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Baettig SJ, Fend RR, Gero D, Gutschow C, Schlaepfer M. Postoperative exacerbated cough hypersensitivity syndrome induces dramatic respiratory alkalosis, lactatemia, and electrolyte imbalance. BMC Anesthesiol 2024; 24:323. [PMID: 39261779 PMCID: PMC11389337 DOI: 10.1186/s12871-024-02695-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 08/23/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND The perioperative management of patients with chronic cough or cough hypersensitivity syndrome and its sometimes severe effects is currently under-researched and under-reported. CASE PRESENTATION A 46-year-old female patient with a history of chronic cough and Cough Hypersensitivity Syndrome. After laparoscopic hiatoplasty and anterior fundoplication under general anesthesia, experienced a pronounced exacerbation of coughing symptoms. Despite prompt and extensive treatment involving antitussives, inhalants, anxiolytics, and sedatives, the symptoms remained uncontrollable. Within a few hours, the patient developed a respiratory alkalosis with severe and life-threatening electrolyte shift (pH 7.705, pCO2 1.72 kPa, K+ 2.1 mmol/l). Lactatemia lasted for more than 12 hours with values up to 6.6 mmol/l. Acute bleeding, pneumothorax, and an acute cardiac event were ruled out. Deep analgosedation and inhalation of high-percentage local anesthetics were necessary to manage the clinical symptoms. CONCLUSIONS This case highlights the challenging nature of chronic cough and hypersensitivity syndrome perioperatively. A tailored anesthesiologic approach, exclusion of other provoking medical problems, and knowledge of possible management and treatment options are key.
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Affiliation(s)
- Sascha Jan Baettig
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
| | | | - Daniel Gero
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Martin Schlaepfer
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Physiology, University of Zurich, Zurich, Switzerland
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Dargent A, Wallet F, Friggeri A, Bohe J, Vacheron CH. Lactic alkalosis in intensive care: a red flag? Crit Care 2023; 27:184. [PMID: 37173749 PMCID: PMC10176709 DOI: 10.1186/s13054-023-04464-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Affiliation(s)
- Auguste Dargent
- Centre Hospitalier Lyon Sud, Département d'Anesthésie Réanimation Médecine Intensive, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, Lyon, France.
- APCSe Aggressions Pulmonaires et Circulatoires dans le Sepsis, UPSP 2016.A101, VetAgro Sup, 69280, Marcy l'Étoile, France.
| | - Florent Wallet
- Centre Hospitalier Lyon Sud, Département d'Anesthésie Réanimation Médecine Intensive, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, Lyon, France
- RESHAPE Research on Healthcare Performance, U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Arnaud Friggeri
- Centre Hospitalier Lyon Sud, Département d'Anesthésie Réanimation Médecine Intensive, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, Lyon, France
- PHE3ID, Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Julien Bohe
- Centre Hospitalier Lyon Sud, Département d'Anesthésie Réanimation Médecine Intensive, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, Lyon, France
| | - Charles-Hervé Vacheron
- Centre Hospitalier Lyon Sud, Département d'Anesthésie Réanimation Médecine Intensive, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, Lyon, France
- PHE3ID, Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Université Lyon 1, Lyon, France
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Urushidani S, Kuriyama A, Matsumura M. Blood Gas Analysis Results and Serum Lactate Levels in Patients with Psychogenic Hyperventilation and Urinary Tract Infection with Suspected Sepsis: A Retrospective Comparative Study. Intern Med 2022; 61:1699-1706. [PMID: 34707052 PMCID: PMC9259313 DOI: 10.2169/internalmedicine.8434-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The prognosis differs considerably between patients with psychogenic hyperventilation syndrome (HVS) and those with urinary tract infection (UTI)-associated sepsis; however, the nonspecific symptoms and signs make the diagnosis and management difficult. We herein report the utility of a blood gas analysis for distinguishing HVS from UTI with suspected sepsis. Methods This single-center retrospective cohort study was conducted in a tertiary-care hospital in Japan. Patients ≥18 years old with a quick Sequential Organ Failure Assessment (qSOFA) score ≥2 and HVS or UTIs were included. The results of an arterial blood gas (ABG) or venous blood gas (VBG) analysis of the two groups were compared using the Mann-Whitney U test. We used a receiver-operating characteristic (ROC) curve analysis of the arterial pH and arterial PCO2 to assess the ability of these analyses to distinguish HVS from UTI with suspected sepsis. Results A total of 64 patients with HVS (ABG, n=14; VBG, n=50) and 53 with UTI with suspected sepsis (ABG, n=35; VBG, n=18) were included. Patients with HVS had alkalemia and lower PCO2 levels than patients with UTI with suspected sepsis, but the serum lactate levels were similar between the groups. The ROC analysis determined the pH cut-off value to be 7.509 (sensitivity: 0.91; specificity: 0.86) and the PCO2 cut-off value to be 21.6 mmHg (sensitivity: 1.00; specificity: 0.64). Conclusion Elevated serum lactate levels alone cannot be used to differentiate between patients with HVS and those with UTI with suspected sepsis, but the degree of pH and PCO2 abnormality can help with the differential diagnosis.
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Affiliation(s)
- Seigo Urushidani
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
| | - Masami Matsumura
- Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, Japan
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Urushidani S, Kuriyama A, Matsumura M. Clinical Utility of Venous Blood Gas Analysis for the Evaluation of Psychogenic Hyperventilation in the Emergency Department. Cureus 2020; 12:e12273. [PMID: 33520489 PMCID: PMC7834592 DOI: 10.7759/cureus.12273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Patients with psychogenic hyperventilation frequently visit emergency departments (EDs). Arterial blood gas (ABG) analysis is performed to evaluate patients with dyspnea. This may show respiratory alkalosis in patients with hyperventilation. ABG may also reveal elevated serum lactate levels, although psychogenic hyperventilation syndrome is a benign condition. However, arterial puncture is a painful and risky procedure. We hypothesized that venous blood gas (VBG) analysis would be sufficient for evaluating patients with suspected psychogenic hyperventilation. Objectives To compare the clinical utility of VBG analysis with ABG analysis for evaluating psychogenic hyperventilation. Methods This was a single-center retrospective cross-sectional study of patients aged ≥18 years with psychogenic hyperventilation attending a tertiary care hospital. We extracted data on age, sex, vital signs, blood gas components, and serum lactate. Spearman’s rank correlation coefficient (ρ) was used to examine the associations between the serum lactate levels and the carbon dioxide partial pressure (PCO2) in the ABG and VBG groups. Results A total of 236 patients (ABG group, n=57; VBG group, n=179) were included in the analysis. Both the ABG and VBG groups had respiratory alkalosis and similarly elevated serum lactate levels (p=0.44). The PCO2 and serum lactate levels were inversely correlated, and the ρ values were −0.74 and −0.50 for the ABG and VBG groups, respectively (both p<0.001). In addition, the bicarbonate ion (\begin{document}\textrm{HCO}_{3}^{-}\end{document}) level was inversely correlated with the serum lactate level, and the pH was positively correlated with the serum lactate levels in both the ABG and VBG groups. Conclusions Among patients with psychogenic hyperventilation, respiratory alkalosis, and the correlation between the PCO2 and serum lactate levels were similar in the ABG and VBG groups, indicating that VBG analysis might be used as an alternative to ABG analysis for evaluating psychogenic hyperventilation.
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Affiliation(s)
- Seigo Urushidani
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, JPN
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, JPN
| | - Masami Matsumura
- Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, Shimotsuke, JPN
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Mohamed MM, Sturman J. Hyperventilation-related hyperlactataemia in a case of paroxysmal vocal cord dysfunction. J Intensive Care Soc 2016; 17:262-265. [PMID: 28979501 DOI: 10.1177/1751143716638369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Paroxysmal Vocal Cords Dysfunction(PVCD), also known as paradoxical vocal cord motion, is abnormal adduction of the vocal cords during inspiration. Like asthma, PCVD can be triggered by breathing in lung irritants, upper respiratory infection or exercise. However, unlike asthma, PCVD is not an immune system reaction and does not involve the lower airways. Treatment for the two conditions differs. Plasma lactate levels are usually associated with acidosis and an increased risk of poor outcome and are described in a number of disease states of circulatory and/or respiratory failure. In patients with psychogenic hyperventilation, high lactates are associated with hypocapnia and alkalosis and should not necessarily be considered as an adverse sign. We describe a case of a young patient with PCVD mimicking asthma with high plasma lactate and discuss the mechanisms involved.
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Primary Hyperventilation in the Emergency Department: A First Overview. PLoS One 2015; 10:e0129562. [PMID: 26110771 PMCID: PMC4482441 DOI: 10.1371/journal.pone.0129562] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 05/10/2015] [Indexed: 11/30/2022] Open
Abstract
Background Primary hyperventilation is defined as a state of alveolar ventilation in excess of metabolic requirements, leading to decreased arterial partial pressure of carbon dioxide. The primary aim of this study was to characterise patients diagnosed with primary hyperventilation in the ED. Methods Our retrospective cohort study comprised adult (≥16 years) patients admitted to our ED between 1 January 2006 and 31 December 2012 with the primary diagnosis of primary (=psychogenic) hyperventilation. Results A total of 616 patients were eligible for study. Participants were predominantely female (341 [55.4%] female versus 275 [44.6%] male respectively, p <0.01). The mean age was 36.5 years (SD 15.52, range 16-85). Patients in their twenties were the most common age group (181, 29.4%), followed by patients in their thirties (121, 19.6%). Most patients presented at out-of-office hours (331 [53.7%]. The most common symptom was fear (586, 95.1%), followed by paraesthesia (379, 61.5%) and dizziness (306, 49.7%). Almost a third (187, 30.4%) of our patients had previously experienced an episode of hyperventilation and half (311, 50.5%) of patients had a psychiatric co-morbidity. Conclusion Hyperventilation is a diagnostic chimera with a wide spectrum of symptoms. Patients predominantly are of young age, female sex and often have psychiatric comorbidities. The severity of symptoms accompanied with primary hyperventilation most often needs further work-up to rule out other diagnosis in a mostly young population. In the future, further prospective multicentre studies are needed to evaluate and establish clear diagnostic criteria for primary hyperventilation and possible screening instruments.
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Batra P, Dwivedi AK, Thakur N. Bedside ABG, electrolytes, lactate and procalcitonin in emergency pediatrics. Int J Crit Illn Inj Sci 2014; 4:247-52. [PMID: 25337488 PMCID: PMC4200552 DOI: 10.4103/2229-5151.141467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Point of care testing, is the term commonly applied to the bedside tests performed in sick patients. Common clinical conditions encountered in pediatric emergency rooms are respiratory, gastro-intestinal, infections and cardiac. Emergencies at most of the places, especially developing countries are overburdened. Availability of tests like arterial blood gas, lactate, electrolytes and procalcitonin, bedside tests or point of care tests can help identify sick patients quickly. Abnormalities like acid-base disturbances and dyselectrolytemias can be dealt with instantly, thus improving the overall prognosis. Lactate levels in emergency give the earliest clue to cardiovascular compromise and poor tissue perfusion. Procalcitonin has recently gained significant importance as an acute phase reactant for early identification of sepsis. Decisions for initiating or withholding antibiotic therapy can also be taken based on procalcitonin levels in emergency. Bedside estimation of serum electrolytes, blood gas analysis and procalcitonin thus facilitate the clinical evaluation and management of critical patients. An extensive literature review of current status of these investigations as point of care tests is appraised here.
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Affiliation(s)
- Prerna Batra
- Department of Pediatrics, University College of Medical Sciences (University of Delhi) and GTB Hospital, New Delhi, India
| | - Ajeet Kumar Dwivedi
- Department of Pediatrics, University College of Medical Sciences (University of Delhi) and GTB Hospital, New Delhi, India
| | - Neha Thakur
- Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India
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Initial venous lactate levels in patients with isolated penetrating extremity trauma: a retrospective cohort study. Eur J Trauma Emerg Surg 2014; 41:203-9. [PMID: 26038266 DOI: 10.1007/s00068-014-0442-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 08/05/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Elevated initial lactate levels have been shown to be associated with severe injury in trauma patients, but some patients who do not appear to be in shock also presented with elevated lactate levels. We hypothesized that in hemodynamically stable patients with isolated penetrating extremity trauma, initial lactate level does not predict clinically significant bleeding. METHODS A 5-year institutional database review was performed. Hemodynamically stable patients (HR < 101, SBP > 90) with isolated penetrating extremity trauma with an initial lactate sent were included. The exposure of interest was captured as a dichotomous variable by initial lactate level normal (N ≤ 2.2 mEq/L), elevated (E > 2.2 mEq/L). The primary outcome measurement was clinically significant bleeding, defined by need for intervention (operation, angioembolization, or transfusion) or laboratory evidence of bleeding (presenting Hg < 7 g/dL, or Hg decrease by >2 g/dL/24 h). Chi-squared and Mann-Whitney tests were used to compare variables. RESULTS A total of 132 patients were identified. There were no differences in demographics or mechanism of injury between the N (n = 43, 7%) and E (n = 89, 14%) groups. Median lactate levels were 1.6 (IQR 1.2-1.9) mEq/dL vs. 3.8 (IQR 2.8-5.2) in the N and E groups, p < 0.001. Lactate was elevated in 89 (67%) patients but was not associated with clinically significant bleeding (37% elevated vs. 39 % not elevated p = 0.82). CONCLUSIONS In hemodynamically stable patients with isolated penetrating trauma to the extremity, elevated initial venous lactate levels (>2.2 mEq/L) are not associated with bleeding or need for interventions. Clinical judgment remains the gold standard for evaluation and management of these patients.
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