients treated without systemic anticoagulation, whereas treatment with high doses of heparin might not lead to brain haemorrhages.

Factors predicting optic nerve axonal degeneration after methanol-induced acute optic neuropathy: a 2-year prospective study in 54 patients

Prospective cross-sectional study was conducted in 54 patients (mean age 46.7 ± 3.7 years) to determine the character of optic nerve axonal degeneration after acute methanol poisoning. Methanol was measured by a gas chromatographic method with flame ionization detection. Formate was measured enzymatically. Measurement of full-field visual evoked potential with monocular checkerboard pattern-reversal stimulation was performed 3–8 and 24–28 months after discharge. The amplitudes of N1P1 and P1N2 components of evoked response were used for analysis of axonal loss. Altogether, 13 of 50 patients (26 %) had abnormal amplitudes at the first examination (including the patients with nonrecordable amplitudes), and 37 patients had normal amplitudes. Mean N1P1/P1N2 amplitudes for right eyes (REs) were 6.30 ± 1.10/8.70 ± 1.50 µV and for left eyes (LEs) were 6.56 ± 1.00/8.30 ± 1.40 µV. The group with abnormal amplitudes had lower arterial pH (p = 0.009), bicarbonate (p = 0.036), higher base deficit (p = 0.005), glucose (p = 0.015), and lactate (p = 0.018). At the second examination, insignificant amplitude changes were registered (REs 6.50 ± 1.10/9.80 ± 1.60 µV, LEs 6.40 ± 1.10/9.30 ± 1.60 µV; both p > 0.05). In 2 of 44 REs (5 %) and in 4 of 45 LEs (9 %) with 2 consecutive examinations the initially normal amplitudes deteriorated to abnormal values. In 3 of 45 patients (7 %) the abnormal amplitudes deteriorated in both eyes indicating the ongoing process of chronic neuronal degeneration. The dynamics of amplitude deterioration correlated with serum lactate (r = 0.533; p < 0.001), glucose (r = 0.462; p = 0.005), and formic acid (r = 0.380; p = 0.046) on admission to hospital. The correlation was present between the magnetic resonance signs of hemorrhagic brain lesions and the amplitude changes (r = −0.535; p < 0.001).

Umbilical blood gas analysis in preeclamptic versus healthy pregnancies with preterm birth

Objective: Comparing the value of umbilical cord arterial blood gas (UC-ABG) analysis in the prediction of neonatal mortality and morbidity in the preeclamptic versus healthy pregnancies with preterm birth. Methods: Eight hundred sixteen preterm (born at <37 gestational weeks) neonates with no other morbidities who were born by cesarean section were evaluated. Immediately after delivery, UC-ABG analysis was performed and the neonates were followed. Results: Preeclamptic women had lower umbilical cord blood (UCB) pH (7.2 4 ± 0.1 versus 7.2 7 ± 0.08, p = 0.008) and higher UCB base deficit (BD) (3.5 ± 3.7 versus 2.2 ± 3.4, p = 0.005) compared with controls. In the preeclamptic group, UCB metabolic acidosis (pH < 7.15 and B.D > 8) was not independently associated with neonatal morbidity or mortality, while in the control group UCB metabolic acidosis was independently associated with low 10-min Apgar (OR, 4.9; 95%CI 1.37–18.03), respiratory distress syndrome (OR, 2.37; 95%CI 1.05–6.17), intraventricular hemorrhage (OR, 3.01; 95%CI 1.13–7.99), and neonatal mortality (OR, 17.33; 95%CI 4.51–66.53). Conclusions: The preterm neonates born to preeclamptic mothers have lower UCB pH and higher BD. In these neonates, UCB acidosis is not independently associated with any adverse neonatal outcomes. In contrast, in the preterm neonates born to healthy mothers, UCB metabolic acidosis is independently associated with neonatal mortality and morbidity.

Arterial pH, bicarbonate levels and base deficit at presentation as markers of predicting mortality in acute pancreatitis: a single-centre prospective study

Background. Arterial blood gas (ABG) parameters such as pH form part of multi-parameter scoring systems for predicting severe acute pancreatitis; however, literature on detailed evaluation of ABG alone in this context is scarce.Methods. Patients with acute pancreatitis presenting to our unit between January 2012 and November 2013 were prospectively studied. ABG analysis was done at admission and development of organ failure, any need for intervention, and mortality were noted. The association between various parameters of ABG analysis and the development of organ failure or local complications, need for interventions (endoscopic/radiological/surgical) and mortality were analysed.Results. Two hundred and five patients (mean age: 39.33 ± 13.85 years; 61.0% males) were prospectively studied. The aetiology of acute pancreatitis was alcohol in 93 patients (45.4%) and gall stone disease in 73 (35.6%). Organ failure developed in 71.2% patients and 83.9% had local complications. In 18% of patients, endoscopic/radiological/surgical interventions were needed and 14.6% died. The patients (n = 35) with metabolic acidosis (pH <7.35) suffered higher frequency of organ failure, need for interventions and mortality. Patients with low arterial bicarbonate levels, as well as higher base deficit, also displayed higher frequency of organ failure, need for interventions and mortality. The receiver operating characteristic (ROC) curves for pH <7.35, bicarbonate <22 meq/L and base deficit of >−4 meq/L for prediction of mortality were 0.771 (95% CI: 0.664–0.878), 0.707 (95% CI: 0.622–0.791) and 0.780 (95% CI: 0.693–0.867), respectively.Conclusion. Arterial pH, bicarbonate levels, and base deficit at presentation are useful early markers for predicting adverse outcome in acute pancreatitis.

Activated Protein C Levels Found In Trauma Patients Are Insufficient To Inactivate Platelet Factor Va and Produce Coagulopathy In An In Vitro Model

Background A subset of severe trauma victims suffering from uncontrolled hemorrhage present to the emergency room with an acute coagulopathy of trauma (ACoT). This condition occurs within the first 30 min following injury, is not the result of resuscitation-associated dilutional effects, and is defined by an INR &gt; 1.2. The mechanisms behind this coagulopathy have not been completely identified, but recent studies posit that the exuberant activation of protein C is a key contributor to ACoT. Protein C is activated through the interaction of thrombin and thrombomodulin on the endothelial surface. Activated protein C (APC) has anti-inflammatory and cytoprotective functions, in addition to regulating coagulation by inactivating factor Va (FVa). Evidence that APC is implicated in ACoT includes: 1) circulating APC levels are elevated 3-5 fold in patients with high injury severity scores (&gt;15) and base deficit (&gt;6); 2) high APC levels (&gt;6 ng/ml, or 105 pM) in these patients are correlated with an increase in prothrombin time (PT) and partial thromboplastin time [Cohen et al. Ann Surg 2012; 255(2): 379-85]. FVa exists in a soluble plasma fraction and in a platelet-associated fraction (in the membrane or alpha-granules). The platelet pool of FVa is more resistant to APC degradation [Camire et al. J Biol Chem 1995; 270(35): 20794-800] and is sufficient to maintain thrombin generation even in patients with severe congenital FV-deficiencies [Duckers et al. Blood 2010; 115(4): 879-86]. We hypothesize that healthy platelets in sufficient quantity will serve as an effective promoter of hemostasis in patients with ACoT, overcoming the effects of APC. Methods and Results We studied the effects of APC on coagulation in commercially obtained FV-deficient plasma (FVdp) and platelets/plasma from healthy volunteers. Tests included prothrombin time, turbidimetric assessment of fibrin cross-linking, and thromboelastography (TEG). Prothrombin time in platelet-free plasma or FVdp subjected to exogenous APC display a dose-dependent response where clotting is only significantly delayed at APC &gt;1 nM, much higher than the systemic concentrations found in the ACoT patients (105pM) or even in subjects treated with drotrecogin alfa, a recombinant APC product intended for the treatment of sepsis (steady-state concentration was found to be ∼790pM) [Macias et al. Clin Pharmacol Ther 2002; 72(4): 391-402]. Examining fibrin crosslinking in a static 96-well turbidimetric plate assay demonstrated that concentrations of APC of 1nM or below had no effect on the initiation time, rate, or strength of clotting in FVdp or PFP from healthy volunteers. Titration of plasma FV into FVdp illustrated that clotting time and rate (as measured by TEG) were not significantly affected at 10nM FV, less than 50% of the “normal” 23nM concentration. Clot strength was unaffected by FV depletion. To examine the contributions of platelet FVa, isolated and washed platelets were introduced in increasing amounts to FVdp and PFP; the rate of clotting and clot strength aligned between the two plasmas given equivalent numbers of platelets, emphasizing the importance of platelet FVa. At lower platelet concentrations (particularly 10,000 to 100,000 / µl), there were statistically significant differences in clotting time between FVdp and normal plasma, but these differences diminished with increasing platelet concentration. To evaluate the resistance of the platelet fraction to APC effects, 200,000 platelets / µl were suspended in FVdp and treated with a titration of APC from 1pM to 100nM. The samples were unaffected by APC up to a dose of at least 10nM as measured by TEG clotting parameters, well above the amounts found in the trauma patients or drotrecogin alfa-treated subjects. Conclusions FV-deficiency affects clotting only in cases of severe depletion (&lt;50%). In a low shear in vitro closed system, APC does not affect coagulation except at very high levels (&gt;1nM). Healthy platelets in sufficient quantity are capable of rescuing FV-deficiency and are resistant to APC effects. APC is unlikely to be the main driver of ACoT. Disclosures: No relevant conflicts of interest to declare.

Acidemia versus Hypercapnia and Risk for Severe Intraventricular Hemorrhage

In extremely low birth weight (ELBW) infants, levels of hypercapnia (Paco 2) > 60 mm Hg are considered a risk factor for severe intraventricular hemorrhage (IVH). Since cerebral vasoreactivity depends on arterial pH (apH) rather than Paco 2, we hypothesize that the role of mild-to-moderate hypercapnia (45-60 mm Hg) in the occurrence of severe IVH is modulated by the metabolic component of acid-base status. ELBW infants (n = 580, born < 28 wk gestation, and BW < 1,000 g) were separated into "high-base deficit (BD)" (n = 291) and "low-BD" (n = 289) groups if infants' median BD were > 4 mEq/L or ≤4 mEq/L, respectively. Rates of severe IVH were higher in "high-BD" (16%) than "low-BD" (9%) group. Although adjusted risk for severe IVH increased with higher Paco 2 and higher BD, apH was the sole predictor of severe IVH. In ELBW infants, higher degree of acidemia, rather than hypercapnia per se, during the first 48 hours of life, is associated with higher occurrences of severe IVH.

Uncommon presentation of common problem: pneumomediastinum in a child with diabetic ketoacidosis

A 12-year-old girl, a known patient with type 1 diabetes mellitus, presented to our paediatric assessment unit with short history of vomiting. She was tachycardic, tachypnoeic and normotensive (117/71) on admission. Her blood sugar was high (26.7 mmol/L) with raised blood ketones and her venous blood gas showed metabolic acidosis with high base deficit confirming DKA. HbA1C was very high (99 mmol/mol). The management of DKA was initiated using the Southwest regional paediatric DKA protocol. Due to significant respiratory distress she underwent a chest radiograph, which revealed pneumomediastinum with no pneumothorax (figure 1). Clinical examination showed no evidence of subcutaneous emphysema and her breathing improved after correction of acidosis. The patient was observed closely and was kept nil by mouth. Repeat chest radiograph after 8 hours (figure 2) showed spontaneous resolution of mediastinal emphysema.