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Abstract
Lactic acidosis occurs commonly and can be a marker of significant physiologic derangements. However what an elevated lactate level and acidemia connotes and what should be done about it is subject to inconsistent interpretations. This review examines the varied etiologies of lactic acidosis, the physiologic consequences, and the known effects of its treatment with sodium bicarbonate. Lactic acidosis is often assumed to be a marker of hypoperfusion, but it can also result from medications, organ dysfunction, and sepsis even in the absence of malperfusion. Acidemia causes deleterious effects in almost every organ system, but it can also have positive effects, increasing localized blood flow and oxygen delivery, as well as providing protection against hypoxic cellular injury. The use of sodium bicarbonate to correct severe acidemia may be tempting to clinicians, but previous studies have failed to show improved patient outcomes following bicarbonate administration. Bicarbonate use is known to decrease vasomotor tone, decrease myocardial contractility, and induce intracellular acidosis. This suggests that mild to moderate acidemia does not require correction. Most recently, a randomized control trial found a survival benefit in a subgroup of critically ill patients with serum pH levels <7.2 with concomitant acute kidney injury. There is no known benefit of correcting serum pH levels ≥ 7.2, and sparse evidence supports bicarbonate use <7.2. If administered, bicarbonate is best given as a slow IV infusion in the setting of adequate ventilation and calcium replacement to mitigate its untoward effects.
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2
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Wang T, Yi L, Zhang H, Wang T, Xi J, Zeng L, He J, Zhang Z, Ma P. Risk Potential for Organ Dysfunction Associated With Sodium Bicarbonate Therapy in Critically Ill Patients With Hemodynamic Worsening. Front Med (Lausanne) 2021; 8:665907. [PMID: 34307402 PMCID: PMC8292723 DOI: 10.3389/fmed.2021.665907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/11/2021] [Indexed: 02/05/2023] Open
Abstract
Background: The role of sodium bicarbonate therapy (SBT) remains controversial. This study aimed to investigate whether hemodynamic status before SBT contributed to the heterogeneous outcomes associated with SBT in acute critically ill patients. Methods: We obtained data from patients with metabolic acidosis from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score matching (PSM) was applied to match the SBT group with the control group. Logistic regression and Cox regression were used to analyze a composite of newly "developed or exacerbated organ dysfunction" (d/eOD) within 7 days of ICU admission and 28-day mortality associated with SBT for metabolic acidosis. Results: A total of 1,765 patients with metabolic acidosis were enrolled, and 332 pairs obtained by PSM were applied to the final analyses in the study. An increased incidence of newly d/eOD was observed in the SB group compared with the control group (54.8 vs. 44.6%, p < 0.01). Multivariable logistic regression indicated that the adjusted OR of SBT for this composite outcome was no longer significant [OR (95% CI): 1.39 (0.9, 1.85); p = 0.164]. This effect of SBT did not change with the quintiles stratified by pH. Interestingly, SBT was associated with an increased risk of the composite of newly d/eOD in the subgroup of patients with worsening hemodynamics before SBT [adjusted OR (95% CI): 3.6 (1.84, 7.22), p < 0.001]. Moreover, the risk potential for this composite of outcomes was significantly increased in patients characterized by both worsening [adjusted OR (95% CI): 2.91 (1.54, 5.47), p < 0.001] and unchanged hemodynamics [adjusted OR (95% CI): 1.94 (1.01, 3.72), p = 0.046] compared to patients with improved hemodynamics before SBT. Our study failed to demonstrate an association between SBT and 28-day mortality in acute critically ill patients with metabolic acidosis. Conclusions: Our findings did not demonstrate an association between SBT and outcomes in critically ill patients with metabolic acidosis. However, patients with either worsening or unchanged hemodynamic status in initial resuscitation had a significantly higher risk potential of newly d/eOD subsequent to SBT.
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Affiliation(s)
- Tiehua Wang
- Critical Care Medicine Department, Peking University Third Hospital, Beijing, China
| | - Lingxian Yi
- Critical Care Medicine Department, Strategic Support Force Characteristic Medical Center of People's Liberation Army, Beijing, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Tianhao Wang
- Emergency Department, The 8th Medical Centre of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jingjing Xi
- Critical Care Medicine Department, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Junlin He
- Department of Medical Affairs, Shanghai Palan DataRx Co. Ltd., Shanghai, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Penglin Ma
- Critical Care Medicine Department, Peking University Third Hospital, Beijing, China
- Critical Care Medicine Department, Guiqian International General Hospital, Guiyang, China
- *Correspondence: Penglin Ma
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3
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Quade BN, Parker MD, Occhipinti R. The therapeutic importance of acid-base balance. Biochem Pharmacol 2021; 183:114278. [PMID: 33039418 PMCID: PMC7544731 DOI: 10.1016/j.bcp.2020.114278] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023]
Abstract
Baking soda and vinegar have been used as home remedies for generations and today we are only a mouse-click away from claims that baking soda, lemon juice, and apple cider vinegar are miracles cures for everything from cancer to COVID-19. Despite these specious claims, the therapeutic value of controlling acid-base balance is indisputable and is the basis of Food and Drug Administration-approved treatments for constipation, epilepsy, metabolic acidosis, and peptic ulcers. In this narrative review, we present evidence in support of the current and potential therapeutic value of countering local and systemic acid-base imbalances, several of which do in fact involve the administration of baking soda (sodium bicarbonate). Furthermore, we discuss the side effects of pharmaceuticals on acid-base balance as well as the influence of acid-base status on the pharmacokinetic properties of drugs. Our review considers all major organ systems as well as information relevant to several clinical specialties such as anesthesiology, infectious disease, oncology, dentistry, and surgery.
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Affiliation(s)
- Bianca N Quade
- Department of Physiology and Biophysics, The State University of New York, The University at Buffalo, Buffalo, NY 14203, USA
| | - Mark D Parker
- Department of Physiology and Biophysics, The State University of New York, The University at Buffalo, Buffalo, NY 14203, USA; Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA; State University of New York Eye Institute, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Rossana Occhipinti
- Department of Physiology and Biophysics, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA.
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4
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Harguindey S, Alfarouk K, Polo Orozco J, Fais S, Devesa J. Towards an Integral Therapeutic Protocol for Breast Cancer Based upon the New H +-Centered Anticancer Paradigm of the Late Post-Warburg Era. Int J Mol Sci 2020; 21:E7475. [PMID: 33050492 PMCID: PMC7589677 DOI: 10.3390/ijms21207475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/13/2022] Open
Abstract
A brand new approach to the understanding of breast cancer (BC) is urgently needed. In this contribution, the etiology, pathogenesis, and treatment of this disease is approached from the new pH-centric anticancer paradigm. Only this unitarian perspective, based upon the hydrogen ion (H+) dynamics of cancer, allows for the understanding and integration of the many dualisms, confusions, and paradoxes of the disease. The new H+-related, wide-ranging model can embrace, from a unique perspective, the many aspects of the disease and, at the same time, therapeutically interfere with most, if not all, of the hallmarks of cancer known to date. The pH-related armamentarium available for the treatment of BC reviewed here may be beneficial for all types and stages of the disease. In this vein, we have attempted a megasynthesis of traditional and new knowledge in the different areas of breast cancer research and treatment based upon the wide-ranging approach afforded by the hydrogen ion dynamics of cancer. The concerted utilization of the pH-related drugs that are available nowadays for the treatment of breast cancer is advanced.
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Affiliation(s)
- Salvador Harguindey
- Department of Oncology, Institute of Clinical Biology and Metabolism, 01004 Vitoria, Spain;
| | - Khalid Alfarouk
- Department of Pharmacology, Al-Ghad International Colleges for Applied Medical Sciences, Al-Madinah Al-Munawarah 42316, Saudi Arabia and Alfarouk Biomedical Research LLC, Tampa, FL 33617, USA;
| | - Julián Polo Orozco
- Department of Oncology, Institute of Clinical Biology and Metabolism, 01004 Vitoria, Spain;
| | - Stefano Fais
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità (National Institute of Health), 00161 Rome, Italy;
| | - Jesús Devesa
- Scientific Direction, Foltra Medical Centre, 15886 Teo, Spain;
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5
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Haines RW, Kirwan CJ, Prowle JR. Managing Chloride and Bicarbonate in the Prevention and Treatment of Acute Kidney Injury. Semin Nephrol 2020; 39:473-483. [PMID: 31514911 DOI: 10.1016/j.semnephrol.2019.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm.
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Affiliation(s)
- Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Christopher J Kirwan
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
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6
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Zanella A, Caironi P, Castagna L, Rezoagli E, Salerno D, Scotti E, Scaravilli V, Deab SA, Langer T, Mauri T, Ferrari M, Dondossola D, Chiodi M, Zadek F, Magni F, Gatti S, Gattinoni L, Pesenti AM. Extracorporeal Chloride Removal by Electrodialysis. A Novel Approach to Correct Acidemia. Am J Respir Crit Care Med 2020; 201:799-813. [DOI: 10.1164/rccm.201903-0538oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Alberto Zanella
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care, and Emergency
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria S. Luigi Gonzaga, Orbassano, Italy; Department of Oncology, University of Turin, Orbassano, Italy
| | | | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, and Discipline of Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, SAOLTA University Health Group, Galway, Ireland
| | - Domenico Salerno
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Eleonora Scotti
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | | | | | - Thomas Langer
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care, and Emergency
| | - Tommaso Mauri
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care, and Emergency
| | - Michele Ferrari
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Daniele Dondossola
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
- General and Liver Transplant Surgery Unit, and
| | - Manuela Chiodi
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Francesco Zadek
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Federico Magni
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy; and
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Antonio M. Pesenti
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care, and Emergency
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Forni LG, Hodgson LE, Selby NM. The Janus faces of bicarbonate therapy in the ICU: not sure! Intensive Care Med 2019; 46:522-524. [PMID: 31820031 PMCID: PMC7223965 DOI: 10.1007/s00134-019-05885-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/27/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Lui G Forni
- The Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, UK.
- Faculty of Health and Medical Sciences, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, GU2 7XH, UK.
| | - Luke E Hodgson
- Western Sussex Hospitals NHS Foundation Trust, Anaesthetics Department, Worthing Hospital, Lyndhurst Rd, Worthing, BN11 2DH, UK
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Joannes-Boyau O, Forni LG. Time to treat metabolic acidosis in the ICU with sodium bicarbonate? Anaesth Crit Care Pain Med 2019; 37:493-494. [PMID: 30573202 DOI: 10.1016/j.accpm.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- O Joannes-Boyau
- Service d'anésthesie-réanimation SUD, hôpital Magellan, CHU de Bordeaux, Bordeaux, France.
| | - L G Forni
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK; Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, UK
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9
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Fülöp T, Zsom L, Rodríguez RD, Chabrier-Rosello JO, Hamrahian M, Koch CA. Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure. Rev Endocr Metab Disord 2019; 20:65-75. [PMID: 30848433 DOI: 10.1007/s11154-019-09483-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cerebral edema and elevated intracranial pressure (ICP) are common complications of acute brain injury. Hypertonic solutions are routinely used in acute brain injury as effective osmotic agents to lower ICP by increasing the extracellular fluid tonicity. Acute kidney injury in a patient with traumatic brain injury and elevated ICP requiring renal replacement therapy represents a significant therapeutic challenge due to an increased risk of cerebral edema associated with intermittent conventional hemodialysis. Therefore, continuous renal replacement therapy (CRRT) has emerged as the preferred modality of therapy in this patient population. We present our current treatment approach, with demonstrative case vignette illustrations, utilizing hypertonic saline protocols (3% sodium-chloride or, with coexisting severe combined metabolic and respiratory acidosis, with 4.2% sodium-bicarbonate) in conjunction with the CRRT platform, to induce controlled hypernatremia of approximately 155 mEq/L in hemodynamically unstable patients with acute kidney injury and elevated ICP due to acute brain injury. Rationale, mechanism of activation, benefits and potential pitfalls of the therapy are reviewed. The impact of hypertonic citrate solution during regional citrate anticoagulation is specifically discussed. Maintaining plasma hypertonicity in the setting of increased ICP and acute kidney injury could prevent the worsening of ICP during renal replacement therapy by minimizing the osmotic gradient across the blood-brain barrier and maximizing cardiovascular stability.
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Affiliation(s)
- Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
| | - Lajos Zsom
- Fresenius Medical Care Hungary Kft, Cegléd, Hungary
| | - Rafael D Rodríguez
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Jorge O Chabrier-Rosello
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Mehrdad Hamrahian
- Department of Medicine - Division of Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christian A Koch
- Medicover GmbH, Berlin, Germany.
- Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Technical University of Dresden, Dresden, Germany.
- University of Tennessee Health Science Center, Memphis, TN, USA.
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10
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Seki JT, Wang TQ, Yip PM, Mazzulli T, Minden MD. Stability of sodium bicarbonate injection 8.4% in syringes over a six-week period in refrigerated temperature. J Oncol Pharm Pract 2017; 24:198-200. [PMID: 29284355 DOI: 10.1177/1078155217694493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Dysfunctional central venous catheter prohibits the administration of potential life-saving chemotherapy and the delivery of essential supportive care needs to patients. Sodium bicarbonate injection has been shown to impede against fibrin clot formation and prolong prothrombin time and thrombin clotting time. Sodium bicarbonate injection has been tried as a second-line agent with good results in a small number of patients (internal data not published) when alteplase failed. We assessed whether the pre-filled sodium bicarbonate injection in 5 mL syringes would not only preserve sterility and retain its pH and concentration but also amount to the potential cost savings for future use when stored in a refrigerated environment. Methodology Twelve pre-filled 5 mL syringes were prepared aseptically, of which four each were tested for pH, sodium bicarbonate injection concentration and sterility when stored in refrigerated temperature over a six-week period. A standard pH meter, enzymatic carbon dioxide analyzer, and a 14-day incubation for microbial detection were employed for this study. Results Sodium bicarbonate concentration measured in the form of carbon dioxide ranged from 923 mmol/L or (1846 mosol/L) to 1006 mmol/L or (2012 mosmol/L), and pH ranged from (7.88 to 8.05) were reported over the duration of the study period. The 14-day incubation period resulted in no microbial growth. Conclusion Our study results have indicated that the pH and sodium bicarbonate injection concentration values were stable and within range, comparable to those reported by the manufacturer within the study period. The contents of the subdivided sodium bicarbonate injection 5 mL syringes retained sterility over a 14-day incubation period.
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Affiliation(s)
- Jack T Seki
- 1 Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Tian Q Wang
- 1 Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Paul M Yip
- 3 Laboratory Medicine Program, University Health Network, Toronto, Canada.,4 Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Tony Mazzulli
- 5 Department of Microbiology, Mount Sinai Hospital/University Health Network, Ontario, Canada
| | - Mark D Minden
- 6 Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
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The Use of Sodium Bicarbonate in the Treatment of Acidosis in Sepsis: A Literature Update on a Long Term Debate. Crit Care Res Pract 2015; 2015:605830. [PMID: 26294968 PMCID: PMC4534594 DOI: 10.1155/2015/605830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 06/29/2015] [Accepted: 07/01/2015] [Indexed: 12/29/2022] Open
Abstract
Introduction. Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods. We conducted a PubMed literature search in order to identify published literature related to the effects of sodium bicarbonate treatment on metabolic acidosis due to sepsis. The search included all articles published in English in the last 35 years. Results. There is ongoing debate regarding the use of bicarbonates for the treatment of acidosis in sepsis, but there is a trend towards not using bicarbonate in sepsis patients with arterial blood gas pH > 7.15. Conclusions. Routine use of bicarbonate for treatment of severe acidemia and lactic acidosis due to sepsis is subject of controversy, and current opinion does not favor routine use of bicarbonates. However, available evidence is inconclusive, and more studies are required to determine the potential benefit, if any, of bicarbonate therapy in the sepsis patient with acidosis.
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Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. Sodium bicarbonate therapy in patients with metabolic acidosis. ScientificWorldJournal 2014; 2014:627673. [PMID: 25405229 PMCID: PMC4227445 DOI: 10.1155/2014/627673] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 01/18/2023] Open
Abstract
Metabolic acidosis occurs when a relative accumulation of plasma anions in excess of cations reduces plasma pH. Replacement of sodium bicarbonate to patients with sodium bicarbonate loss due to diarrhea or renal proximal tubular acidosis is useful, but there is no definite evidence that sodium bicarbonate administration to patients with acute metabolic acidosis, including diabetic ketoacidosis, lactic acidosis, septic shock, intraoperative metabolic acidosis, or cardiac arrest, is beneficial regarding clinical outcomes or mortality rate. Patients with advanced chronic kidney disease usually show metabolic acidosis due to increased unmeasured anions and hyperchloremia. It has been suggested that metabolic acidosis might have a negative impact on progression of kidney dysfunction and that sodium bicarbonate administration might attenuate this effect, but further evaluation is required to validate such a renoprotective strategy. Sodium bicarbonate is the predominant buffer used in dialysis fluids and patients on maintenance dialysis are subjected to a load of sodium bicarbonate during the sessions, suffering a transient metabolic alkalosis of variable severity. Side effects associated with sodium bicarbonate therapy include hypercapnia, hypokalemia, ionized hypocalcemia, and QTc interval prolongation. The potential impact of regular sodium bicarbonate therapy on worsening vascular calcifications in patients with chronic kidney disease has been insufficiently investigated.
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Affiliation(s)
- María M. Adeva-Andany
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Carlos Fernández-Fernández
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - David Mouriño-Bayolo
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Elvira Castro-Quintela
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Alberto Domínguez-Montero
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
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Randomized trial of frequent low-efficiency and short hemodialysis/hemofiltration in hemodialysis patients with acute brain injury. Int J Artif Organs 2013; 36:793-802. [PMID: 24338654 DOI: 10.5301/ijao.5000249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of the study was to compare effects of frequent low-efficiency and short hemodialysis (FLESHD) and frequent low-efficiency and short hemofiltration (FLESHF) in hemodialysis (HD) patients with acute brain injury (ABI).
METHODS We randomly divided 13 HD patients with ABI into FLESHD (n = 6) or FLESHF (n = 7) groups. Conditions for the first to third sessions were as follows. FLESHD intravenous administration of glycerol 400 ml/session, blood flow rate (QB) 100 ml/min, dialysate flow rate 300 ml/min, and treatment duration 2 h (HD-1). FLESHF intravenous administration of glycerol 400 ml/session, QB 150 ml/min, substitution flow rate 10 l/session, and treatment duration 4 h (HF-1). After the fourth session, we gradually changed the conditions and stopped glycerol administration (HD-2 and HF-2).
RESULTS There were no significant differences in survival rate, consciousness level, or adverse effects during hospitalization in either group. In mixed model analysis, the level of HCO3- post FLESHF was significantly (p<0.0001) increased compared with the level post FLESHD. However, no significant differences were seen in the levels of osmolality, in blood pressure before and after either dialysis method, or in the level of HCO3- pre dialysis. The variation in the relative ratio of BUN before FLESHF was significantly higher (p<0.05) than the relative ratio before FLESHD in the sixth session. In the FLESHD groups, serum sodium was higher and serum potassium was lower than in the FLESHF groups.
CONCLUSIONS FLESHD with glycerol under these conditions may be a better therapeutic option for managing patients with ABI, although the short-term survival rate is similar.
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Cerdá J, Tolwani AJ, Warnock DG. Critical care nephrology: management of acid–base disorders with CRRT. Kidney Int 2012; 82:9-18. [DOI: 10.1038/ki.2011.243] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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15
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Continuous Renal Replacement Therapy for Refractory Intracranial Hypertension? ACTA ACUST UNITED AC 2010; 68:1506-9. [DOI: 10.1097/ta.0b013e3181dbbf1b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Infection-induced lung injury is worsened after renal buffering of hypercapnic acidosis. Crit Care Med 2009; 37:2953-61. [DOI: 10.1097/ccm.0b013e3181b028ce] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Dilutional acidosis or uncovered cellular metabolism? Intensive Care Med 2009; 35:2009-11. [DOI: 10.1007/s00134-009-1700-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 09/23/2009] [Indexed: 01/13/2023]
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18
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Fletcher JJ, Bergman K, Feucht EC, Blostein P. Continuous renal replacement therapy for refractory intracranial hypertension. Neurocrit Care 2009; 11:101-5. [PMID: 19267223 DOI: 10.1007/s12028-009-9197-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Little is known about the effects of hemodialysis on the injured brain, however; concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy. Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety. Furthermore, exacerbations of cerebral edema have been reported. CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance. We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension. METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma. He required significant volume resuscitation. Intensive care unit course was complicated by shock, acute respiratory distress syndrome, ventilator associated pneumonia, and development of intracranial hypertension (IH). Data were collected by retrospective chart review. RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy. Within hours of initiation increase, ICP improved and normalized. Hemofiltration was safely discontinued after 48 h. Modified Rankin Score was 2 at 90 days. CONCLUSION Though unproven, CRRT may be beneficial in patients with IH due to gentle removal of fluid, solutes, and inflammatory cytokines. Given the limited data on safety of CRRT in patients with ABI, we encourage further reports.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Neurology (Neurocritical Care), Bronson Methodist Hospital, 601 John Street Suite M-124, Kalamazoo, MI 49007, USA.
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19
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Abstract
Mechanical ventilation using high tidal volume (VT) and transpulmonary pressure can damage the lung, causing ventilator-induced lung injury. Permissive hypercapnia, a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure, has been accepted progressively in critical care for adult, pediatric, and neonatal patients requiring mechanical ventilation and is one of the central components of current protective ventilatory strategies.
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Affiliation(s)
- Alex Rogovik
- Pediatric Research in Emergency Therapeutics (PRETx) Program, Division of Pediatric Emergency Medicine, Ambulatory Care Building, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
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20
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Key Questions in Ventilator Management of the Burn-Injured Patient (First of Two Parts). J Burn Care Res 2009; 30:128-38. [DOI: 10.1097/bcr.0b013e318191fe44] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Tsukamoto S, Maruyama K, Nakagawa H, Iwase Y, Kitamura A, Hayashida M. Fatal Hyperkalemia Due to Rapid Red Cell Transfusion in a Critically Ill Patient. J NIPPON MED SCH 2009; 76:258-64. [DOI: 10.1272/jnms.76.258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Sakiko Tsukamoto
- Department of Anesthesiology, International Medical Center, Saitama Medical University
| | - Koichi Maruyama
- Department of Anesthesiology, International Medical Center, Saitama Medical University
| | - Hideyuki Nakagawa
- Department of Anesthesiology, International Medical Center, Saitama Medical University
| | - Yoshinori Iwase
- Department of Anesthesiology, International Medical Center, Saitama Medical University
| | - Akira Kitamura
- Department of Anesthesiology, International Medical Center, Saitama Medical University
| | - Masakazu Hayashida
- Department of Anesthesiology, International Medical Center, Saitama Medical University
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22
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Koch A, Kaske M. Clinical efficacy of intravenous hypertonic saline solution or hypertonic bicarbonate solution in the treatment of inappetent calves with neonatal diarrhea. J Vet Intern Med 2008; 22:202-11. [PMID: 18289311 PMCID: PMC7166734 DOI: 10.1111/j.1939-1676.2007.0029.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: The clinical efficacy of IV administered hypertonic saline solution and hypertonic bicarbonate solution (HBS) in the treatment of inappetent diarrheic calves has not been compared yet. Hypothesis: HBS is more advantageous than hypertonic saline in the treatment of calves with severe metabolic acidosis. Animals: Twenty‐eight dehydrated, inappetent calves with neonatal diarrhea. Methods: In 2 consecutive clinical studies, calves were initially treated with saline (5.85%; 5 mL/kg body weight [BW] over 4 minutes; study I: N = 16) or bicarbonate solution (8.4%; 10 mL/kg BW over 8 minutes; study II: N = 12), respectively, followed by oral administration of 3 L isotonic electrolyte solution 5 minutes after injection. Clinical and laboratory variables were monitored for 72 hours. Results: Treatment failed in 6 calves of study I and in 1 calf of study II as indicated by a deterioration of the general condition. All treatment failures had more severe metabolic acidosis compared with successfully treated calves before treatment. In the latter, rehydration was completed within 18 hours after injection; metabolic acidosis was corrected within 24 hours (study I) and 6 hours (study II) after injection. Conclusions and Clinical Importance: Diarrheic calves with slight metabolic acidosis (base excess [BE] >−10 mM) can be treated successfully with hypertonic saline. HBS is appropriate in calves without respiratory problems with more severe metabolic acidosis (BE up to −20 mM). Intensive care of the calves is required to ensure a sufficient oral fluid intake after the initial IV treatment.
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Affiliation(s)
- A Koch
- Clinic for Cattle, University of Veterinary Medicine Hannover, Hannover, Germany
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23
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Abstract
The correct identification of the cause, and ideally the individual acid, responsible for metabolic acidosis in the critically ill ensures rational management. In Part 2 of this review, we examine the elevated (corrected) anion gap acidoses (lactic, ketones, uraemic and toxin ingestion) and contrast them with nonelevated conditions (bicarbonate wasting, renal tubular acidoses and iatrogenic hyperchloraemia) using readily available base excess and anion gap techniques. The potentially erroneous interpretation of elevated lactate signifying cell ischaemia is highlighted. We provide diagnostic and therapeutic guidance when faced with a high anion gap acidosis, for example pyroglutamate, in the common clinical scenario 'I can't identify the acid--but I know it's there'. The evidence that metabolic acidosis affects outcomes and thus warrants correction is considered and we provide management guidance including extracorporeal removal and fomepizole therapy.
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Affiliation(s)
- C G Morris
- Intensive Care Medicine and Anaesthesia, Derby Hospitals Foundation Trust, Derby Royal Infirmary, London Road, Derby DE1 2QY, UK.
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24
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Effect of Tris-Hydroxymethyl Aminomethane on intracellular pH depends on the extracellular non-bicarbonate buffering capacity. Transl Res 2007; 150:350-6. [PMID: 18022597 DOI: 10.1016/j.trsl.2007.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 05/08/2007] [Accepted: 05/13/2007] [Indexed: 11/23/2022]
Abstract
The effect of Tris-Hydroxymethyl Aminomethane (THAM) on intracellular pH (pHi) is unknown. We previously demonstrated that the effect of sodium bicarbonate on pHi depends on the non-bicarbonate buffering system. First, human hepatocytes from hepatocytes cell culture (HepG2) were perfused with an acidotic artificial medium containing 5-mmol/L (H5) or 30-mmol/L (H30) concentrations of 4-(2-hydroxyethyl)-1-piperazineethane sulfonic acid (HEPES), a non-bicarbonate buffer. We studied the effect of THAM on the pHi in both conditions. We repeated the same protocol using an acidotic human blood with a 5% or 40% hematocrit. The pHi was measured with the pH-sensitive fluorescent dye bis-carboxyethyl carboxy-fluorescein (BCECF). Gas analysis was performed before and during the alkaline infusion. The results showed that THAM caused an intracellular alkalization that was higher when the non-bicarbonate buffer concentration was low (0.45 +/- 0.21 and 0.22 +/- 0.14 pH units with H5 and H30, respectively). A significant relationship was found between changes in pHi and changes in PCO(2). Similar results were obtained with the human blood. In conclusion, the intracellular alkalizing effect of THAM is caused by the induced decrease of PCO(2) linked to the extracellular non-bicarbonate buffer capacity: The smaller the concentration of extracellular non-bicarbonate buffer, the higher the PCO(2) decrease caused by THAM.
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25
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Abstract
Despite the commonly accepted indications for hemodialysis and extracorporeal depuritive techniques, some clinicians have come to rely on blood purification for clinical states where the targeted substance for removal differs from uremic waste products. Over the last decade, a number of studies have emerged to help define the application of extracorporeal blood purification (ECBP) to these "nonuremic" indications. This review describes the application of extracorporeal blood purification in clinical states including sepsis, rhabdomyolysis, congestive heart failure, hepatic failure, tumor lysis syndrome, adult respiratory distress syndrome, intravenous contrast exposure, and lactic acidosis. Additional comments are provided to review existing literature on thermoregulation and osmoregulation, including acute brain injury.
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Affiliation(s)
- Andrew E Briglia
- Department of Medicine, Division of Nephrology, University of Maryland, Baltimore, Maryland 21201, USA.
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26
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Bacaner M, Brietenbucher J, LaBree J. Prevention of Ventricular Fibrillation, Acute Myocardial Infarction (Myocardial Necrosis), Heart Failure, and Mortality by Bretylium. Am J Ther 2004; 11:366-411. [PMID: 15356432 DOI: 10.1097/01.mjt.0000126444.24163.81] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
It is widely, but mistakenly, believed that ischemic heart disease (IsHD) and its complications are the sole and direct result of reduced coronary blood flow by obstructive coronary artery disease (CAD). However, cardiac angina, acute myocardial infarction (AMI), and sudden cardiac death (SCD) occur in 15%-20% of patients with anatomically unobstructed and grossly normal coronaries. Moreover, severe obstructive coronary disease often occurs without associated pathologic myocardiopathy or prior symptoms, ie, unexpected sudden death, silent myocardial infarction, or the insidious appearance of congestive heart failure (CHF). The fact that catecholamines explosively augment oxidative metabolism much more than cardiac work is generally underappreciated. Thus, adrenergic actions alone are likely to be more prone to cause cardiac ischemia than reduced coronary blood flow per se. The autonomic etiology of IsHD raises contradictions to the traditional concept of anatomically obstructive CAD as the lone cause of cardiac ischemia and AMI. Actually, all the signs and symptoms of IsHD reflect autonomic nervous system imbalance, particularly adrenergic hyperactivity, which may by itself cause ischemia as in rest angina. Adrenergic activity causing ischemia signals cardiac pain to pain centers via sympathetic efferent pathways and tend to induce arrhythmogenic and necrotizing ischemic actions on the cardiovascular system. This may result in ischemia induced metabolic myocardiopathy not unlike that caused by anatomic or spasmogenic coronary obstruction. The clinical study and review presented herein suggest that adrenergic hyperactivity alone without CAD can be a primary cause of IsHD. Thus, adrenergic heart disease (AdHD), or actually adrenergic cardiovascular heart disease (ACVHD), appears to be a distinct entity, most commonly but not necessarily occurring in parallel with CAD. CAD certainly contributes to vulnerability as well as the progression of IsHD. This vicious cycle, which explains the frequent parallel occurrence of arteriosclerosis and IHD, an association that appears to be linked by the same cause, comprises a common vulnerability to deleterious adrenergic actions on the myocardium, lipid metabolism, and vascular system alike, rather than viewing CAD and IsHD as having a putative cause and effect relationship as commonly thought. Adrenergic actions can also cause the abnormal lipid metabolism that is associated with CAD and IsHD by catecholamine-induced metabolic actions on lipid mobilization by activation of phospholipases. This may also be part of toxic catecholamine hypermetabolic actions by enhancing deleterious cholesterol and lipid actions in damaging coronary vessels by plaque formation as well as inducing obstructive coronary spasm and platelet aggregation. This may also cause direct toxic necrosis on the myocardium as well as atherosclerosis in blood vessels. In fact, drugs that inhibit adrenergic actions like propranolol, reserpine, and guanethidine all inhibit arteriosclerosis induced by hypercholesterolemia in experimental animals and prevent carotid vascular disease (associated with stroke) in humans. The concomitant development of myocardiopathy and coronary vascular lesions or coronary and carotid artery intimal medial thickening by catecholamine toxicity is reflected by the frequent primary presentation of patients with catecholamine-secreting pheochromocytoma with cardiovascular disease, ie, hypertension arrhythmias, AMI, SCD, CHF, and vascular disease, which represents a clear example of the primary deleterious impact of catecholamines on the entire cardiovascular system causing adrenergic cardiovascular disease. Thus, like myocardiopathy, CAD and atherosclerosis in general may be the consequences of or a complication of catecholamine actions rather than its putative cause. This report shows how prophylactic bretylium not only prevents arrhythmias but prevents myocardial necrosis, shock, CHF, maintains or restores normal contractility, and lowers mortality in AMI patients by inducing adrenergic blockade.
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Affiliation(s)
- Marvin Bacaner
- Department of Physiology, University of Minnesota, Minneapolis, USA.
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27
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O' Croinin D, Ni Chonghaile M, Higgins B, Laffey JG. Bench-to-bedside review: Permissive hypercapnia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 9:51-9. [PMID: 15693984 PMCID: PMC1065087 DOI: 10.1186/cc2918] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Current protective lung ventilation strategies commonly involve hypercapnia. This approach has resulted in an increase in the clinical acceptability of elevated carbon dioxide tension, with hypoventilation and hypercapnia 'permitted' in order to avoid the deleterious effects of high lung stretch. Advances in our understanding of the biology of hypercapnia have prompted consideration of the potential for hypercapnia to play an active role in the pathogenesis of inflammation and tissue injury. In fact, hypercapnia may protect against lung and systemic organ injury independently of ventilator strategy. However, there are no clinical data evaluating the direct effects of hypercapnia per se in acute lung injury. This article reviews the current clinical status of permissive hypercapnia, discusses insights gained to date from basic scientific studies of hypercapnia and acidosis, identifies key unresolved concerns regarding hypercapnia, and considers the potential clinical implications for the management of patients with acute lung injury.
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Affiliation(s)
- Donall O' Croinin
- Clinical Research Fellow, Department of Physiology, University College Dublin, Dublin
| | - Martina Ni Chonghaile
- Clinical Research Fellow, Department of Anaesthesia, University College Hospital, and Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway, Ireland
| | - Brendan Higgins
- Postdoctoral Research Fellow, Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Clinical Lecturer, Department of Anaesthesia, University College Hospital, and Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway, Ireland
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28
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Gehlbach BK, Schmidt GA. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit - the role of buffers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:259-65. [PMID: 15312208 PMCID: PMC522834 DOI: 10.1186/cc2865] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The recognition and management of acid-base disorders is a commonplace activity for intensivists. Despite the frequency with which non-bicarbonate-losing forms of metabolic acidosis such as lactic acidosis occurs in critically ill patients, treatment is controversial. This article describes the properties of several buffering agents and reviews the evidence for their clinical efficacy. The evidence supporting and refuting attempts to correct arterial pH through the administration of currently available buffers is presented.
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Affiliation(s)
- Brian K Gehlbach
- Instructor of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Gregory A Schmidt
- Professor of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
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29
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Laffey JG, O'Croinin D, McLoughlin P, Kavanagh BP. Permissive hypercapnia--role in protective lung ventilatory strategies. Intensive Care Med 2004; 30:347-56. [PMID: 14722644 DOI: 10.1007/s00134-003-2051-1] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2003] [Accepted: 09/29/2003] [Indexed: 11/29/2022]
Abstract
"Permissive hypercapnia" is an inherent element of accepted protective lung ventilation. However, there are no clinical data evaluating the efficacy of hypercapnia per se, independent of ventilator strategy. In the absence of such data, it is necessary to determine whether the potential exists for an active role for hypercapnia, distinct from the demonstrated benefits of reduced lung stretch. In this review, we consider four key issues. First, we consider the evidence that protective lung ventilatory strategies improve survival and we explore current paradigms regarding the mechanisms underlying these effects. Second, we examine whether hypercapnic acidosis may have effects that are additive to the effects of protective ventilation. Third, we consider whether direct elevation of CO(2), in the absence of protective ventilation, is beneficial or deleterious. Fourth, we address the current evidence regarding the buffering of hypercapnic acidosis in ARDS. These perspectives reveal that the potential exists for hypercapnia to exert beneficial effects in the clinical context. Direct administration of CO(2) is protective in multiple models of acute lung and systemic injury. Nevertheless, several specific concerns remain regarding the safety of hypercapnia. At present, protective ventilatory strategies that involve hypercapnia are clinically acceptable, provided the clinician is primarily targeting reduced tidal stretch. There are insufficient clinical data to suggest that hypercapnia per se should be independently induced, nor do outcome data exist to support the practice of buffering hypercapnic acidosis. Rapidly advancing basic scientific investigations should better delineate the advantages, disadvantages, and optimal use of hypercapnia in ARDS.
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Affiliation(s)
- John G Laffey
- Department of Anaesthesia, University College Hospital, Galway and Clinical Sciences Institute, National University of Ireland, Galway, Ireland,
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30
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Abstract
Metabolic acidosis is characterized by a decrease of the blood pH associated with a decrease in the bicarbonate concentration. This may be secondary to a decrease in the strong ion difference or to an increase in the weak acids concentration, mainly the inorganic phosphorus. From a conceptual point of view, two types of nontoxic metabolic acidosis must be differentiated: the mineral metabolic acidosis that reveals the presence of an excess of nonmetabolizable anions, and the organic metabolic acidosis that reveals an excess of metabolizable anions. Significance and consequences of these two types of acidosis are radically different. Mineral acidosis is not caused by a failure in the energy metabolic pathways, and its treatment is mainly symptomatic by correcting the blood pH (alkali therapy) or accelerating the elimination of excessive mineral anions (renal replacement therapy). On the other hand, organic acidosis gives evidence that a severe underlying metabolic distress is in process. No reliable argument exists to prove that this acidosis is harmful under these conditions in humans. Experimental data even show that hypoxic cells are able to survive only if the medium is kept acidic. The management of an acute organic metabolic acidosis is therefore primarily based on the cause of the acidosis, and no scientific argument exists to justify the correction of the acid-base imbalance in this context.
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Affiliation(s)
- Jacques Levraut
- Departemente d'Anesthesie Reanimation Est, Hopital Saint Roch-5, rue Pierre Devoluy, F-06006, Nice.
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31
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Magdesian KG, Madigan JE. Volume replacement in the neonatal ICU: Crystalloids and colloids. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1534-7516(03)000210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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32
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Guest T, Venn R, Forni LG. Anions and the anaesthetist 1. Anaesthesia 2002; 57:712; author reply 713. [PMID: 12109419 DOI: 10.1046/j.1365-2044.2002.27093.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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33
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Heijnen BHM, Elkhaloufi Y, Straatsburg IH, Van Gulik TM. Influence of acidosis and hypoxia on liver ischemia and reperfusion injury in an in vivo rat model. J Appl Physiol (1985) 2002; 93:319-23. [PMID: 12070220 DOI: 10.1152/japplphysiol.01112.2001] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The contribution of acidosis to the development of reperfusion injury is controversial. In this study, we examined the effects of respiratory acidosis and hypoxia in a frequently used in vivo liver ischemia and reperfusion (I/R) injury rat model. Rats were anesthetized with intraperitoneal anesthetics and subjected to partial liver ischemia (70%) for 60 min and subsequent reperfusion for 90 min under the following conditions: 1) no acidosis and normoxia, maintained by controlled ventilation; 2) acidosis and normoxia, maintained by passive supply with oxygen; 3) no acidosis and hypoxia, maintained by bicarbonate administration without respiratory support; and 4) acidosis and hypoxia, i.e., without respiratory support or pH correction. Changes in plasma aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured as parameters of hepatocellular injury, and bile secretion was monitored. AST and ALT levels were lowest in the ventilated rats and highest in the bicarbonate-treated rats. No differences in bile secretion were found between groups. Our results suggest that respiratory acidosis significantly enhanced liver I/R injury under normoxic conditions, whereas respiratory acidosis significantly reduced liver I/R injury under hypoxic conditions.
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Affiliation(s)
- Bob H M Heijnen
- Surgical Laboratory, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands.
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34
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Abstract
Despite the lack of evidence for its effectiveness in the treatment of acid-base disturbances in critically ill patients of all ages, and despite several lines of evidence that indicate it might be dangerous, bicarbonate therapy is used routinely in many neonatal intensive care units. The justification for the persistent use of this controversial therapy comes from a variety of sources, many based more in philosophy than in science. Clinicians contemplating the use of bicarbonate therapy should consider what they expect the intervention to accomplish and what evidence exists that their therapeutic objective will be met. Without rigorous scientific support for this therapy, it should be considered of unproven value and, therefore, experimental.
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Affiliation(s)
- Amer N Ammari
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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35
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Levraut J, Giunti C, Ciebiera JP, de Sousa G, Ramhani R, Payan P, Grimaud D. Initial effect of sodium bicarbonate on intracellular pH depends on the extracellular nonbicarbonate buffering capacity. Crit Care Med 2001; 29:1033-9. [PMID: 11378618 DOI: 10.1097/00003246-200105000-00032] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The effect of sodium bicarbonate on intracellular pH under conditions close to those in vivo, with both bicarbonate and nonbicarbonate buffering systems, is unknown. We postulated that this effect depends on the nonbicarbonate buffering capacity because the alkali-induced back-titration of these buffers results in a concentration-dependent release of CO2 in the extracellular space, leading to a decrease in intracellular pH. DESIGN The study was conducted in two stages. First, human hepatocytes were perfused with pH 7 bicarbonate-buffered medium (5 mM HCO3-, 20 torr Pco2) containing no nonbicarbonate buffer or small amounts (5 mM 4-[2-hydroxyethyl]-1-piperazineethanesulfonic acid [HEPES]) or large amounts (20 mM HEPES) of nonbicarbonate buffer. Second, the changes in intracellular pH of hepatocytes placed in acidotic human blood (pH 7, 5 mM HCO3-, 20 torr Pco2) at three hematocrits (40%, 20%, and 5%) were measured. SETTING Research laboratory at a medical university. SUBJECTS Cryopreserved human hepatocytes thawed the day before the experiments. INTERVENTIONS Sodium bicarbonate was infused for 10 mins to increase the HCO3- concentration from 5 to 30 mM. In the second part, 20 mM sodium bicarbonate was added directly to the blood bathing the cells. MEASUREMENTS AND MAIN RESULTS The intracellular pH was measured with the pH-sensitive fluorescent dye bis-carboxyethyl carboxy-fluorescein in its esterified form, acetoxy-methyl ester, by using a single-cell imaging technique. Gas analyses were performed before and during the sodium bicarbonate load. Sodium bicarbonate caused a decrease in intracellular pH with all media except the artificial medium containing no HEPES. This decrease was small in media with low nonbicarbonate buffering capacity (5 mM HEPES and 5% hematocrit blood) and large in media with high nonbicarbonate buffering capacity (20 mM HEPES and 40% hematocrit blood). The change in intracellular pH was linked closely to the change in Pco2 caused by the sodium bicarbonate. CONCLUSIONS The effect of sodium bicarbonate on intracellular pH depends on changes in Pco2 in the medium bathing the cells. The increase in Pco2 is correlated with the extracellular nonbicarbonate buffering capacity because of the release of H+ ions coming from the back-titration of these buffers. We conclude that sodium bicarbonate may exacerbate cell acidosis under buffering conditions close to those in vivo and that the initial changes in cell pH caused by sodium bicarbonate depend on the extracellular nonbicarbonate buffering capacity.
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Affiliation(s)
- J Levraut
- Centre Hospitalier Universitaire de Nice-Sophia Antipolis, Département d'Anesthésie-Réanimation, Hôpital Saint-Roch, Nice, France
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37
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Abstract
The patient with an acute brain injury requiring renal replacement therapy presents a major problem in that conventional intermittent hemodialysis may exacerbate the injury by compromising cerebral perfusion pressure, either after a reduction in cerebral perfusion or because of increased cerebral edema. Compared with standard intermittent hemodialysis, the continuous forms of renal replacement therapy (CRRT) provide an effective therapy in terms of solute clearance, coupled with improved cardiovascular and intracranial stability. The disadvantage of CRRT is that anticoagulation may be required, and anticoagulants with systemic effects may provoke intracerebral hemorrhage, either at the site of damage or around the intracranial pressure monitoring device. Although peritoneal dialysis does not require anticoagulation, the clearances achieved are often less than those of CRRT, and sudden changes in intraperitoneal volume may provoke cardiovascular and thus intracranial instability.
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Affiliation(s)
- A Davenport
- Royal Free and University College Hospital Medical School, Centre for Nephrology, Royal Free Hospital, London, UK.
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38
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Tung A. Perioperative Ventilation of the Vascular Surgery Patient. Semin Cardiothorac Vasc Anesth 2000. [DOI: 10.1177/108925320000400408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although cardiovascular disease represents the most com mon comorbidity in patients undergoing vascular surgery, perioperative ventilatory issues can also play a vital role in achieving good outcomes. Postoperative respiratory failure is uncommon after carotid endarterectomy or peripheral revascularization procedures, the risk of pulmonary compli cations following intra-abdominal or intrathoracic vascular surgery is high. In addition to primary lung diseases such as chronic obstructive pulmonary disease, associated organ dysfunction syndromes such as stroke, renal failure, and congestive heart failure can also contribute to respiratory morbidity. An approach to minimizing respiratory complica tions begins with a careful preoperative search for ways to maximize pulmonary function and establishment of targets for postoperative weaning. Intraoperative attention should be paid to intraoperative management of bronchospasm, auto-positive end-expiratory pressure, and acid-base status. Postoperative management should strive for rapid extuba tion, continuation of pharmacologic conditioning programs begun preoperatively, and consideration of the use of post operative regional analgesia for patients with severe lung disease.
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Affiliation(s)
- Avery Tung
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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40
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Abstract
Lactic acidosis often challenges the intensivist and is associated with a strikingly high mortality. Treatment involves discerning and correcting its underlying cause, ensuring adequate oxygen delivery to tissues, reducing oxygen demand through sedation and mechanical ventilation, and (most controversially) attempting to alkalinize the blood with IV sodium bicarbonate. Here we review the literature to answer the following questions: Is a low pH bad? Can sodium bicarbonate raise the pH in vivo? Does increasing the blood pH with sodium bicarbonate have any salutary effects? Does sodium bicarbonate have negative side effects? We find that the oft-cited rationale for bicarbonate use, that it might ameliorate the hemodynamic depression of metabolic acidemia, has been disproved convincingly. Further, given the lack of evidence supporting its use, we cannot condone bicarbonate administration for patients with lactic acidosis, regardless of the degree of acidemia.
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Affiliation(s)
- S M Forsythe
- Department of Medicine, University of Chicago School of Medicine, Chicago, IL, USA
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Laffey JG, Engelberts D, Kavanagh BP. Buffering hypercapnic acidosis worsens acute lung injury. Am J Respir Crit Care Med 2000; 161:141-6. [PMID: 10619811 DOI: 10.1164/ajrccm.161.1.9905080] [Citation(s) in RCA: 169] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypoventilation, associated with hypercapnic acidosis (HCA), may improve outcome in acute lung injury (ALI). We have recently reported that HCA per se protects against ALI. The current study explored whether the mechanisms of protection with HCA were related to acidosis versus hypercapnia. Because CO(2) equilibrates rapidly across cell membranes, we hypothesized that (1) HCA would afford greater protection than metabolic acidosis. We further hypothesized that (2) buffering HCA would attenuate its protection. Forty isolated perfused rabbit lung preparations were randomized to: control (normal pH, PCO(2)); HCA; metabolic acidosis; or buffered hypercapnia. After ischemia-reperfusion (IR) injury wet:dry ratio was greatest with control and buffered hypercapnia, and rank order of capillary filtration coefficient was: control approximately buffered hypercapnia > metabolic acidosis > HCA. Isogravimetric pressure reduction was greatest with buffered hypercapnia. Despite comparable injury, pulmonary artery pressure elevation was less with buffered hypercapnia versus control. In vitro xanthine oxidase (XO) activity depended on pH, not PCO(2). We conclude that: (1) HCA and metabolic acidosis are protective, but HCA is the most protective; (2) buffering HCA attenuates its protection; (3) buffering HCA causes pulmonary vasodilation; (4) because metabolic acidosis and HCA similarly inhibit in vitro XO activity, the differential effects cannot be explained solely on the basis of extracellular XO activity.
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Affiliation(s)
- J G Laffey
- Respiratory Research Unit, Department of Anaesthesia and the MSICU, The Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- T Duke
- Goroka Base Hospital, PO Box 392, Goroka, EHP, Papua New Guinea.
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