Serum Lactate Concentrations Research Articles

Postanesthetic rhabdomyolysis in 7 warmblood horses.

To describe the clinical findings, outcomes, and muscle histopathology in warmblood horses that developed severe rhabdomyolysis in the perianesthetic period despite remaining stable while under general anesthesia. 7 warmblood horses, 6 geldings and 1 mare, with a median age of 9 years (range, 4 to 18 years) and median weight of 615 kg (range, 550 to 703 kg). Records from the Valberg Neuromuscular Diagnostic Laboratory and Michigan State University were reviewed (2016 to 2023) to identify warmbloods with postanesthetic myopathy (PAM). Warmblood horses with no history of myopathy developed PAM after remaining stable while under general anesthesia. Five of 7 horses were in regular work prior to anesthesia, and activity level was unknown in 2 horses. Time to standing in recovery was prolonged, 3 horses were euthanized due to persistent recumbency, and rhabdomyolysis recurred in 4 horses 5 to 11 days after anesthesia, with 1 surviving. Horses had muscle stiffness, pain, and sweating and struggled to remain standing. As PAM developed, serum creatine kinase activity and lactate concentrations (12 ± 7 mmol/L; n = 5) were markedly increased. At necropsy, histopathology revealed complete glycogen depletion (5 of 7), acute myodegeneration (6 of 7), and chronic active myodegeneration of representative skeletal muscle samples. A semimembranosus biopsy obtained 14 days after anesthesia from the survivor had rare glycogen-depleted fibers. Warmblood horses are susceptible to fatal PAM characterized by acute myodegeneration, lactic acidosis, and muscle glycogen depletion that occurs up to 11 days after anesthesia. In horses with delayed recovery after anesthesia, monitoring for 2 weeks after anesthesia, including assessment of serum creatine kinase activity and blood lactate, could potentially improve outcomes.

Characterisation of older patients that require, but do not undergo, emergency laparotomy: a multicentre cohort study

BackgroundOlder adults (≥65 yr) account for the majority of emergency laparotomies in the UK and are well characterised with reported outcomes. In contrast, there is limited knowledge on those patients that require emergency laparotomy but do not undergo surgery (NoLaps). MethodsA multicentre cohort study (n=64 UK surgical centres) recruited 750 consecutive NoLap patients (February 15th - November 15th 2021, inclusive of a 90-day follow up period). Each patient was admitted to hospital with a surgical condition treatable by an emergency laparotomy (defined by The National Emergency Laparotomy Audit (NELA) criteria), but a decision was made not to undergo surgery (NoLap). ResultsNoLap patients were predominately female (452 patients, 60%), of advanced age (median age 83.0 yr, interquartile range 77.0–88.8), frail (523 patients, 70%), and had severe comorbidity (750 patients, 100%); 99% underwent CT scanning. The commonest diagnoses were perforation (26%), small bowel obstruction (17%), and ischaemic bowel (13%). The 90-day mortality was 79% and influencing factors were >80 yr, underweight BMI, elevated serum lactate or creatinine concentration. The majority of patients died in hospital (77%), with those with ischaemic bowel dying early. For the 21% of NoLap patients that survived to 90 days, 77% returned home with increased care requirements. ConclusionsThis study reports that the NoLap patient population present significant medical challenges because of their extreme levels of comorbidity, frailty, and physiology. Despite these complexities a fifth remained alive at 90 days. Further work is underway to explore this high-risk decision-making process. Clinical trial registrationISRCTN14556210.

The time course of lactate and endocrine changes in dogs suffering from dog bite wounds.

The stress response after acute trauma in humans and animals has been well-recognised in the literature. However, data on temporal changes in endocrine parameters after acute trauma in previously healthy dogs are scant. To longitudinally track endocrine variables and lactate concentrations in dogs with canine bite wounds. Prospective study involving 20 dogs hospitalised after being bitten by another dog. Serum cortisol, thyroxine (total T4), thyrotropin (TSH), and lactate concentrations were measured on admission and every 8 hours after the recorded bite incident, for a 72-hour period. Median cortisol concentration was markedly elevated on admission (314.6 nmol/L; IQR 229.3-369.6) but returned to within the reference interval by 16 hours post-bite (99.5 nmol/L; IQR 48.7-225.4) and reached a nadir at 48 hours post-bite (38.5 nmol/L; IQR 32.1-115.9). Median total T4 concentration was within the reference interval on admission (20.6 nmol/L; IQR 12.7-27.9) but decreased below the reference interval by 8 hours (11.0 nmol/L; IQR 5.0-14.1) and reached a nadir 16 hours postbite (7.0 nmol/L; IQR 2.9-19.7), before gradually increasing after 64 hours to reach the reference range by 72 hours. The median TSH concentrations remained within the reference interval throughout the study period. Median lactate concentration was mildly elevated on admission (3.0 mmol/L; IQR 2.0-3.9). This study produced novel data on the temporal relationships of the hypothalamic-pituitary-adrenal and hypothalamicpituitary- thyroidal axes alterations after an acute traumatic insult in dogs.

Clinical predictors and outcomes of ST-elevation myocardial infarction related cardiogenic shock in the Asian population

BackgroundCardiogenic shock (CS) complicating myocardial infarction is associated with poor outcomes. Data among Asian populations are scarce. We aimed to investigate the long-term outcomes, prognostic factors, and predictors of CS among Asian ST elevation myocardial infarction (STEMI) patients. MethodsThis was a retrospective cohort study of consecutive patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI within our regional STEMI network between 2015 and 2019. The long-term outcomes of those with and without CS were compared. Clinical predictors of outcomes and development of CS were investigated. ResultsA total of 1791 patients who underwent PPCI were included. Patients completed at least 2 years’ follow-up with a median follow-up period of 2.6 years (IQR 1.0, 3,9). Overall, 208/1791 (11.6 %) STEMI patients developed CS. These patients were older (61.1 ± 12.5 vs 57.8 ± 12.2, P < 0.001) and mostly men (87.0 %). All-cause mortality (59.9 % vs 4.7 % P < 0.001), cardiac mortality (43.8 % vs 2.2 %, P < 0.001) and major adverse cardiovascular events (MACE) was significantly higher in the CS group (59.1 % vs 14.0 %, P < 0.001). Independent predictors of survival were higher index LVEF (adjusted hazards ratio [aHR] 0.967, 95 %CI 0.951–0.984, p < 0.001) and higher arterial pH at onset of shock (aHR 0.750, 0.626–0.897, p = 0.002). Increased serum lactate concentration independently predicts poor prognosis (aHR 1.084, 95 % CI 1.046–1.124, p < 0.001). ConclusionIn Asian STEMI patients who underwent PPCI, CS was associated with poor outcomes. Higher LVEF on index admission was associated with better outcomes; while lactic acidosis independently predicted mortality.

The Role of Serum Lactate Values as a Predictor of Morbidity in Preterm Infants

Abstract Background Early hemodynamic assessment of critically ill newborns requires mostly invasive measurements in neonatal intensive care unit. Base deficit and serum lactate concentrations may be important prognostic indicators in preterm infants. Aim and Objectives to investigate the relationship between serum lactate levels and adverse outcome in preterm infants who were admitted to NICU of Ain Shams University Hospital. Subjects and Methods This study is prospective cohort study, that included 90 preterm patients that were admitted to neonatal intensive care unit during a period of 6 months, all the neonates had the level of serum lactate been evaluated by ELISA (at 6, 12, 18 and 24 hours of birth) and correlated with the incidence of intracranial hemorrhage as diagnosed by cranial ultrasonography. Result: The initial serum lactate level was compared with the follow up readings at 12, 18 and 24 hours and showed statistically significant reduction of serum lactate in follow up recordings (p-value &amp;lt;0.05), Serum lactate was statistically significant predictors of death with increase serum lactate at 12hrs., at 18hrs. and at 24hrs, with p-value (p &amp;lt; 0.05). Serum lactate had no statistically significant association with intracranial hemorrhage as detected by transcranial ultrasonography. Conclusion Serial lactate measurements greater than 5.6 mmol/l predict adverse outcome and may aid the clinician in bedside decision making.

#746 Lactic acidosis in patients with acute kidney injury treated with renal replacement therapy in intensive care unit

Abstract Background and Aims Lactic acidosis (LA) is the most common cause of metabolic acidosis in hospitalised patients. LA is frequent in intensive care unit (ICU) patients with acute kidney injury (AKI) treated with renal replacement therapy (RRT). The aim of our study was to analyse the impact of LA on mortality. Method We conducted a retrospective observational study in a tertiary care hospital with a 12-bed ICU. During the study period of 4 years before the COVID pandemic, 2939 patients were admitted to the ICU, 503 patients were diagnosed with AKI and 210 of them required RRT. Due to missing data, we retrospectively analysed only 176 patients. LA was defined as a serum lactate concentration above 4 mmol/L on admission to the ICU. Demographic data, comorbidities, laboratory data at ICU admission and 30-day survival after ICU admission were obtained from the medical record. Survival was estimated using the Kaplan-Meier method, and factors associated with 30-day mortality were assessed in a Cox regression. Results The mean age of patients was 63.4±12.9 years, and 68.2% were men. Sixty-five (36.9%) of patients had LA. The prevalence of comorbidities prior to admission and baseline laboratory values are shown in Table 1. All patients were treated with RRT, 137 (77.8%) with continuous RRT and 39 (22.2%) with intermittent hemodialysis. The mean ICU stay was 14.6 ± 12 days, and 114 (64.8%) patients died during the observational period of 30 days. A Kaplan-Meier survival analysis showed that the survival was statistically significantly lower (log-rank; p = 0.027) in the group of patients with LA (Fig. 1). Univariate Cox regression analysis showed that LA was a significant predictor of 30-day survival (HR 1.51; 95% CI 1.038-2.197; p = 0.031). In the multivariate Cox regression analysis, which included age, gender, diabetes, hypertension, LA and C-reactive protein, only age (HR 1.029; 95% CI 1.011-1.046; p = 0.001) and LA (HR 1.515; 95% CI 1.030-2.228; p = 0.035) were independent predictors of mortality. Conclusion LA on ICU admission is an independent, highly prognostic factor for death within 30 days of admission in patients with AKI treated with RRT.

Prognostic accuracy of mean arterial pressure and serum lactate level in patients with acute myocardial infarction.

Mean arterial pressure (MAP) can be used to evaluate macro-circulatory perfusion while serum lactate concentration is a marker of tissue perfusion. It is important to note that the primary objective of initial medical interventions is to restore microcirculatory perfusion rather than focusing solely on macro-hemodynamics. We aimed to investigate the prognostic value of the combination of MAP and serum lactate levels measured on admission to the hospital in relation to patients' 30-day survival rate in patients with acute myocardial infarction (MI). Data from 532 consecutive patients with acute MI treated with percutaneous coronary intervention were analyzed. The study endpoint was 30-day all-cause mortality. We found that both MAP and lactate levels were relevant predictors of the 30-day mortality in multivariable Cox regression analysis (HR, 0.83; 95% CI, 0.71-0.97; P = 0.02 and HR, 1.16; 95% CI, 1.06-1.16; P = 0.01, respectively). There was a significant increase in the prognostic performance in relation to 30-day mortality for the combination of both MAP and lactate levels in comparison to MAP alone (P = 0.03 for comparison between areas under the curve). Conversely, the combination of MAP and lactates did not add a significant prognostic value in comparison to lactates alone (P = 0.53 for comparison between areas under the curve). In patients with acute MI, serum lactate level seems to have a higher prognostic value in comparison to MAP. Our data suggest that on initial assessment of patients with acute myocardial infarction, we should move toward a tissue perfusion-based approach instead of focusing on a blood pressure-oriented strategy alone.

Potentially compromised systemic and local lactate metabolic balance in glaucoma, which could increase retinal glucose and glutamate concentrations

To investigate the association between lactate metabolism and glaucoma, we conducted a multi-institutional cross-sectional clinical study and a retinal metabolomic analysis of mice with elevated intraocular pressure (IOP) induced by intracameral microbead injection. We compared lactate concentrations in serum and aqueous humor in age-matched 64 patients each with primary open-angle glaucoma (POAG) and cataract. Neither serum nor aqueous humor lactate concentrations differed between the two groups. Multiple regression analysis revealed that only body mass index showed a significant positive correlation with serum and aqueous humor lactate concentration in POAG patients (rs = 0.376, P = 0.002, and rs = 0.333, P = 0.007, respectively), but not in cataract patients. l-Lactic acid was one of the most abundantly detected metabolites in mouse retinas with gas chromatography and mass spectrometry, but there were no significant differences among control, 2-week, and 4-week IOP elevation groups. After 4 weeks of elevated IOP, d-glucose and l-glutamic acid ranked as the top two for a change in raised concentration, roughly sevenfold and threefold, respectively (ANOVA, P = 0.004; Tukey–Kramer, P < 0.05). Glaucoma may disrupt the systemic and intraocular lactate metabolic homeostasis, with a compensatory rise in glucose and glutamate in the retina.

Hypoxia modulation vs. chemotherapy and tumor shrinkage on early response assessment in diffuse large B-cell lymphoma

Background: Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy remains the standard of first-line treatment for diffuse large B-cell lymphoma (DLBCL). Up to 40% of DLBCL is characterized by relapse and refractory after treatment. Preliminary study reported Hypoxia-inducible factor-1? (HIF-1?) overexpression in 88.5% of DLBCL tumors in the Dr. Kariadi Hospital. Moreover, the role of hypoxia and HIF-1? has previously never been explored in DLBCL. Objectives: To evaluate the effect of hypoxia modulation to increased chemotherapeutic response in DLBCL. Methods: Single blind randomized control study was performed, with pre-test and post-test control group design. Research sampling consisted of DLBCL patients. The inclusion criteria include newly diagnosed DLBCL with HIF-1? overexpression and randomized to receive hypoxia modulation consisting of carbogen inhalation and nicotinamide administration, before R-CHOP chemotherapy. The tissue biopsy, histopathology and immunohistochemical studies were done. Chemotherapeutic responses were evaluated after 10-14 days following the first cycle of R-CHOP chemotherapy. Results: Out of twenty-six DLBCL participants with HIF-1? overexpression, there were 20 participants who completed the research protocol: 10 participants each in the intervention and control group. Demographic, clinicopathological, laboratory and disease characteristics were not statistically different between the two research groups (p&gt;0.05). Baseline tumor volume to be evaluated was also considered equal (172.3 cm3 vs. 152.8 cm3, p=0.597). Following the carbogen inhalation and nicotinamide administration, serum HIF-1? and lactate reduction can be observed. There was also a significant tumor volume shrinkage in both the intervention and control (mean ?85.7 cm3 vs. ?118.27 cm3) group, though the reduction was not statistically different (Delta 58.85% vs. 65.63%, p=0.474). Conclusion: The addition of hypoxia modulation to R-CHOP chemotherapy for DLBCL has shown beneficial effects on both serum HIF-1? and lactate concentration. However, the benefits did not correlate to increase a better tumor response compared to the control group.

Кислотно-щелочное состояние крови у пациентов с мочекаменной болезнью. Исследование I: роль бикарбонатов.

Introduction. Kidneys play a leading role in maintaining acid-base balance. Kidney disorders lead to the acid-base balance violations. Data analysis showed that there are not enough attention to the problem of assessing blood acid-base balance in patients with urolithiasis. The aim of the first stage of this work was to determine the presence and severity of changes in one of the main indicators of acid-base balance - the level of blood bicarbonate in patients with urolithiasis. Materials and methods. We analyzed data from 83 patients: 39 men and 44 women aged 18 to 74 years. All patients were prescribed a biochemical blood test, a biochemical analysis of daily urine, blood acid-base balance and stone chemical composition. We studied the relationship of actual serum bicarbonate (actHCO3 - ) and standard bicarbonate (stdHCO3- ) in urolithiasis patients with level of other blood and urine parameters. Statistical analysis was performed using the methods of descriptive statistics, comparative statistical analysis, calculation of the t-test for independent groups, correlation analysis for two variables using the computer program Statistica 10.0 (StatSoft USA). Results. According to the statistical analysis performed using the calculation of Student's t-test, patients with actual serum bicarbonate [actHCO3- ] &lt;21.0 mmol/l and urine pH&gt;5.8 had lower serum total calcium levels (p&lt;0.05 ), higher serum [Cl-] (p&lt;0.05), higher serum creatinine (p&lt;0.05) and urea (p&lt;0.05), lower serum pH (p&lt;0, 05), serum pCO2 (p&lt;0.05), serum lactate concentration (p&lt;0.05), lower BE (p&lt;0.05) than patients with [actHCO3- ] blood &gt;28.0 mmol/l. Correlation analysis showed that there is a relationship between the level of [actHCO3- ] and indicators of total blood calcium (p &lt;0.05), blood chloride (p&lt;0.05), creatinine and blood urea (p &lt;0.05) and the concentration of calcium and magnesium in the daily urine (p&lt;0.05). There was no statistically confirmed relationship between the level of standard blood bicarbonate [stdHCO3- ] and the concentration of other indicators of blood and daily urine. Conclusion. Determination of the serum bicarbonate level is necessary to clarify the metabolic state in urolithiasis patients. It is necessary to determine the concentration of actual blood bicarbonate (actHCO3- ) in urolithiasis patients.

Factors Associated with Postintubation Hypotension Among Patients with Suspected Sepsis in Emergency Department.

Postintubation hypotension (PIH) is a recognized complication that increases both in-hospital mortality and hospital length of stay. Sepsis is reportedly a factor associated with PIH. However, no study to date has examined which factors, including the intubation method, may be clinical predictors of PIH in patients with sepsis. This study aims to investigate factors associated with the occurrence of PIH in patients with suspected sepsis in emergency department. This retrospective cross-sectional study was performed over a 5-year period (January 2013-December 2017) and involved patients with suspected sepsis who underwent endotracheal intubation in the emergency department of Ramathibodi Hospital. The patients were divided into those with and without PIH, and factors associated with the occurrence of PIH were analyzed. PIH was defined as any recorded systolic blood pressure of <90 mmHg within 60 minutes of intubation. In total, 394 patients with suspected sepsis were included. PIH occurred in 106 patients (26.9%) and was associated with increased in-hospital mortality (43.00% in the PIH group vs 31.25% in the non-PIH group, P = 0.034). Multivariable logistic regression showed that the factors associated with PIH were an age of ≥61 years (adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.14-4.43; P = 0.019) and initial serum lactate concentration of >4.4 mmol/L (aOR 2.00; 95% CI 1.16-3.46; P = 0.013). Rapid sequence intubation and difference types of induction agents was unrelated to PIH. Monitoring the development of PIH in patients with sepsis is essential because of its correlation with higher in-hospital mortality. This is particularly critical for older individuals and those with severe infections and high initial lactate concentrations.

Analysis of P(v-a)CO2/C(a-v)O2 Ratio and Other Perfusion Markers in a Population of 98 Pediatric Patients Undergoing Cardiac Surgery.

The so-called Low Cardiac Output Syndrome (LCOS) is one of the most common complications in pediatric patients with congenital heart disease undergoing corrective surgery. LCOS requires high concentrations of inotropes to support cardiac contractility and improve cardiac output, allowing for better systemic perfusion. To date, serum lactate concentrations and central venous oxygen saturation (ScVO2) are the most commonly used perfusion markers, but they are not completely reliable in identifying a state of global tissue hypoxia. The study aims to evaluate whether the venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio [P(v-a)CO2/C(a-v)O2] can be a good index to predict the development of LCOS in the aforementioned patients, so as to treat it promptly. This study followed a population of 98 children undergoing corrective cardiac surgery from June 2018 to October 2020 at the Department of Cardiac Surgery of University Hospital Integrated Trust and their subsequent admission at the Postoperative Cardiothoracic Surgery Intensive Care Unit. During the study, central arterial and venous blood gas analyses were carried out before and after cardiopulmonary bypass (CPB) (pre-CPB and post-CPB), at admission to the intensive care unit, before and after extubation, and at any time of instability or modification of the patient's clinical and therapeutic conditions. The data analysis shows that 46.9% of the children developed LCOS (in line with the current literature) but that there is no statistically significant association between the P(v-a)CO2/C(a-v)O2 ratio and LCOS onset. Despite the limits of statistical significance, however, a 31% increase in the ratio emerged from the pre-CPB phase to the post-CPB phase when LCOS is present. This study confirms a statistically significant association between the most used markers in adult patients (serum lactate concentration, ScVO2, and oxygen extraction ratio-ERO2) measured in the pre-CPB phase and the incidence of LCOS onset, especially in patients with hemodynamic instability before surgery.

Effects of the menstrual cycle on EPOC and fat oxidation after low-volume high-intensity interval training.

Low-volume high-intensity interval training (HIIT) for weight loss has become prevalent in recent years, with increased excess post-exercise oxygen consumption (EPOC) as the mechanism. However, the influence of the menstrual cycle on EPOC and fat oxidation following low-volume HIIT is unclear. This study aimed to investigate the effect of the menstrual cycle on the increase in EPOC and fat oxidation after low-volume HIIT. Twelve eumenorrheic women participated during their early follicular and luteal phases. On each experimental day, they performed low-volume HIIT comprising fifteen repeated 8 s sprint cycling tests with 12 s rests, for 5 min. Expired gas samples were collected before and every 60 min until 180 min post-exercise. EPOC was defined as the increase in oxygen consumption from the resting state, and the total EPOC and fat oxidation were calculated from the total time of each measurement. Blood samples for serum estradiol, progesterone, free fatty acids, blood glucose, lactate, and plasma noradrenaline were collected and assessed before immediately after, and at 180 min post-exercise and were assessed. Serum estradiol and progesterone were significantly higher in the luteal phase than the follicular phase (P<0.01 for both). No significant differences in total EPOC and fat oxidation were found between the menstrual phases. Serum free fatty acid, blood glucose, lactate, and plasma noradrenaline concentrations were not affected by the menstrual cycle. These results suggest that the menstrual cycle does not affect the increase in EPOC or fat oxidation after low-volume HIIT.

Serum lactate in refractory out-of-hospital cardiac arrest: Post-hoc analysis of the Prague OHCA study

BackgroundThe severity of tissue hypoxia is routinely assessed by serum lactate. We aimed to determine whether early lactate levels predict outcomes in refractory out-of-hospital cardiac arrest (OHCA) treated by conventional and extracorporeal cardiopulmonary resuscitation (ECPR). MethodsThis study is a post-hoc analysis of a randomized Prague OHCA study (NCT01511666) assessing serum lactate levels in refractory OHCA treated by ECPR (the ECPR group) or conventional resuscitation with prehospital achieved return of spontaneous circulation (the ROSC group). Lactate concentrations measured on admission and every 4 hours (h) during the first 24 h were used to determine their relationship with the neurological outcome (the best Cerebral Performance Category score within 180 days post-cardiac arrest). ResultsIn the ECPR group (92 patients, median age 58.5 years, 83% male) 26% attained a favorable neurological outcome. In the ROSC group (82 patients, median age 55 years, 83% male) 59% achieved a favorable neurological outcome. In ECPR patients lactate concentrations could discriminate favorable outcome patients, but not consistently in the ROSC group. On admission, serum lactate >14.0 mmol/L for ECPR (specificity 87.5%, sensitivity 54.4%) and >10.8 mmol/L for the ROSC group (specificity 83%, sensitivity 41.2%) predicted an unfavorable outcome. ConclusionIn refractory OHCA serum lactate concentrations measured anytime during the first 24 h after admission to the hospital were found to correlate with the outcome in patients treated by ECPR but not in patients with prehospital ROSC. A single lactate measurement is not enough for a reliable outcome prediction and cannot be used alone to guide treatment.

Identification of indications for albumin administration in septic patients with liver cirrhosis

BackgroundAlbumin infusion is the primary therapeutic strategy for septic patients with liver cirrhosis. Although recent studies have investigated the efficacy of albumin in the resuscitation stage of septic patients with liver cirrhosis, it remains unclear whether daily albumin administration can improve outcomes. Furthermore, the indications for initiating albumin therapy are not well defined.MethodsSeptic patients with liver cirrhosis were obtained from the Medical Information Mart for Intensive Care (MIMIC-IV 2.0) database. Marginal structural Cox models were employed to investigate the association between daily albumin infusion and 28-day mortality. We also aimed to explore under what circumstances enrolled patients could benefit most from albumin administration, based on the clinical parameters collected on the day of albumin infusion, including serum albumin concentration, serum lactate concentration, mean arterial pressure (MAP), and vasopressor dosage.ResultsA total of 2265 patients were included in the final analysis, of whom 1093 (48.3%) had received albumin treatment at least once. The overall 28-day mortality was 29.6%. After marginal structural modeling, daily albumin infusion was associated with a reduced risk of 28-day death (hazard ratio, 0.76; 95% CI 0.61–0.94). We found that patients benefit most from albumin infusion when initiated on the day of serum albumin concentration between 2.5 and 3.0 g/dL, serum lactate concentration greater than or equal to 2 mmol/L, MAP less than 60 mmHg, or vasopressor dosage between 0.2 and 0.3 mcg/kg/min (norepinephrine equivalent, NEE).ConclusionsAlbumin infusion is associated with a reduction in mortality in septic patients with liver cirrhosis under specific circumstances. Serum albumin concentration, serum lactate, MAP, and vasopressor dosage were found to be modifiers of treatment effectiveness and should be considered when deciding to initial albumin infusion.

PrOgnosis in Pulmonary Embolism (PoPE): 30-Day mortality risk score based on five admission parameters

Introduction and objectiveSeveral scoring systems have been developed for risk stratification in patients with acute pulmonary embolism (PE). The Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) are among the most used, however the high number of variables hinder its application. Our aim was to derive an easy-to-perform score based on simple parameters obtained at admission to predict 30-day mortality in acute PE patients. MethodsRetrospective study in 1115 patients with acute PE from two institutions (derivation cohort n=835, validation cohort n=280). The primary endpoint was all-cause mortality at 30 days. Statistically and clinically relevant variables were selected for multivariable Cox regression analysis. We derived and validated a multivariable risk score model and compared to other established scores. ResultsThe primary endpoint occurred in 207 patients (18.6%). Our model included five variables weighted as follows: modified shock index ≥1.1 (hazard ratio [HR] 2.57, 1.68–3.92, p<0.001), active cancer (HR 2.27, 1.45–3.56, p<0.001), altered mental state (HR 3.82, 2.50–5.83, p<0.001), serum lactate concentration ≥2.50 mmol/L (HR 5.01, 3.25–7.72, p<0.001), and age ≥80 years (HR 1.95, 1.26–3.03, p=0.003). The prognostic ability was superior to other scores (area under curve [AUC] 0.83 [0.79–0.87] vs 0.72 [0.67–0.79] in PESI and 0.70 [0.62–0.75] in sPESI, p<0.001) and its performance in the validation cohort was deemed good (73 events in 280 patients, 26.1%, AUC=0.76, 0.71–0.82, p<0.0001) and superior to other scores (p<0.05). ConclusionsThe PoPE score (https://tinyurl.com/ybsnka8s) is an easy tool with superior performance to predict early mortality in patients admitted for PE with non-high-risk PE.

Perioperative EEG background and discharge abnormalities in children undergoing cardiac surgery: a prospective single-centre observational study

BackgroundWe analysed the characteristics of abnormal electroencephalogram (EEG) patterns before, during, and 48 h after cardiac surgery in patients with heterogeneous congenital heart disease to assess their relationship to demographic and perioperative variables and to early patient outcomes. MethodsIn 437 patients enrolled in a single centre, EEG was evaluated for background (including sleep-wake cycle) and discharge (seizures, spikes/sharp waves, pathological delta brushes) abnormalities. Clinical data (arterial blood pressure, doses of inotropic drugs, and serum lactate concentrations) were recorded every 3 h. Postoperative brain MRI was performed before discharge. ResultsPreoperative, intraoperative, and postoperative EEG was monitored in 139, 215, and 437 patients, respectively. Patients with a degree of preoperative background abnormalities (n=40) had more severe intraoperative and postoperative EEG abnormalities (P<0.0001). Intraoperatively, 106/215 (49.3%) patients progressed into an isoelectric EEG. Longer durations of isoelectric EEG were associated with more severe postoperative EEG abnormalities and brain injury on MRI (Ps≤0.003). Postoperative background abnormalities occurred in 218/437 (49.9%) patients, and 119 (54.6%) of them had not recovered after surgery. Seizures occurred in 36/437 (8.2%) patients, spikes/sharp waves in 359/437 (82.2%), and pathological delta brushes in 9/437 (2.0%). Postoperative EEG abnormalities correlated with degree of brain injury on MRI (Ps≤0.02). Demographic and perioperative variables were significantly correlated with postoperative EEG abnormalities, which in turn correlated with adverse clinical outcomes. ConclusionsPerioperative EEG abnormalities occurred frequently and correlated with numerous demographic and perioperative variables and adversely correlated with postoperative EEG abnormalities and early outcomes. The relation of EEG background and discharge abnormalities with long-term neurodevelopmental outcomes remains to be explored.

#6156 TUBULAR CHANGES IN PATIENTS WITH AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Abstract Background and Aims Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the presence of multiple cysts, leading to progressive reduction in renal function and systemic involvement. The possible presence of tubular alterations has been suggested, but the mechanisms involved have not yet been fully identified. The study aims to highlight possible tubular alterations in ADPKD patients compared to patients with chronic kidney disease (CKD). Method A total of 145 patients were enrolled, including 37 with ADPKD and CKD, while 108 had CKD with the same clinical characteristics, and a comparative analysis of urinary and serum parameters were performed. A venous blood gas analysis was performed on each patient to assess serum pH, lactate concentration, and base excess, and a spot urine test was performed to evaluate urinary pH using a pH meter and specific gravity (SG). Results The comparative analysis of serum parameters showed a significant reduction in serum pH (spH) in ADPKD patients (p &amp;lt;0.001), with a significant increase in lactates (1.3 vs 0.9 mmol/L, p &amp;lt;0.001) and a significant reduction in base excess (BE) (p &amp;lt;0.001). The evaluation of urinary parameters in ADPKD patients showed a urinary pH (upH) that was on average more acidic compared to patients with CKD (p &amp;lt; 0.001) with a reduction in the capacity to concentrate urine (p &amp;lt; 0.001). No statistically significant differences were found in terms of glomerular filtration rate between the two groups. Conclusion The collected data showed some alterations in the serum and urinary metabolic profile of ADPKD patients compared to the CKD group. The alterations in upH are consistent with those of recent studies in the literature, where it is hypothesized that a urinary concentration defect, already present in early stages, may cause a reduction in upH due to a reduced medullary trapping of ammonium and a reduced presence of bicarbonates. The hypothesis of a preferentially anaerobic metabolism in ADPKD patients is also in line with the increased levels of serum lactates.

Insights into Hemodynamic Features of Survivors and the Deceased with Acute Brain Injury: A Step Forward Tailored Treatment.

Pulmonary artery catheters are widely used for hemodynamical monitoring in critically ill patients. Acute brain injury is among the severe conditions treated in an intensive care unit. The advanced monitoring of hemodynamical parameters, fluid balance and adequate administered treatment based on those values are components of goal-directed therapy. A prospective observational study included adult patients who were hospitalized in the ICU due to acute bran injury, excluding brain oedema after cardiac arrest. Each patient had PAC inserted and hemodynamic data were collected during the first 3 days of the ICU stay every 6 h. Patients were divided into two groups based on the endpoint: the survivors and the deceased. Length of stay in hospital differed between patiens. All patients, regardless of their outcome, had noradrenaline administered. The initial values of PAP differed between the groups (p = 0.05). There were positive correlations noticed between noradrenaline dose, CVP and fluid balance when compared to PCWP in a group of survivors and a positive correlation in the fluid balance when compared to PAP and PVRI. Lactate serum concentrations presented a correlation with the dose of noradrenaline in both groups. Upon acute brain injury, values of PVRI and PAP increase. This is corelated with fluid load and worsened by an excessive fluid treatment in the case of an inconsiderate approach for stabilizing the patient hemodynamically. PAC may present limited advantages in terms of PAP and PVRI control during the treatment.

Metformin-associated lactic acidosis reported to the United Kingdom National Poisons Information Service (NPIS) between 2010 and 2019: a ten-year retrospective analysis

Introduction Metformin toxicity following therapeutic use or overdose may result in metabolic acidosis with hyperlactatemia. This study aims to assess the relationship between serum lactate concentration, arterial pH, and ingested dose with severity of poisoning, and to identify if serum lactate concentration is a useful marker of severity in metformin toxicity. Methods A retrospective study of telephone enquiries relating to metformin exposures to the National Poisons Information Service between 2010 and 2019 from hospitals in the United Kingdom. Results Six-hundred and thirty-seven cases were identified; 117 involved metformin only and 520 involved metformin with other drugs. The majority of cases involved acute (87%) and intentional (69%) exposures. There was a statistically significant difference in doses between the Poisoning Severity Scores, as well as between intentional and unintentional or therapeutic error doses (P < 0.0001). The distribution of cases for each Poisoning Severity Score differed between the metformin only and metformin with other drugs cases (P < 0.0001). Lactic acidosis was reported in 232 cases. Serum lactate concentration and arterial pH differed across Poisoning Severity Scores. Arterial pH inversely correlated with ingested dose (r=-0.3, P = 0.003), and serum lactate concentration positively correlated with ingested dose (r = 0.37, P < 0.0001). Serum lactate concentration and arterial pH did not correlate with each other. Twenty-five deaths were recorded, all following intentional overdoses. Discussion The dataset focuses mostly on acute, intentional overdoses. Increasing ingested metformin dose, a higher serum lactate concentration and worsening arterial pH were all associated with an unfavourable Poisoning Severity Score in patients in both metformin only and metformin with other drugs groups. As serum lactate concentration did not correlate with arterial pH, it represents an independent marker of poisoning severity. Conclusions Data from the present study suggest that serum lactate concentration can be used to assess severity of poisoning in patients who have reportedly ingested metformin.