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Gomez DE, Buczinski S, Darby S, Palmisano M, Beatty SSK, Mackay RJ. Agreement of 2 electrolyte analyzers for identifying electrolyte and acid-base disorders in sick horses. J Vet Intern Med 2020; 34:2758-2766. [PMID: 32965055 PMCID: PMC7694849 DOI: 10.1111/jvim.15889] [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] [Received: 04/14/2020] [Revised: 08/11/2020] [Accepted: 08/19/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Use of different analyzers to measure electrolytes in the same horse can lead to different interpretation of acid-base balance when using the simplified strong ion difference (sSID) approach. OBJECTIVE Investigate the level of agreement between 2 analyzers in determining electrolytes concentrations, sSID variables, and acid-base disorders in sick horses. ANIMALS One hundred twenty-four hospitalized horses. METHODS Retrospective study using paired samples. Electrolytes were measured using a Beckman Coulter AU480 Chemistry analyzer (PBMA) and a Nova Biomedical Stat Profile (WBGA), respectively. Calculated sSID variables included strong ion difference, SID4 ; unmeasured strong ions, USI; and total nonvolatile buffer ion concentration in plasma (Atot ). Agreement between analyzers was explored using Passing-Bablok regression and Bland-Altman analysis. Kappa (κ) test evaluated the level of agreement between analyzers in detecting acid-base disorders. RESULTS Methodologic differences were identified in measured Na+ and Cl- and calculated values of SID4 and USI. Mean bias (95% limits of agreement) for Na+ , Cl- , SID4 , and USI were: -1.2 mmol/L (-9.2 to 6.8), 4.4 mmol/L (-4.4 to 13), -5.4 mmol/L (-13 to 2), and -6.2 mmol/L (-14 to 1.7), respectively. The intraclass correlation coefficient for SID4 and USI was .55 (95%CI: -0.2 to 0.8) and .2 (95%CI: -0.15 to 0.48), respectively. There was a poor agreement between analyzers for detection of SID4 (κ = 0.20, 95%CI, 0.1 to 0.31) or USI abnormalities (κ = -0.04, 95%CI, -0.11 to 0.02). CONCLUSIONS AND CLINICAL IMPORTANCE Differences between analyzer methodology in measuring electrolytes led to a poor agreement between the diagnosis of acid-base disorders in sick horses when using the sSID approach.
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Affiliation(s)
- Diego E Gomez
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada.,Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Sébastien Buczinski
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Montréal, Quebec, Canada
| | - Shannon Darby
- Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Megan Palmisano
- Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Sarah S K Beatty
- Department of Comparative, Diagnostic & Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Robert J Mackay
- Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
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Drolz A, Horvatits T, Roedl K, Rutter K, Brunner R, Zauner C, Schellongowski P, Heinz G, Funk GC, Trauner M, Schneeweiss B, Fuhrmann V. Acid-base status and its clinical implications in critically ill patients with cirrhosis, acute-on-chronic liver failure and without liver disease. Ann Intensive Care 2018; 8:48. [PMID: 29675709 PMCID: PMC5908779 DOI: 10.1186/s13613-018-0391-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 04/12/2018] [Indexed: 12/21/2022] Open
Abstract
Background Acid–base disturbances are frequently observed in critically ill patients at the intensive care unit. To our knowledge, the acid–base profile of patients with acute-on-chronic liver failure (ACLF) has not been evaluated and compared to critically ill patients without acute or chronic liver disease. Results One hundred and seventy-eight critically ill patients with liver cirrhosis were compared to 178 matched controls in this post hoc analysis of prospectively collected data. Patients with and without liver cirrhosis showed hyperchloremic acidosis and coexisting hypoalbuminemic alkalosis. Cirrhotic patients, especially those with ACLF, showed a marked net metabolic acidosis owing to increased lactate and unmeasured anions. This metabolic acidosis was partly antagonized by associated respiratory alkalosis, yet with progression to ACLF resulted in acidemia, which was present in 62% of patients with ACLF grade III compared to 19% in cirrhosis patients without ACLF. Acidemia and metabolic acidosis were associated with 28-day mortality in cirrhosis. Patients with pH values < 7.1 showed a 100% mortality rate. Acidosis attributable to lactate and unmeasured anions was independently associated with mortality in liver cirrhosis. Conclusions Cirrhosis and especially ACLF are associated with metabolic acidosis and acidemia owing to lactate and unmeasured anions. Acidosis and acidemia, respectively, are associated with increased 28-day mortality in liver cirrhosis. Lactate and unmeasured anions are main contributors to metabolic imbalance in cirrhosis and ACLF. Electronic supplementary material The online version of this article (10.1186/s13613-018-0391-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andreas Drolz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Thomas Horvatits
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karoline Rutter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Richard Brunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Division of Oncology and Infectious Diseases, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg-Christian Funk
- Department of Respiratory and Critical Care Medicine, and Ludwig Boltzmann Institute for COPD, Otto-Wagner Hospital, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bruno Schneeweiss
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Passos RDH, Ramos JGR, Gobatto A, Mendonça EJB, Miranda EA, Dutra FRD, Coelho MFR, Pedroza AC, Batista PBP, Dutra MMD. Lactate clearance is associated with mortality in septic patients with acute kidney injury requiring continuous renal replacement therapy: A cohort study. Medicine (Baltimore) 2016; 95:e5112. [PMID: 27749594 PMCID: PMC5059097 DOI: 10.1097/md.0000000000005112] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The aim of the study was to assess the clinical utility of lactate measured at different time points to predict mortality at 48 hours and 28 days in septic patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).Consecutive critically ill patients with septic AKI requiring CRRT were prospectively studied. Variables were collected at initiation of CRRT and 24 hours later.In total, 186 patients were analyzed. Overall mortality at 48 hours was 28% and at 28 days was 69%. Initial lactate, lactate at 24 hours and the proportion of patients with a lactate clearance superior to 10% were different between survivors at 28 days [2.0 mmol/L, 1.95 mmol/L and 18/45 (40%)] and nonsurvivors [3.46 mmol, 4.66 mmol, and 18/94 (19%)]. Multivariate analysis demonstrated that lactate at 24 hours and lactate clearance, but not initial lactate, were independently associated to mortality. Area under the ROC curves for 28-day mortality was 0.635 for initial lactate; 0.828 for lactate at 24 hours and 0.701 for lactate clearance.Lactate clearance and lactate after 24 hours of CRRT, but not initial lactate, were independently associated with mortality in septic AKI patients undergoing CRRT. Serial lactate measurements may be useful prognostic markers than initial lactate in these patients.
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Affiliation(s)
- Rogério da Hora Passos
- Critical Care Unit Hospital Sao Rafael, Salvador, Brazil /Nephrology Division Hospital Portugues, Salvador
- Correspondence: Rogério da Hora Passos, Critical Care Unit Hospital Sao Rafael, Salvador, Brazil/Nephrology Division Hospital Portugues, Salvador, Brazil (e-mail: )
| | - Joao Gabriel Rosa Ramos
- Critical Care Unit Hospital São Rafael, Salvador, Brazil/UNIME Medical School, Lauro de Freitas
| | | | | | | | | | | | | | - Paulo Benigno Pena Batista
- Hospital São Rafael Critical Care Unit Hospital São Rafael, Salvador, Brazil/UNIME Medical School, Lauro de Freitas, Brazil
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Regional citrate anticoagulation in patients with liver failure supported by a molecular adsorbent recirculating system. Crit Care Med 2011; 39:273-9. [PMID: 20975551 DOI: 10.1097/ccm.0b013e3181fee8a4] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Regional citrate anticoagulation has emerged as a promising method in critically ill patients at high risk of bleeding. However, in patients with liver failure, citrate accumulation may lead to acid-base and electrolyte imbalances, notably of calcium. The aim of this study was to evaluate the feasibility and safety of regional citrate anticoagulation during liver support using a molecular adsorbent recirculating system as well as its effects on electrolyte and acid-base balance in patients with liver failure. DESIGN Prospective observational study. SETTING University hospital. PATIENTS Twenty critically ill patients supported by molecular adsorbent recirculating system resulting from liver failure between January 2007 and May 2009. MEASUREMENTS AND MAIN RESULTS The median duration of molecular adsorbent recirculating system treatment was 20 hrs (interquartile range, 18-22 hrs). Two of 77 molecular adsorbent recirculating system treatments (2%) were prematurely discontinued as a result of filter clotting and bleeding, respectively. The median citrate infusion rate, necessary to maintain the postfilter ionized calcium between 0.2 and 0.4 mmol/L, was 3.1 mmol/L (interquartile range, 2.3-4 mmol/L) blood flow. The median calcium chloride substitution rate was 0.9 mmol/L (0.3-1.7 mmol/L) dialysate. Total serum calcium remained stable during molecular adsorbent recirculating system treatments. There was a statistically significant increase of the ratio of total calcium to systemic ionized calcium (2.04 ± 0.32 mmol/L to 2.17 ± 0.35; p = .01), which reflected citrate accumulation resulting from liver failure. Under close monitoring, no clinically relevant electrolytes or acid-base disorders were observed. CONCLUSIONS Our results suggest that regional citrate anticoagulation is a safe and feasible method to maintain adequate circuit lifespan without increasing the risk of hemorrhagic complications while maintaining a normal acid-base as well as electrolyte balance in patients with liver failure supported by molecular adsorbent recirculating system.
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Agarwal B, Kovari F, Saha R, Shaw S, Davenport A. Do bicarbonate-based solutions for continuous renal replacement therapy offer better control of metabolic acidosis than lactate-containing fluids? Nephron Clin Pract 2011; 118:c392-8. [PMID: 21346374 DOI: 10.1159/000324157] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Evidence that bicarbonate haemofiltration and dialysate fluids are superior to lactate in patients with acute kidney injury treated by continuous renal replacement therapy (CRRT) remains controversial. METHODS We prospectively audited acid-base during the first 48 h of CRRT in 62 patients, using bicarbonate and lactate fluids. RESULTS Baseline lactate was greater in the bicarbonate group (4.76 ± 0.77 vs. 2.92 ± 0.5 mmol/l, p < 0.01), but pH, bicarbonate, chloride and base excess were similar. Lactate fell significantly in the bicarbonate group to 2.88 ± 0.3 mmol/l at 24 h and 2.39 ± 0.2 mmol/l at 48 h, but not in the lactate group. Base excess improved more with bicarbonate, median increase in the first 24 h was 51.6% (29.1-96.9) versus 18.5% (-5 to 55) with lactate and 74.2% (38.5-123) versus 36.1% (-3.6 to 68), p < 0.05 at 48 h. However, there were no significant differences in bicarbonate, chloride, pH, blood pressure and vasopressor requirements. 13.3% of patients were switched from lactate to bicarbonate fluids due to failure to correct acidosis. Subgroup analysis of 19 patients with liver failure showed similar results. CONCLUSION Bicarbonate fluids led to a more rapid fall in lactate and greater improvement in base excess during CRRT, but not overall control of acidosis.
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Affiliation(s)
- B Agarwal
- Intensive Care Unit, Royal Free Hospital, London, UK
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Vitin A, Muczynski K, Bakthavatsalam R, Martay K, Dembo G, Metzner J. Treatment of severe lactic acidosis during the pre-anhepatic stage of liver transplant surgery with intraoperative hemodialysis. J Clin Anesth 2010; 22:466-72. [DOI: 10.1016/j.jclinane.2009.07.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Revised: 06/23/2009] [Accepted: 07/04/2009] [Indexed: 01/30/2023]
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Kurtz I, Kraut J, Ornekian V, Nguyen MK. Acid-base analysis: a critique of the Stewart and bicarbonate-centered approaches. Am J Physiol Renal Physiol 2008; 294:F1009-31. [PMID: 18184741 DOI: 10.1152/ajprenal.00475.2007] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
When approaching the analysis of disorders of acid-base balance, physical chemists, physiologists, and clinicians, tend to focus on different aspects of the relevant phenomenology. The physical chemist focuses on a quantitative understanding of proton hydration and aqueous proton transfer reactions that alter the acidity of a given solution. The physiologist focuses on molecular, cellular, and whole organ transport processes that modulate the acidity of a given body fluid compartment. The clinician emphasizes the diagnosis, clinical causes, and most appropriate treatment of acid-base disturbances. Historically, two different conceptual frameworks have evolved among clinicians and physiologists for interpreting acid-base phenomena. The traditional or bicarbonate-centered framework relies quantitatively on the Henderson-Hasselbalch equation, whereas the Stewart or strong ion approach utilizes either the original Stewart equation or its simplified version derived by Constable. In this review, the concepts underlying the bicarbonate-centered and Stewart formulations are analyzed in detail, emphasizing the differences in how each approach characterizes acid-base phenomenology at the molecular level, tissue level, and in the clinical realm. A quantitative comparison of the equations that are currently used in the literature to calculate H+concentration ([H+]) is included to clear up some of the misconceptions that currently exist in this area. Our analysis demonstrates that while the principle of electroneutrality plays a central role in the strong ion formulation, electroneutrality mechanistically does not dictate a specific [H+], and the strong ion and bicarbonate-centered approaches are quantitatively identical even in the presence of nonbicarbonate buffers. Finally, our analysis indicates that the bicarbonate-centered approach utilizing the Henderson-Hasselbalch equation is a mechanistic formulation that reflects the underlying acid-base phenomenology.
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