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Vidanapathirana M. Sodium bicarbonate and intubation in severe diabetic ketoacidosis: are we too quick to dismiss them? Clin Diabetes Endocrinol 2024; 10:13. [PMID: 38616273 PMCID: PMC11017618 DOI: 10.1186/s40842-024-00171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/24/2024] [Indexed: 04/16/2024] Open
Abstract
Management of diabetic ketoacidosis (DKA) has internationally established guidelines. However, management of severe, refractory DKA with multiple contributors to acidosis, and management of DKA in patients with altered mentation, remain ambiguous. Use of sodium bicarbonate and intubation in DKA are unpopular treatment practices, but warrant consideration in these unique clinical scenarios. This paper describes a 61-year-old Sri Lankan female who presented with severe DKA, seizures and altered level of consciousness. In her case, the acidosis was secondary to DKA, hyperlactatemia, hyperchloraemic acidosis and acute kidney injury (AKI). Intravenous sodium bicarbonate was used in the management of acidosis. She was intubated due to altered level of consciousness with inadequate respiratory drive to compensate for metabolic acidosis. The outcome in her case was favorable. Intravenous sodium bicarbonate in DKA should be considered for patients with severe, refractory acidosis with hemodynamic instability, hyperkalemia and compounding acidosis due to normal anion gap acidosis or AKI. Intubation should be considered for patients with obtunded mentation unable to achieve respiratory compensation and obtunded mentation where reversal of DKA is unlikely to improve consciousness. Both strategies should be personalized with consideration of individual risk vs benefit.
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Fatal Cerebral Edema in a Young Adult with Diabetic Ketoacidosis: Blame the Bicarbonate? Case Rep Crit Care 2020; 2020:5917459. [PMID: 32411486 PMCID: PMC7210517 DOI: 10.1155/2020/5917459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/25/2020] [Indexed: 12/14/2022] Open
Abstract
Cerebral edema is a devastating complication of DKA which is extremely rare in adults but is the leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of a young adult with DKA as the presenting symptom of diabetes, whose clinical course was complicated by renal failure, refractory shock, and cerebral edema. This case addresses the controversy surrounding bicarbonate therapy in DKA and its possible role in the development of a rare fatal complication of DKA.
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Patel MP, Ahmed A, Gunapalan T, Hesselbacher SE. Use of sodium bicarbonate and blood gas monitoring in diabetic ketoacidosis: A review. World J Diabetes 2018; 9:199-205. [PMID: 30479686 PMCID: PMC6242725 DOI: 10.4239/wjd.v9.i11.199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/30/2018] [Accepted: 10/09/2018] [Indexed: 02/05/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a severe and too-common complication of uncontrolled diabetes mellitus. Acidosis is one of the fundamental disruptions stemming from the disease process, the complications of which are potentially lethal. Hydration and insulin administration have been the cornerstones of DKA therapy; however, adjunctive treatments such as the use of sodium bicarbonate and protocols that include serial monitoring with blood gas analysis have been much more controversial. There is substantial literature available regarding the use of exogenous sodium bicarbonate in mild to moderately severe acidosis; the bulk of the data argue against significant benefit in important clinical outcomes and suggest possible adverse effects with the use of bicarbonate. However, there is scant data to support or refute the role of bicarbonate therapy in very severe acidosis. Arterial blood gas (ABG) assessment is an element of some treatment protocols, including society guidelines, for DKA. We review the evidence supporting these recommendations. In addition, we review the data supporting some less cumbersome tests, including venous blood gas assessment and routine chemistries. It remains unclear that measurement of blood gas pH, via arterial or venous sampling, impacts management of the patient substantially enough to warrant the testing, especially if sodium bicarbonate administration is not being considered. There are special circumstances when serial ABG monitoring and/or sodium bicarbonate infusion are necessary, which we also review. Additional studies are needed to determine the utility of these interventions in patients with severe DKA and pH less than 7.0.
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Affiliation(s)
- Mit P Patel
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501, United States
| | - Ali Ahmed
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501, United States
| | - Tharini Gunapalan
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501, United States
| | - Sean E Hesselbacher
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501, United States
- Medicine Service, Hampton Veterans Affairs Medical Center, Hampton, VA 23667, United States
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Zager E, Fletcher DJ, Goggs R. Evaluation of the association between strong ion acid-base disturbances and mortality in dogs: a retrospective study. Vet Med Sci 2018; 4:206-217. [PMID: 29635886 PMCID: PMC6090410 DOI: 10.1002/vms3.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Acid-base abnormalities are frequently encountered in veterinary emergency and critical care, but information regarding the prognostic value of these findings is limited. Several systems for analysing acid-base disturbances have been reported, but the prognostic abilities of these systems have not been compared in dogs. The objectives of this retrospective study were to determine if the commonly used acid-base interpretation methods (Henderson-Hasselbalch, Stewart and semi-quantitative) have prognostic value, and to compare the performance of the three methods. Electronic medical records were searched to create a database containing point-of-care blood-gas, electrolyte and serum chemistry values for 1024 dogs assessed at a university teaching hospital. Dogs with contemporaneous blood-gas analysis, blood lactate and serum biochemistry samples were eligible for study, and only the first recorded analyses for each patient visit were included. Components of the Henderson-Hasselbalch, Stewart and semi-quantitative methods were calculated. To assess prognostic ability and to compare analysis system performance, receiver-operating characteristic (ROC) curves for survival to hospital discharge were created. Of the 1024 dogs identified, case fatality rate was 23.8%. Area under the ROC curve did not exceed 0.63 for any calculated variable. Performance of all three analysis systems was similar. While some acid-base abnormalities identified were associated with mortality, no individual abnormality or system output yielded sensitive and specific cut-off values for mortality prediction, and no interpretation method outperformed the others. This study suggests that initial acid-base abnormalities have limited prognostic utility and that various analysis systems can be used to assess acid-base disturbances in critically ill dogs.
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Affiliation(s)
- Erik Zager
- Department of Clinical SciencesCornell University College of Veterinary MedicineIthacaNew YorkUSA
| | - Daniel J. Fletcher
- Department of Clinical SciencesCornell University College of Veterinary MedicineIthacaNew YorkUSA
| | - Robert Goggs
- Department of Clinical SciencesCornell University College of Veterinary MedicineIthacaNew YorkUSA
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Bai K, Fu Y, Liu C, Xu F, Zhu M. Pediatric non-diabetic ketoacidosis: a case-series report. BMC Pediatr 2017; 17:209. [PMID: 29258472 PMCID: PMC5735941 DOI: 10.1186/s12887-017-0960-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 12/08/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND This study is to explore the clinical characteristics, laboratory diagnosis, and treatment outcomes in pediatric patients with non-diabetic ketoacidosis. METHODS Retrospective patient chart review was performed between March 2009 to March 2015. Cases were included if they met the selection criteria for non-diabetic ketoacidosis, which were: 1) Age ≤ 18 years; 2) urine ketone positive ++ or >8.0 mmol/L; 3) blood ketone >3.1 mmol/L; 4) acidosis (pH < 7.3) and/or HCO3 < 15 mmol/L; 5) random blood glucose level < 11.1 mmol/L. Patients who met the criteria 1, 4, 5, plus either 2 or 3, were defined as non-diabetic ketoacidosis and were included in the report. RESULTS Five patients with 7 episodes of non-diabetic ketoacidosis were identified. They all presented with dehydration, poor appetite, and Kussmaul breathing. Patients treated with insulin plus glucose supplementation had a quicker recovery from acidosis, in comparison to those treated with bicarbonate infusion and continuous renal replacement therapy. Two patients treated with bicarbonate infusion developed transient coma and seizures during the treatment. CONCLUSION Despite normal or low blood glucose levels, patients with non-diabetic ketoacidosis should receive insulin administration with glucose supplementation to correct ketoacidosis.
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Affiliation(s)
- Ke Bai
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Labortory of Pediatrics, 136 Zhongshang Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Yueqiang Fu
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Labortory of Pediatrics, 136 Zhongshang Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Chengjun Liu
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Labortory of Pediatrics, 136 Zhongshang Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China.
| | - Feng Xu
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Labortory of Pediatrics, 136 Zhongshang Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Min Zhu
- Department of Endocrinology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Labortory of Pediatrics, Chongqing, 400014, People's Republic of China
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The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions. Int J Nephrol 2017; 2017:7831358. [PMID: 28932601 PMCID: PMC5591930 DOI: 10.1155/2017/7831358] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/02/2017] [Accepted: 07/11/2017] [Indexed: 01/21/2023] Open
Abstract
Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. In this article, we review the data regarding the impact of systemic sodium bicarbonate administration in the management of certain poisonings including sodium channel blocker toxicities, salicylate overdose, and ingestion of some toxic alcohols and in various pharmacological toxicities. Based on the available literature and empiric experience, the administration of sodium bicarbonate appears to be beneficial in the management of a patient with the above-mentioned toxidromes. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. The potential mechanisms of sodium bicarbonate include high sodium load and the development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance with subsequent increased urinary excretion. While receiving sodium bicarbonate, patients must be monitored for the development of associated side effects including electrolyte abnormalities, the progression of metabolic alkalosis, volume overload, worsening respiratory status, and/or worsening metabolic acidosis. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate.
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Kim SY. The Author Reply: Endocrine and metabolic emergencies in children: hypocalcemia, hypoglycemia, adrenal insufficiency, and metabolic acidosis including diabetic ketoacidosis. Ann Pediatr Endocrinol Metab 2016; 21:111-2. [PMID: 27462590 PMCID: PMC4960014 DOI: 10.6065/apem.2016.21.2.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 06/24/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Se Young Kim
- Department of Pediatrics, Bundang Jeseang General Hospital, Daejin Medical Center, Seongnam, Korea
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[Hyperglycemic crisis in patients with diabetes mellitus]. Med Klin Intensivmed Notfmed 2012; 107:435-9. [PMID: 22907518 DOI: 10.1007/s00063-012-0114-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most acute life-threatening complications of diabetes mellitus and in most cases treatment should be administered in an intensive care unit. Clinically, DKA and HHS differ according to the presence of metabolic acidosis; however, the treatment of DKA and HHS is similar. The main principles are intravenous administration of insulin and correction of fluid and electrolyte abnormalities which are typically present. By the application of a standardized treatment algorithm a low mortality rate can be achieved.
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Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis - a systematic review. Ann Intensive Care 2011; 1:23. [PMID: 21906367 PMCID: PMC3224469 DOI: 10.1186/2110-5820-1-23] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 07/06/2011] [Indexed: 01/31/2023] Open
Abstract
Objective This study was designed to examine the efficacy and risk of bicarbonate administration in the emergent treatment of severe acidemia in diabetic ketoacidosis (DKA). Methods PUBMED database was used to identify potentially relevant articles in the pediatric and adult DKA populations. DKA intervention studies on bicarbonate administration versus no bicarbonate in the emergent therapy, acid-base studies, studies on risk association with cerebral edema, and related case reports, were selected for review. Two reviewers independently conducted data extraction and assessed the citation relevance for inclusion. Results From 508 potentially relevant articles, 44 were included in the systematic review, including three adult randomized controlled trials (RCT) on bicarbonate administration versus no bicarbonate in DKA. We observed a marked heterogeneity in pH threshold, concentration, amount, and timing for bicarbonate administration in various studies. Two RCTs demonstrated transient improvement in metabolic acidosis with bicarbonate treatment within the initial 2 hours. There was no evidence of improved glycemic control or clinical efficacy. There was retrospective evidence of increased risk for cerebral edema and prolonged hospitalization in children who received bicarbonate, and weak evidence of transient paradoxical worsening of ketosis, and increased need for potassium supplementation. No studies involved patients with an initial pH < 6.85. Conclusions The evidence to date does not justify the administration of bicarbonate for the emergent treatment of DKA, especially in the pediatric population, in view of possible clinical harm and lack of sustained benefits.
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Affiliation(s)
- Horng Ruey Chua
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia.
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Abstract
Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.
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Abstract
Saline should be used for fluid replacement rather than Hartmann's solution
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Sasi P, English M, Berkley J, Lowe B, Shebe M, Mwakesi R, Kokwaro G. Characterisation of metabolic acidosis in Kenyan children admitted to hospital for acute non-surgical conditions. Trans R Soc Trop Med Hyg 2006; 100:401-9. [PMID: 16257025 PMCID: PMC2719867 DOI: 10.1016/j.trstmh.2005.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2004] [Revised: 07/26/2005] [Accepted: 07/26/2005] [Indexed: 10/25/2022] Open
Abstract
Metabolic acidosis is associated with most severe malaria deaths in African children, and most deaths occur before maximum antimalarial action is achieved. Thus, specific acidosis treatment may reduce mortality. However, the underlying mechanisms remain poorly understood and no specific interventions have been developed. A detailed characterisation of this acidosis is critical in treatment development. We used the traditional and Stewart's approach to characterise acidosis in consecutive paediatric admissions for malaria and other acute non-surgical conditions to Kilifi District Hospital in Kenya. The overall acidosis prevalence was 21%. Gastroenteritis had the highest prevalence (61%). Both the mean albumin-corrected anion gap and the strong ion gap were high (>13 mmol/l and >0 mmol/l, respectively) in malaria, gastroenteritis, lower respiratory tract infection and malnutrition. Presence of salicylate in plasma was not associated with acidosis but was associated with signs of severe illness (odds ratio 2.11, 95% CI 1.1-4.2). In malaria, mean (95% CI) strong ion gap was 15 (14-7) mmol/l, and lactate, creatinine and inorganic phosphorous explained only approximately 40% of the variability in base excess (adjusted R2 = 0.397). Acidosis may be more common than previously recognised amongst paediatric admissions in Africa and is characterised by the presence of currently unidentified strong anions. In malaria, lactate and ketones, but not salicylate, are associated with acidosis. However, unidentified anions may be more important.
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Affiliation(s)
- P Sasi
- KEMRI/Wellcome Trust Research Programme, Center for Geographic Medicine Research--Coast, P.O. Box 230-80108, Kilifi, Kenya.
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Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care 2006. [PMID: 16644656 DOI: 10.2337/dc06-9909] [Citation(s) in RCA: 204] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, Boston, Massachusetts, USA
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14
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Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child 2004; 89:188-94. [PMID: 14736641 PMCID: PMC1719805 DOI: 10.1136/adc.2003.044875] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.
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Affiliation(s)
- D B Dunger
- University of Cambridge, Department of Paediatrics, Addenbrooke's Hospital, Level 8, Box 116, Cambridge CB2 2QQ, UK.
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Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004; 113:e133-40. [PMID: 14754983 DOI: 10.1542/peds.113.2.e133] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- David B Dunger
- European Society for Paediatric Endocrinology, West Smithfield, London, United Kingdom.
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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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Affiliation(s)
- Neil H White
- Division of Endocrinology and Metabolism, Department of Pediatrics, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8208, St. Louis, Missouri 63110, USA.
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