Metabolic Acidosis Rate Research Articles

Trends in Apgar scores and umbilical artery pH: a population-based cohort study on 10,696,831 live births in Germany, 2008–2022

Low Apgar scores and low umbilical arterial (UA) blood pH are considered indicators of adverse perinatal events. This study investigated trends of these perinatal health indicators in Germany. Perinatal data on 10,696,831 in-hospital live births from 2008 to 2022 were obtained from quality assurance institutes. Joinpoint regression analysis was used to quantify trends of low Apgar score and UA pH. Additional analyses stratified by mode of delivery were performed on term singletons with cephalic presentation. Robustness against unmeasured confounding was analyzed using the E-value sensitivity analysis. The overall rates of 5-min Apgar scores < 7 and UA pH < 7.10 in liveborn infants were 1.17% and 1.98%, respectively. For low Apgar scores, joinpoint analysis revealed an increase from 2008 to 2011 (annual percent change (APC) 5.19; 95% CI 3.66–9.00) followed by a slower increase from 2011 to 2019 (APC 2.56; 95% CI 2.00–3.03) and a stabilization from 2019 onwards (APC − 0.64; 95% CI − 3.60 to 0.62). The rate of UA blood pH < 7.10 increased significantly between 2011 and 2017 (APC 5.90; 95% CI 5.15–7.42). For term singletons in cephalic presentation, the risk amplification of low Apgar scores was highest after instrumental delivery (risk ratio 1.623, 95% CI 1.509–1.745), whereas those born spontaneous had the highest increase in pH < 7.10 (risk ratio 1.648, 95% CI 1.615–1.682). Conclusion: Rates of low 5-min Apgar scores and UA pH in liveborn infants increased from 2008 to 2022 in Germany.What is Known:• Low Apgar scores at 5 min after birth and umbilical arterial blood pH are associated with adverse perinatal outcomes.• Prospective collection of Apgar scores and arterial blood pH data allows for nationwide quality assurance.What is New:• The rates of liveborn infants with 5-min Apgar scores < 7 rose from 0.97 to 1.30% and that of umbilical arterial blood pH < 7.10 from 1.55 to 2.30% between 2008–2010 and 2020–2022. • In spontaneously born term singletons in cephalic presentation, the rate of metabolic acidosis with pH < 7.10 and BE < −5 mmol/L in umbilical arterial blood roughly doubled between the periods 2008–2010 and 2020–2022.

ST waveform analysis vs cardiotocography alone for intrapartum fetal monitoring: An updated systematic review and meta-analysis of randomized trials.

ST waveform analysis (STAN) was introduced as an adjunct to cardiotocography (CTG) to improve neonatal and maternal outcomes. The aim of the present study was to quantify the efficacy of STAN vs CTG and assess the quality of the evidence using GRADE. We performed systematic literature searches to identify randomized controlled trials and assessed included studies for risk of bias. We performed meta-analyses, calculating pooled risk ratio (RR) or Peto odds ratio (OR). We also performed post hoc trial sequential analyses for selected outcomes to assess the risk of false-positive results and the need for additional studies. Nine randomized controlled trials including 28 729 women were included in the meta-analysis. There were no differences between the groups in operative deliveries for fetal distress (10.9 vs 11.1%; RR 0.96; 95% confidence interval [CI] 0.82-1.11). STAN was associated with a significantly lower rate of metabolic acidosis (0.45% vs 0.68%; Peto OR 0.66; 95% CI 0.48-0.90). Accordingly, 441 women need to be monitored with STAN instead of CTG alone to prevent one case of metabolic acidosis. Women allocated to STAN had a reduced risk of fetal blood sampling compared with women allocated to conventional CTG monitoring (12.5% vs 19.6%; RR 0.62; 95% CI 0.49-0.80). The quality of the evidence was high to moderate. Absolute effects of STAN were minor and the clinical significance of the observed reduction in metabolic acidosis is questioned. There is insufficient evidence to state that STAN as an adjunct to CTG leads to important clinical benefits compared with CTG alone.

Cervical Osmotic Dilators versus Dinoprostone for Cervical Ripening during Labor Induction: A Systematic Review and Meta-analysis of 14 Controlled Trials.

This study aimed to conduct a systematic review and meta-analysis of all randomized and nonrandomized controlled trials (RCTs and NCTs, respectively) that explored the maternal-neonatal outcomes of cervical osmotic dilators versus dinoprostone in promoting cervical ripening during labor induction. Six major databases were screened until August 27, 2022. The quality of included studies was evaluated. The data were summarized as mean difference or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model. Overall, 14 studies with 15 arms were analyzed (n = 2,380 patients). Ten and four studies were RCTs and NCTs, respectively. The overall quality for RCTs varied (low risk n = 2, unclear risk n = 7, and high risk n = 1), whereas all NCTs had good quality (n = 4). For the primary endpoints, there was no significant difference between both groups regarding the rate of normal vaginal delivery (RR = 1.04, 95% CI: 0.95-1.14, p = 0.41) and rate of cesarean delivery (RR = 1.04, 95% CI: 0.93-1.17, p = 0.51). Additionally, there was no significant difference between both groups regarding the mean change in Bishop score and mean time from intervention to delivery. The rate of uterine hyperstimulation was significantly lower in the cervical osmotic dilator group. For the neonatal outcomes, during cervical ripening, the rate of fetal distress was significantly lower in the cervical osmotic dilator group. There was no significant difference between both groups regarding the mean Apgar scores, rate of meconium-stained amniotic fluid, rate of umbilical cord metabolic acidosis, rate of neonatal infection, and rate of neonatal intensive care unit admission. During labor induction, cervical ripening with cervical osmotic dilators and dinoprostone had comparable maternal-neonatal outcomes. Cervical osmotic dilators had low risk of uterine hyperstimulation compared with dinoprostone. Overall, cervical osmotic dilators might be more preferred over dinoprostone in view of their analogous cervical ripening effects, comparable maternal-neonatal outcomes, and lack of drug-related adverse events. · This is the first analysis of cervical osmotic dilators versus PGE2 for cervical ripening during labor.. · There was no difference between both arms regarding the rates of normal vaginal/cesarean deliveries.. · There was no difference between both arms regarding the rates of neonatal adverse events.. · Cervical osmotic dilators had significant lower risk of uterine hyperstimulation compared with PGE2.. · Cervical osmotic dilators may be superior to PGE2 in view of their similar efficacy and better safety..

Cardiotocography combined with ST analysis versus cardiotocography combined with fetal blood sampling in deliveries with abnormal CTG: a randomized trial.

The aim was to investigate if intrapartum monitoring with cardiotocography (CTG) in combination with ST analysis (STAN) results in an improved perinatal outcome. We performed a two-center randomized trial. 1013 women with term fetuses in cephalic presentation entered the trial. If a CTG showed intermediate or pathological abnormalities, they were offered fetal blood sampling (FBS) and inclusion if the pH value was above 7.25. They were randomized to either CTG + FBS or CTG + STAN. The primary outcome was neonatal metabolic acidosis, defined as umbilical cord arterial blood pH below 7.05, and base excess equal to or below -10. The secondary outcomes included operative vaginal delivery for fetal distress. The rate of metabolic acidosis was 0.8% in the CTG + FBS group and 1.5% in women in the CTG + STAN (P = 0.338). More women in the CTG + STAN group delivered by operative vaginal delivery (25.6% vs 33.5%, P = 0.006). Significantly fewer women in the CTG + STAN group had three to five (28.8% vs 11.0%, P = < 0.001) and six to ten fetal blood samples taken (3.4% vs 0.4%, P = < 0.001). CTG + STAN did not reduce the incidence of neonatal metabolic acidosis compared to CTG + FBS. CTG + STAN was, however, associated with an increased risk of operative vaginal delivery and a reduced use of FBS. If STAN is used for fetal surveillance, we recommend that it is combined with other methods, such as FBS, for confirmation of the need for operative delivery. gov ID: NCT01699646. Date of registration: October 4, 2012 (retrospectively registered). https://clinicaltrials.gov/ct2/show/NCT01699646?id=NCT01699646&draw=2&rank=1.

Prevalence Rate of Proteinuria and Metabolic Acidosis Among Kidney Transplant Recipients in a Tertiary Teaching Hospital and Its Relationship to Dietary Intake

Proteinuria and metabolic acidosis adversely affect long term renal allograft outcome and are highly prevalent in reported studies. The role of dietary intake in influencing proteinuria and metabolic acidosis remained uncertain. This study aims to determine the prevalence rate of proteinuria and metabolic acidosis among kidney transplant recipients (KTRs) and to study their relationship with dietary intake. We performed a cross-sectional study on KTRs with functioning renal allograft and at least 3 months post transplant. Dietary protein, salt, and dietary acid load were estimated using 24-hour urine collection. Demographic characteristics, concomitant medications, medical history, and laboratory results were obtained from electronic medical records. A total of 204 KTRs were recruited with median age of 48 years (interquartile range [IQR], 18 years); male to female ratio was 61:39. A total of 79.9% (n=163) were living related kidney transplants. The median duration after transplant was 71 months (IQR, 131 months), and median eGFR was 65 mL/min/1.73 m2 (IQR, 25 mL/min/1.73 m2). The prevalence rates of proteinuria (defined as ≥ 0.5 g/d) and metabolic acidosis (defined as at least 2 readings of serum bicarbonate ≤ 22 mmol/L in the past 6 months) were 17.7 % and 6.2%, respectively. High dietary protein of > 1.2 g/kg ideal body weight (adjusted odds ratio, 3.13; 95% CI, 1.35-7.28; P=.008) was significantly associated with proteinuria. Dietary protein, salt, and acid load did not correlate with chronic metabolic acidosis. The prevalence rate of proteinuria is consistent with published literature, but metabolic acidosis rate is extremely low in our cohort. High protein intake (> 1.2 g/kg ideal body weight) is a risk factor of proteinuria and may have negative impact on KTR outcome.

Diagnostic value of clinical criteria in the diagnosis of hemodynamically significant patent ductus arteriosus in the preterm infants on their third day of life

Aim: The purpose of this study is to compare the clinical criteria of preterm infants on their third day of life with their echocardiographic findings for the correct diagnosis of hemodynamically significant patent ductus arteriosus (hsPDA). Material And Methods:The infants with a gestational age of &amp;lt;31 weeks and with a birth weight of &amp;lt;1250 g who underwent echocardiography on their third day of life were included in this retrospective study. The primary motive of this study is to identify whether clinical findings are feasible in the prediction of hsPDA. Results: Of the 47 preterm infants, 29 had hsPDA (the hsPDA group) and 18 did not had patent ductus arteriosus (the control group). This observation was made by an echocardiographic examination. The rate of tachypnea and increased oxygen requirement were statistically significantly higher in the hsPDA group than in the control group (p = 0.01 and p = 0.004, respectively). The incidence of tachycardia and hypotension was statistically significantly higher in the hsPDA group than in the control group (p = 0.03 and p = 0.004, respectively). The rate of metabolic acidosis was significantly higher in the hsPDA group than in the control group (p = 0.005). There were no significant differences in murmur, hyperdynamic precordium, and widened pulse pressure between the groups. The incidence rates of tachycardia, hypotension, and metabolic acidosis were statistically significantly higher in the hsPDA group even when the rates of tachypnea increased the oxygen requirement. Thelogistic regression demonstrated that the metabolic acidosis was the only significant predictor of hsPDA [OR: 7.10 (p = 0.02, 95% CI: 1.34–37.53)]. Conclusion: Metabolic acidosis is the most reliable clinical finding for the prediction of hsPDA in the preterm infants on the third day of life.

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

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

Clinico-pathological Evaluation and Outcomes of Emergency Right Hemicolectomies in the HIV Era

Emergency right hemicolectomies (RH) are attended by high morbidity and mortality. A primary ileocolic anastomosis (PA) or stoma may be performed, depending upon clinical risk factors. In HIV/AIDS patients, multiple pathologies involve the ileo-caecal area, and may necessitate a RH. To provide a clinico-pathological evaluation and outcome analysis of emergency RH. A retrospective chart analysis of 55 patients undergoing an emergency RH in two regional referral centres in KwaZulu-Natal, from January 2013 to December 2018, was undertaken. A total of 55 patients, median age 35 (range 12–83 years), underwent emergency RH. Seventeen patients were HIV-positive (30.9%) and 36 HIV-negative (65.5%), while 2 were not tested. A RH with PA was more commonly performed (61.8%). There was a higher rate of metabolic acidosis (p = 0.0046) and inotropic support (p = 0.001) in the RH and ileostomy cohort. The mortality rate was significantly higher in the RH and ileostomy cohort (42.9% vs 14.7%), p = 0.0275. There was a significantly higher rate of RH and ileostomy done in the HIV-positive cohort than in the HIV-negative cohort (58.8% vs 27.7%), p = 0.03. Ileo-caecal tuberculosis was more common in HIV-positive patients (35.3% vs 2.8%), p = 0.003. Overall, complicated appendicitis was the most common indication for RH (38.2%). Emergency RH with ileostomy is performed more often in the physiologically unstable patient and, hence, has a high mortality rate. Ileo-caecal TB is more common in HIV-positive patients leading to a higher ileostomy rate. Complicated appendicitis was the most common indication for emergency RH.

Fetal electrocardiography ST-segment analysis for intrapartum monitoring: a critical appraisal of conflicting evidence and a way forward

In the past century, some areas of obstetric including intrapartum care have been slow to benefit from the dramatic advances in technology and medical care. Although fetal heart rate monitoring (cardiotocography) became available a half century ago, its interpretation often differs between institutions and countries, its diagnostic accuracy needs improvement, and a technology to help reduce the unnecessary obstetric interventions that have accompanied the cardiotocography is urgently needed. During the second half of the 20th century, key findings in animal experiments captured the close relationship between myocardial glycogenolysis, myocardial workload, and ST changes, thus demonstrating that ST waveform analysis of the fetal electrocardiogram can provide information on oxygenation of the fetal myocardium and establishing the physiological basis for the use of electrocardiogram in intrapartum fetal surveillance. Six randomized controlled trials, 10 meta-analyses, and more than 20 observational studies have evaluated the technology developed based on this principle. Nonetheless, despite this intensive assessment, differences in study protocols, inclusion criteria, enrollment rates, clinical guidelines, use of fetal blood sampling, and definitions of key outcome parameters, as well as inconsistencies in randomized controlled trial data handling and statistical methodology, have made this voluminous evidence difficult to interpret. Enormous resources spent on randomized controlled trials have failed to guarantee the generalizability of their results to other settings or their ability to reflect everyday clinical practice. The latest meta-analysis used revised data from primary randomized controlled trials and data from the largest randomized controlled trials from the United States to demonstrate a significant reduction of metabolic acidosis rates by 36% (odds ratio, 0.64; 95% confidence interval, 0.46-0.88) and operative vaginal delivery rates by 8% (relative risk, 0.92; 95% confidence interval, 0.86-0.99), compared with cardiotocography alone.

Significant reduction in umbilical artery metabolic acidosis after implementation of intrapartum ST waveform analysis of the fetal electrocardiogram

Although the evidence regarding the benefit of using ST waveform analysis of the fetal electrocardiogram is conflicting, ST waveform analysis is considered as adjunct to identify fetuses at risk for asphyxia in our center. Most randomized controlled trials and meta-analyses have not shown a significant decrease in umbilical metabolic acidosis, while some observational studies have shown a gradual decrease of this outcome over a longer period of time. Observational studies can give more insight into the effect of implementation of the ST technology in daily clinical practice. To evaluate the change in frequency of perinatal intervention and adverse neonatal outcome after the implementation of ST waveform analysis of the fetal electrocardiogram from 2000 to2013. This retrospective longitudinal study was conducted in a tertiary referral center. A total of 19,664 medium- and high-risk singleton pregnancies with fetuses in cephalic presentation, a gestational age of ≥36 weeks, and the intention to deliver vaginally were included. ST waveform analysis of the fetal electrocardiogram was implemented in the year 2000 and by 2010 all deliveries were monitored using this technology. Data were collected on the following perinatal outcomes: fetal blood sampling, mode of delivery, umbilical cord blood gases, Apgar scores, neonatal encephalopathy, and perinatal death. Longitudinal trend analysis was used to detect changes over time in all deliveries monitored by cardiotocography either alone or in adjunct to ST waveform analysis of the fetal electrocardiogram. Logistic regression was used to correct for possible confounders. The umbilical artery metabolic acidosis rate declined from 2.5% (average rate of 2000+ 2001+ 2002) to 0.4% (average of 2011+ 2012+ 2013) (P < .001), which represents an 84% decrease. This decrease largely occurred between 2006 and 2008, during the Dutch randomized trial on fetal electrocardiogram ST waveform analysis. At this time, approximately 20% of deliveries were monitored using this method. Furthermore, there were significant reductions in fetal blood sampling rate (P < .001). Overall cesarean and vaginal instrumental deliveries decreased significantly (P < .001), but not for fetal distress. There were no changes in the Apgar scores. The incidence of neonatal encephalopathy was significantly lower in the second part of the study (odds ratio 0.39, 95% confidence interval 0.17-0.89). There was an 84% decrease in the incidence of umbilical artery metabolic acidosis in all deliveries between 2000 and 2013. The neonatal encephalopathy rate, fetal blood sampling rate, and the total number of cesarean and vaginal instrumental deliveries also decreased.

Treatment of Metabolic Acidosis in Altering Inflammatory Biomarkers in Renal Transplant Recipients; A Randomized Clinical Trial

Background: Metabolic acidosis following kidney transplantation can lead to several undesirable effects such as disturbing the protein balance resulting in a negative nitrogen equilibrium, increased protein degradation, and essential amino acid oxidation. Objectives: The current study aimed tocompare the effect of normal saline as a common crystalloid in kidney transplant surgery to reduce the risk of hyperkalemia and sodium bicarbonate on the metabolic acidosis rate after renal transplantation. Methods: A total of 40 patients with end-stage renal disease (ESRD) and candidates receiving renal transplant from a living donor referring to the kidney transplantation department of a University affiliated hospital, Tehran, Iran, that meeting the inclusion criteria of this study, were randomly assigned to the intervention group, who were treated with sodium bicarbonate, and the control group, who were treated with normal saline. The primary outcomes measured in this study were acidosis biomarkers including BE, HCO3, PaCO2, and PH and the secondary outcomes included some inflammatory biomarkers and some renal function biomarkers. Results: The mean ± standard deviation of age in the intervention and control groups was 44.4 ± 12.4 and 40.0 ± 13.0, respectively (P = 0.01). A total of 29 of the participants were male (14 in the intervention group and 15 in the control group), and 11 of them (six in the intervention group and five in the control group) were female. The mean ± standard deviation of change in the concentration of PH, BE, HCO3, and PaCO2 in the intervention and control groups was 0.01 ± 0.1 and -0.08 ± 0.1 (P < 0.001); 0.61 ± 4.2 and -3.8 ± 2.6 (P < 0.001); 0.36 ± 2.9 and -2.67 ± 2.1 (P: 0.001); and 0.8 ± 5.4 and 1.4 ± 5.3 (P: 0.799), respectively. Conclusions: The present study revealed that the patients who received sodium bicarbonate had a better status than the normal saline recipients in terms of the maintenance of acid-base homeostasis, inflammatory indexes, and renal function.

The importance of the learning process in ST analysis interpretation and its impact in improving clinical and neonatal outcomes

Intrapartum fetal heart rate monitoring was introduced with the goal to reduce fetal hypoxia and deaths. However, continuous fetal heart rate monitoring has been shown to have a high sensitivity but also a high false-positive rate. To improve specificity, adjunctive technologies have been developed to identify fetuses at risk for intrapartum asphyxia. Intensive research on the value of ST-segment analysis of the fetal electrocardiogram as an adjunct to standard electronic fetal monitoring in lowering the rates of fetal metabolic acidosis and operative deliveries has been ongoing. The conflicting results in randomized and observational studies may partly be due to differences in study design. This study aims to determine the significance of the learning process for the introduction of ST analysis into clinical practice and its impact on initial and subsequent obstetric outcomes. This was a prospective observational study with the primary objective to evaluate the importance of the learning period on the rates of metabolic acidosis and operative deliveries after the implementation of ST analysis. The study was conducted at the Turku University Hospital, Turku, Finland, with 3400-4200 annual deliveries. The whole study population consisted of all 42,146 deliveries during the study period 2001 through 2011. The ST analysis usage rate was 18%. The data were collected prospectively from labors monitored with ST analysis as an adjunct to conventional intrapartum fetal heart rate monitoring. Primary endpoints were the rates of metabolic acidosis (cord artery pH <7.05 and an extracellular fluid compartment base deficit >12.0 mmol/L), fetal scalp blood sampling, and operative deliveries. Comparisons of these outcomes were made between the initiation period (the first 2 years) and the subsequent usage period (the next 9 years). In the whole study population the prevalence of cord pH <7.05 decreased from 1.5-0.81% (relative risk, 0.54; 95% confidence interval, 0.43-0.67), the rate of cesarean deliveries from 17.2-14.1% (relative risk, 0.82; 95% confidence interval, 0.89-0.97), and the rate of fetal scalp blood sampling from 1.75-0.82% (relative risk, 0.47; 95% confidence interval, 0.38-0.58) when the 2 study periods were compared. In the ST analysis group, the frequency of cord metabolic acidosis rate was reduced from 1.0-0.25% (relative risk, 0.33; 95% confidence interval, 0.15-0.72). We provide evidence that the results improve over time and there is a learning curve in the introduction of the ST analysis method. This was demonstrated by the lower rates of metabolic acidosis and operative deliveries after the initial implementation period.

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

The BMJ Awards 2017: Clinical leadership

Nigel Hawkes finds out how this year’s nominees are transforming practice Oxygen deprivation during labour is universally recognised as a disaster in the making, but is enough done to prevent...

Profile of children with increased intracranial pressure on mannitol treatment

Background Early recognition of increased intracranial pressure(IIP) and well-monitored management are determining indicatorsfor treatment outcome. As far as we know, data of children with IIPon mannitol treatment has not been available.Objective To elicit the profile of IIP patients who received mannitolat the Department of Child Health, Cipto Mangunkusumo Hospital,Jakarta.Methods This was a cross-sectional study. Data were obtainedfrom medical records of patients with increased intracranial pres-sure who received mannitol at the Department of Child Health,Cipto Mangunkusumo Hospital, Jakarta between July 2001 to Oc-tober 2003Results Fifty-four IIP patients with mannitol treatment were included.Forty-two (78%) were under-five years old. Thirty-six subjects (67%)were boys; 30 (56%) were undernourished. Central nervous systeminfections (meningitis and encephalitis) were the most frequent causesof IIP. Most of the head CT scan revealed cerebral edema, hydroceph-alus, and cerebral hemorrhage. Fifty subjects (93%) had decline of con-sciousness; most of them were somnolent. Improvement in conscious-ness was identified in 31 subjects, in which 21 subjects reached fullconsciousness. Vomiting, which was found in 25 subjects (46%), sub-sided after mannitol administration. Behavioral changes were found in49 subjects (91%); 32 subjects still had persistent behavioral changesafter mannitol administration. Large and protruding fontanel was foundin 7/22 subjects, cerebral nerve paralysis in 23 subjects (43%) andpapillary edema in 6 of 34 subjects who underwent funduscopy. Duringthe treatment with mannitol, fever was found in 5 subjects, vomiting in 2subjects, skin edema and tachycardia each in 1 subject. Metabolic aci-dosis was found in 6/13 subjects, hyponatremia and hypokalemia in 16and 13 out of 30 subjects respectively. Death occurred in 9 subjects(17%).Conclusion In IIP patients, the administration of mannitol has atendency to improve consciousness, vomiting, and behavioral orpersonality changes. The high incidence rate of electrolyte imbal-ances and metabolic acidosis during the treatment indicated theneed of periodic monitoring to detect early disorders.

Development of Metabolic Acidosis after Neobladder Reconstruction

Objectives: Metabolic acidosis frequently develops in patients after neobladder reconstruction. However, the incidence of metabolic acidosis in patients with neobladder and the factors associated with the development of metabolic acidosis have not been well elucidated. We aimed to investigate the incidence and the potential predictors for the development of metabolic acidosis after neobladder reconstruction with intestinal segment. Methods: We included patients who underwent neobladder reconstruction using intestinal segment at Ewha Womans University Mokdong Hospital between January 1, 2005 and December 31, 2014. A subgroup of patients according to the time of metabolic acidosis occurrence was further analyzed in order to characterize predictors for metabolic acidosis. Results: Metabolic acidosis was encountered in 79.4% of patients with neobladder during follow up period. When patients were divided into 2 groups according to anion gap (AG), total CO2 (18.9±2.1 mEq/L vs. 20.0±1.3 mEq/L, P=0.001) and chloride (106.6±4.9 mE/L vs. 109.4±3.6 mEq/L, P 12 and AG≤12. Furthermore, when patients were divided into 3 groups; patients with metabolic acidosis at postoperative day (POD) 1; from POD 2 to 14 days; after 14 days, there was significant difference among those subgroups. Conclusion: Our study showed the rate of metabolic acidosis in patients underwent neobladder reconstruction and the difference between patients with metabolic acidosis and those without metabolic acidosis for the first time in Korea. In the future, well designed prospective study will be needed to prevent metabolic acidosis after neobladder reconstruction. (Ewha Med J 2015;38(3):98-105) Received May 6, 2015 Accepted July 2, 2015

Efectividad de la electrocardiografía fetal frente a la pulsioximetría para la determinación del bienestar fetal

Labor poses a potential risk for fetal well-being. New methods have been developed of continuous fetal pulse oximetry and fetal electrocardiogram analysis (STAN®). Our aim was to compare clinical outcomes after the STAN® system or pulse oximetry to determine fetal well-being during labor. We carried out specific searches in the major databases and applied predefined inclusion and exclusion criteria. Two prospective studies and a systematic review were selected.The instrumental delivery rate was higher with STAN® than with pulse oximetry. Metabolic acidosis rates, neonatal encephalopathy rates, and the number of pH determinations were lower when STAN® was used in combination with cardiotocography than when cardiotocography was used alone.

A critical appraisal of the evidence for using cardiotocography plus ECG ST interval analysis for fetal surveillance in labor. Part II: the meta-analyses.

We appraised the methodology, execution and quality of the five published meta-analyses that are based on the five randomized controlled trials which compared cardiotocography (CTG)+ST analysis to cardiotocography. The meta-analyses contained errors, either created de novo in handling of original data or from a failure to recognize essential differences among the randomized controlled trials, particularly in their inclusion criteria and outcome parameters. No meta-analysis contained complete and relevant data from all five randomized controlled trials. We believe that one randomized controlled trial excluded in two of the meta-analyses should have been included, whereas one randomized controlled trial that was included in all meta-analyses, should have been excluded. After correction of the uncovered errors and exclusion of the randomized controlled trial that we deemed inappropriate, our new meta-analysis showed that CTG+ST monitoring significantly reduces the fetal scalp blood sampling usage (risk ratio 0.64; 95% confidence interval 0.47–0.88), total operative delivery rate (0.93; 0.88–0.99) and metabolic acidosis rate (0.61; 0.41–0.91).

A critical appraisal of the evidence for using cardiotocography plus ECG ST interval analysis for fetal surveillance in labor. Part I: the randomized controlled trials.

We reappraised the five randomized controlled trials that compared cardiotocography plus ECG ST interval analysis (CTG+ST) vs. cardiotocography. The numbers enrolled ranged from 5681 (Dutch randomized controlled trial) to 799 (French randomized controlled trial). The Swedish randomized controlled trial (n = 5049) was the only trial adequately powered to show a difference in metabolic acidosis, and the Plymouth randomized controlled trial (n = 2434) was only powered to show a difference in operative delivery for fetal distress. There were considerable differences in study design: the French randomized controlled trial used different inclusion criteria, and the Finnish randomized controlled trial (n = 1483) used a different metabolic acidosis definition. In the CTG+ST study arms, the larger Plymouth, Swedish and Dutch trials showed lower operative delivery and metabolic acidosis rates, whereas the smaller Finnish and French trials showed minor differences in operative delivery and higher metabolic acidosis rates. We conclude that the differences in outcomes are likely due to the considerable differences in study design and size. This will enhance heterogeneity effects in any subsequent meta-analysis.

Sodium nitroprusside is not associated with metabolic acidosis during intraoperative infusion in children

BackgroundSodium nitroprusside (SNP) is a potent vasodilator that has been used to induce deliberate hypotension in children during surgery involving significant blood loss, including craniofacial and spinal fusion procedures. SNP metabolism liberates cyanide, which may cause interference with cellular energy metabolism, leading to metabolic acidosis and central nervous system injury. We performed a retrospective, case–control study to determine whether the short-term intra-operative use of SNP for deliberate hypotension is associated with metabolic acidosis in children undergoing surgical procedures for craniofacial or spinal anomalies. Cyanide and thiocyanate concentrations were also recorded in patients who received SNP.MethodsData from 166 children undergoing craniofacial and spinal fusion surgery between 2005 and 2010 at Lucile Packard Children's Hospital (LPCH) at Stanford were analyzed. Records from 60 patients who received SNP (SNP group) as part of a multicenter, randomized, double-blind study were compared with records from 106 eligible patients who had blood pressure reduction using anesthetic agents and did not receive SNP (control group). Metabolic acidosis was defined as serum bicarbonate (HCO3) < 18.5 mEq/L. Whole blood CN, plasma thiocyanate and urinary thiocyanate concentrations were measured in patients in the SNP group. Differences in metabolic acidosis rates between the SNP and control groups were assessed through a test of noninferiority in the rate for the SNP group with a noninferiority threshold of 0.2. A z-test was used to test the null hypothesis. The alternative hypothesis was that the difference in these rates was less than 0.2. The same noninferiority threshold of 0.2 was also used to perform separate, secondary tests for noninferiority in the proportion of patients with HCO3 levels below 18.5 mEq/L and the proportion of patients who required HCO3 administration.ResultsFewer patients in the SNP group experienced metabolic acidosis compared to the control group (31.7% vs. 36.8%, respectively; p < .001). No whole blood CN levels above the lower limit of quantification were detected in any of the 51 patients with validated CN data. Plasma and urinary thiocyanate levels were also low.ConclusionsOur findings suggest that SNP, when used for short-term deliberate hypotension, does not cause an increased incidence of metabolic acidosis compared with the use of anesthetic agents alone.Trial registrationTrial registration number: NCT00135668