Serum Base Excess Research Articles

Inclusion of Albumin in the Initial Resuscitation of Adult Patients with Medical Sepsis or Septic Shock: a Propensity Score-Matched Analysis.

The impact of albumin resuscitation on sepsis outcomes is debated, particularly in the initial phase of resuscitation. We aimed to investigate the association between albumin use in the initial 6 h of resuscitation and subsequent outcomes in adult septic patients. This single-center, retrospective, propensity score-matched cohort study included adult patients admitted to intensive care units (ICUs) with sepsis or septic shock from January 1, 2006, to May 4, 2018, at a tertiary referral hospital. We compared two groups based on albumin receipt within the initial six resuscitation hours (albumin group vs. non-albumin group). We performed a 1:2 propensity score matching to assess shock-free time in ICU as the primary outcome. Of 2,732 patients with medical sepsis, 286 cases in the albumin group were matched with 549 individuals in the non-albumin group. Compared to the non-albumin group, the albumin group required more intravenous fluids and had higher net fluid balance, lower mean arterial pressure, and lower serum base excess level in the initial 6 and 24 h of resuscitation. Shock-free time, ICU and hospital length of stay, and 28-day mortality were not different between albumin and non-albumin groups (56 vs. 66 h, P = 0.18; 3.5 days vs. 3.7 days, P = 0.61; 9.1 days vs. 9.5 days, P = 0.27; 36% vs. 32%, P = 0.25, respectively). Using albumin during the initial 6 h of resuscitation was not associated with benefits in clinical outcomes of patients with medical sepsis.

Validating the utilisation of venous bicarbonate as a predictor of acute kidney injury in crush syndrome from sjambok injuries.

Crush injury secondary to sjambok beatings is a well-described phenomenon in southern Africa. Owing to a number of factors, it can result in acute kidney injury (AKI). In 1992, Muckart et al. described a risk stratification system using venous bicarbonate (VB) that can be used in the management of these patients. To validate this score in the modern era of AKI risk stratification. A retrospective study was performed on a local trauma database from June 2010 to December 2012. All patients with crush injury from sjambok/blunt instrument beatings were included in the analysis. VB was compared with the Kidney Disease Improving Global Outcomes scoring system for AKI. Serum base excess (BE) and creatine kinase were also examined as biomarkers. The endpoints were the need for renal replacement therapy (RRT) and mortality. Three hundred and ten patients were included. The overall mortality rate was 1.9%, 14.8% of patients had AKI, and 3.9% required RRT. Both VB and BE performed well in RRT prediction, with areas under the receiver operating characteristic curve of 0.847 (95% confidence interval (CI) 0.756 - 0.938; p<0.001) and 0.871 (95% CI 0.795 - 0.947; p<0.001), respectively. The sensitivity and specificity of BE were 83.3% and 80.2% at an optimal cut-point of -7.25 mmol/L, while those of VB were 83.3% and 79.5% at an optimal cut-point of 18.85mmol/L. VB was significantly different across the AKI risk groups (p<0.001), in keeping with the original Muckart risk stratification system. The risk stratification score using VB is valid and should continue to be used as a tool in the management of patients with sjambok injuries. BE performs well in predicting the need for RRT, with a value of <-7.25 mmol/L indicating severe injury.

Comparison of the Effectiveness of Hydroxyethyl Starch (Voluven) Solution With Normal Saline in Hemorrhagic Shock Treatment in Trauma.

BackgroundAppropriate fluid therapy affects morbidity and mortality rates. A conclusion is yet to be reached on the role of crystalloids and colloids in immediate fluid therapy. This study was done to determine the suitable solution in immediate resuscitation of patients with hemorrhagic shock caused by tissue trauma.MethodsOne hundred trauma patients with hemorrhagic shock, who underwent fluid therapy in the emergency unit, were assigned randomly to two groups of hydroxyethyl starch (Voluven) and normal saline. Before and after fluid therapy, 1 cc of blood was taken from all patients in order to determine and compare base excess levels.ResultsIn hydroxyethyl starch (Voluven) and normal saline groups, base excess level after solution therapy increased about 9.65 and 5.46 volumes, respectively, in which augmentation in hydroxyethyl starch (Voluven) group is significantly higher than normal saline group (P ≤ 0.001).ConclusionBy using hydroxyethyl starch (Voluven) for fluid therapy in hemorrhagic shock caused by trauma, serum base excess decreases and results in improvement in tissue perfusion and better balance in acid-base status and it seems to be superior over normal saline administration, but the building block of the ideal fluid therapy should still remain with the physician’s final clinical judgment.

Bicarbonate- versus lactate-buffered solutions for acute continuous haemodiafiltration or haemofiltration.

Acute kidney injury (AKI) is a severe loss of kidney function that results in patients' inability to appropriately excrete nitrogenous wastes and creatinine. Continuous haemodiafiltration (HDF) or haemofiltration (HF) are commonly used renal replacement therapies for people with AKI. Buffered dialysates and solutions used in HDF or HF have varying effects on acid-base physiology and several electrolytes. The benefits and harms of bicarbonate- versus lactate-buffered HDF or HF solutions for treating patients with AKI remain unclear. To assess the benefits and harms of bicarbonate- versus lactate-buffered solutions for HDF or HF for treating people with AKI. We searched the Cochrane Renal Group's Specialised Register to 6 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched the Chinese Biomedical Literature Database. All randomised controlled trials (RCT) and quasi-RCTs that reported comparisons of bicarbonate-buffered solutions with lactate-buffered solutions for AKI were selected for inclusion irrespective of publication status or language. Two authors independently assessed titles and abstracts, and where necessary the full text of studies, to determine which satisfied our inclusion criteria. Data were extracted by two authors who independently assessed studies for eligibility and quality using a standardised data extraction form. Methodological quality was assessed using the Cochrane risk of bias tool. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). We identified four studies (171 patients) that met our inclusion criteria. Overall, study quality was suboptimal. There were significant reporting omissions related to methodological issues and potential harms. Outcome measures were not defined or reported adequately. The studies were small and lacked follow-up phases.Serum lactate levels were significantly lower in patients treated with bicarbonate-buffered solutions (4 studies, 171 participants: MD -1.09 mmol/L, 95% CI -1.30 to -0.87; I(2) = 0%). There were no differences in mortality (3 studies, 163 participants: RR 0.76, 95% CI 0.50 to 1.15; I(2) = 0%); serum bicarbonate levels (3 studies, 163 participants: MD 0.27 mmol/L, 95% CI -1.45 to 1.99; I(2) = 78%), serum creatinine (2 studies, 137 participants: MD -22.81 µmol/L, 95% CI -129.61 to 83.99; I(2) = 73%), serum base excess (3 studies, 145 participants: MD 0.80, 95% CI -0.91 to 2.50; I(2) = 38%), serum pH (4 studies, 171 participants: MD 0.01, 95% CI -0.02 to 0.03; I(2) = 70%) or carbon dioxide partial pressure (3 studies, 151 participants: MD -1.04, 95% CI -3.84 to 1.76; I(2) = 83%). A single study reported fewer cardiovascular events (RR 0.39, 95% CI 0.20 to 0.79), higher mean arterial pressure (10.25 mm Hg, 95% CI 6.68 to 13.82) and less hypotensive events (RR 0.44, 95% CI 0.26 to 0.75) in patients receiving bicarbonate-buffered solutions. One study reported no significant difference in central venous pressure (MD 2.00 cm H2O, 95% CI -0.7 to, 4.77). Total length of hospital and ICU stay and relapse were not reported by any of the included studies. There were no significant different between bicarbonate- and lactate-buffered solutions for mortality, serum bicarbonate levels, serum creatinine, serum base excess, serum pH, carbon dioxide partial pressure, central venous pressure and serum electrolytes. Patients treated with bicarbonate-buffered solutions may experience fewer cardiovascular events, lower serum lactate levels, higher mean arterial pressure and less hypotensive events. With the exception of mortality, we were not able to assess the main primary outcomes of this review - length of time in ICU, total length of hospital stay and relapse.

Hypertonic saline in paediatric traumatic brain injury: a review of nine years' experience with 23.4% hypertonic saline as standard hyperosmolar therapy.

We describe the protocolised use of 23.4% hypertonic saline solution (HTS) for intracranial hypertension in the context of traumatic brain injury in the paediatric population. This study represents the largest published data on the use of 23.4% HTS in the paediatric population. In this retrospective cohort, we focus on the efficacy, biochemical and metabolic consequences of 23.4% HTS administration in a Level 1 paediatric trauma centre. Mortality in the first seven days was 6% (2/32) with a mean intensive care unit length-of-stay of ten days (range 2 to 25, standard deviation [SD] 6). All-cause hospital mortality was 6%, with no deaths after the seven-day study period. Mean intracranial pressure (ICP) response to HTS was 10 mmHg (range 1 to 30, SD 8). For biochemistry data, the mean highest daily serum sodium was 148 mmol/l (139 to 161, SD 6), mean highest serum chloride was 115 mmol/l (range 101 to 132, SD 8) with matched mean serum base excess of -1.5 mmol/l (range 2 to -8, SD 3) and mean peak serum creatinine was 73 mmol/l (range 32 to 104, SD 32). Glasgow outcome scores of >3 (independent function) were achieved in 74% of patients. We describe the use of 23.4% HTS, demonstrating it to be a practical and efficacious method of delivering osmoles and may be advantageous in minimising total fluid volume. Thus, the bolus versus infusion debate may best be served via combining both approaches.

647 Comparison of Balanced 6% Hes Solution to Unbalanced 6% Hes Solution in Hypovolemic Critical Ill Children

Goal of the study: The third generation of unbalanced hydrxyethyl starch (HES) (130/04) (Voluven®) shows favorable physicochemical properties and avoids negative effects on coagulation Recently, increasing evidence reported that balanced, plasma-adapted HES preparation (Volulyte®) has advantage over the unbalanced HES solution in chirurgical adult population and avoids hyperchloremic acidosisWe compare the efficacy Volulyte to Voluven in non chirurgical hypovolemic critically ill children. Materials and Methods: Up to 40 ml/kg of the study fluid was infused until stabilization in 20 pediatric patients admitted with circulatory or respiratory failure with shockThe hemodynamic parameters, volume of the study fluid, biological analysis as well as the evolution of the pH, base excess, bicarbonate, chloride and anion gap were analyzed before, after and 24 hours later after administration. Results: After fluid administration and hemodynamic stabilization, no difference in respiratory frequency, ventilatory conditions, kidney, hematological or coagulation values between different treatment groups was observedIn Voluven group (n= 10 patients) however, there was a significantly higher need for treatment volume per kg body weight. The pH, serum base excess, and anion gap were significantly higher in the Volulyte group (n= 10 patients) while the serum chloride remained significantly lower when compared to the Voluven group whereas the serum bicarbonate remained stable. Conclusion: The two study fluid showed no difference in term of hemodynamic, coagulation or kidney functions The Volulyte group showed however, a clear lower serum chloride values as well as less acidosis as indicated by a higher pH and base excess.

Concepts of the Strong Ion Difference Applied to Large Volume Resuscitation

The occurrence of acidosis following trauma or other clinical conditions that require large volumes of resuscitation fluid may be modified by manipulation of the physical chemistry properties of substances within plasma. These include the strong ion difference, modification of hydrogen ion production through control of alveolar ventilation, and protection/provision of protein and phosphate-based weak acids. An understanding of these principles as an alternative method to analyze/anticipate acid-base abnormalities is important during resuscitation. Loss of protein-based weak acids may often occur after trauma or other conditions requiring large-volume resuscitation. These losses may potentially be replaced with albumin-based colloid solutions. Large quantities of normal saline should be avoided so as to avoid hyperchloremia-induced metabolic acidosis. Ringer's lactate solution is preferred. Alveolar ventilation must be adjusted so as to eliminate further hydrogen ion production caused by hypercarbia. The serum base excess and/or hyperlactemia have only limited value in diagnosing acidosis and guiding resuscitation. Current experimental data and reviews of this topic were obtained from a Medline literature search. In addition, the personal experience and investigations of the authors in critically ill and injured patients were used to formulate recommendations.