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1
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Cuddy LN, Hopper K, Burkitt-Creedon JM, Epstein SE. Retrospective evaluation of acid-base analysis in dogs and cats with diabetic ketosis (2017-2021): 96 cases. J Vet Emerg Crit Care (San Antonio) 2025; 35:65-72. [PMID: 39831448 DOI: 10.1111/vec.13447] [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: 09/01/2023] [Revised: 11/15/2023] [Accepted: 12/16/2023] [Indexed: 01/22/2025]
Abstract
OBJECTIVE To describe the acid-base balance of diabetic animals with ketosis and to identify underlying mechanisms of acid-base changes using semiquantitative analysis. DESIGN Retrospective study. SETTING University teaching hospital. ANIMALS Eighty-one client-owned dogs and 15 client-owned cats with diabetes and concurrent ketosis presented to a university teaching hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The medical records database was searched from January 2017 through December 2021 for dogs and cats with diabetes mellitus and ketones present in urine or blood samples that also had venous blood gas and serum biochemical assays performed within 24 hours of each other. Traditional analysis identified normal acid-base status in 20% of dogs and 7% of cats. A simple metabolic acidosis with an elevated anion gap was observed in 17% of dogs and 20% of cats, and a metabolic alkalosis was present in 4% of dogs and 7% of cats. The semiquantitative approach identified metabolic acid-base disorders in all animals. One or more acidifying processes were evident in 100% of dogs and 100% of cats, 1 or more alkalotic processes in 93% of dogs and 100% of cats, concurrent alkalotic and acidotic processes in 85% of dogs and 100% of cats, and unmeasured anions in all cases. CONCLUSIONS Dogs and cats with diabetic ketosis can have variable and complex acid-base disorders that may be better recognized using semiquantitative analysis. Diagnostic criteria such as low pH or a high anion gap may prevent the clinical recognition of diabetic ketoacidosis.
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Affiliation(s)
- Lindsay N Cuddy
- Veterinary Medical Teaching Hospital, University of California, Davis, Davis, California, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Jamie M Burkitt-Creedon
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
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2
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de Souza SP, Caldas JR, Lopes MB, Duarte Silveira MA, Coelho FO, Oliveira Queiroz I, Domingues Cury P, Passos RDH. Physico-chemical characterization of acid base disorders in patients with COVID-19: A cohort study. World J Nephrol 2024; 13:92498. [PMID: 38983762 PMCID: PMC11229835 DOI: 10.5527/wjn.v13.i2.92498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 05/08/2024] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Acid-base imbalance has been poorly described in patients with coronavirus disease 2019 (COVID-19). Study by the quantitative acid-base approach may be able to account for minor changes in ion distribution that may have been overlooked using traditional acid-base analysis techniques. In a cohort of critically ill COVID-19 patients, we looked for an association between metabolic acidosis surrogates and worse clinical outcomes, such as mortality, renal dialysis, and length of hospital stay. AIM To describe the acid-base disorders of critically ill COVID-19 patients using Stewart's approach, associating its variables with poor outcomes. METHODS This study pertained to a retrospective cohort comprised of adult patients who experienced an intensive care unit stay exceeding 4 days and who were diagnosed with severe acute respiratory syndrome coronavirus 2 infection through a positive polymerase chain reaction analysis of a nasal swab and typical pulmonary involvement observed in chest computed tomography scan. Laboratory and clinical data were obtained from electronic records. Categorical variables were compared using Fisher's exact test. Continuous data were presented as median and interquartile range. The Mann-Whitney U test was used for comparisons. RESULTS In total, 211 patients were analyzed. The mortality rate was 13.7%. Overall, 149 patients (70.6%) presented with alkalosis, 28 patients (13.3%) had acidosis, and the remaining 34 patients (16.2%) had a normal arterial pondus hydrogenii. Of those presenting with acidosis, most had a low apparent strong ion difference (SID) (20 patients, 9.5%). Within the group with alkalosis, 128 patients (61.0%) had respiratory origin. The non-survivors were older, had more comorbidities, and had higher Charlson's and simplified acute physiology score 3. We did not find severe acid-base imbalance in this population. The analyzed Stewart's variables (effective SID, apparent SID, and strong ion gap and the effect of albumin, lactate, phosphorus, and chloride) were not different between the groups. CONCLUSION Alkalemia is prevalent in COVID-19 patients. Although we did not find an association between acid-base variables and mortality, the use of Stewart's methodology may provide insights into this severe disease.
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Affiliation(s)
- Sergio Pinto de Souza
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
- Faculty of Medicine, Escola Bahiana de Medicina e Saúde Pública-EBMSP, Salvador, BA 40290000, Brazil
| | - Juliana R Caldas
- Department of Intensive Care, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Marcelo Barreto Lopes
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Marcelo Augusto Duarte Silveira
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Fernanda Oliveira Coelho
- Department of Nephrology, Hospital São Rafael, Salvador, BA 41253190, Brazil
- Department of Nephrology, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Igor Oliveira Queiroz
- Hospital São Rafael, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Pedro Domingues Cury
- Hospital São Rafael, D’Or Institute for Research and Education (IDOR), Salvador, BA 41253190, Brazil
| | - Rogério da Hora Passos
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652900, Brazil
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Zhang K, Han Y, Gu F, Gu Z, Zhao J, Chen J, Chen B, Gao M, Hou Z, Yu X, Cai T, Gao Y, Hu R, Xie J, Liu T, Li B. U-Shaped Association between Serum Chloride Levels and In-Hospital Mortality in Patients with Congestive Heart Failure in Intensive Care Units. Int Heart J 2024; 65:237-245. [PMID: 38556334 DOI: 10.1536/ihj.23-331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Serum chloride level has clinical significance in the prognosis of heart failure. Little is known regarding the association between serum chloride levels and in-hospital mortality in patients with heart failure.This retrospective study used clinical data obtained from the Medical Information Mart for Intensive Care Database. The study cohort comprised patients who were categorized on the basis of their serum chloride levels, and the primary endpoint was in-hospital mortality. To assess the impact of serum chloride levels at the time of intensive care unit admission on in-hospital mortality, we used various statistical approaches, including multivariable logistic regression models, a generalized additive model, and a two-piecewise linear regression model. In addition, subgroup analysis was conducted to examine the robustness of the main findings.This study comprised 15,983 participants. When compared with the reference group (Q5), the groups with the highest (Q7) and lowest (Q1) blood chloride levels exhibited increased in-hospital mortality, with fully adjusted odds ratios (ORs) of 1.36 [95% confidence interval (CI): 1.08-1.71] and 1.25 (95% CI: 1-1.56), respectively. A U-shaped relationship was observed between blood chloride levels and in-hospital mortality, with the lowest risk observed at a threshold of 105.017 mmol/L. The effect sizes and corresponding CIs below and above the threshold were 0.969 (95% CI: 0.957-0.982) and 1.039 (95% CI: 1.002-1.076), respectively. Stratified analyses demonstrated the robustness of this correlation.The relationship between serum chloride levels and in-hospital mortality in patients with heart failure was U-shaped, with an inflection point of 105.017 mmol/L.
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Affiliation(s)
- Kai Zhang
- The Second Hospital of Jilin University
| | - Yu Han
- Department of Ophthalmology, The First Hospital of Jilin University
| | | | | | | | - Jianguo Chen
- Bethune First College of Clinical Medicine, Jilin University
| | - Bowen Chen
- Bethune First College of Clinical Medicine, Jilin University
| | - Min Gao
- Department of Cancer Center, The First Hospital of Jilin University
| | - Zhengyan Hou
- Bethune Second School of Clinical Medicine, Jilin University
| | - Xiaoqi Yu
- Bethune Second School of Clinical Medicine, Jilin University
| | - Tianyi Cai
- Bethune Second School of Clinical Medicine, Jilin University
| | - Yafang Gao
- Bethune Second School of Clinical Medicine, Jilin University
| | - Rui Hu
- Bethune Third College of Clinical Medicine, Jilin University
| | - Jinyu Xie
- The Second Hospital of Jilin University
| | - Tianzhou Liu
- Department of Gastrointestinal Surgery, The Second Hospital of Jilin University
| | - Bo Li
- The Second Hospital of Jilin University
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4
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Ring T. Strong ions and charge-balance. Scand J Clin Lab Invest 2023; 83:111-118. [PMID: 36811448 DOI: 10.1080/00365513.2023.2180658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
It has been shown that the ability to predict the pH in any chemically characterized fluid, together with its buffer-capacity and acid content can be based on the requirement of electroneutrality, conservation of mass, and rules of dissociation as provided by physical chemistry. More is not required, and less is not enough. The charge in most biological fluids is dominated by the constant charge on the completely dissociated strong ions but, nonetheless, a persistent narrative in physiology has problematized the notion that these have any role at all in acid-base homeostasis. While skepticism is always to be welcomed, some common arguments against the importance of strong ions are examined and refuted here. We find that the rejection of the importance of strong ions comes with the prize that even very simple systems such as fluids containing nothing else, or solutions of sodium bicarbonate in equilibrium with known tensions of CO2 become incomprehensible. Importantly, there is nothing fundamentally wrong with the Henderson-Hasselbalch equation but the idea that it is sufficient to understand even simple systems is unfounded. What it lacks for a complete description is a statement of charge-balance including strong ions, total buffer concentrations, and water dissociation.
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Affiliation(s)
- Troels Ring
- Department of Biomedicine, Aarhus University, Århus C, Denmark
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5
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Ring T, Rees SE, Frische S. Acid content and buffer-capacity: a charge-balance perspective. Scand J Clin Lab Invest 2022; 82:356-362. [PMID: 35792720 DOI: 10.1080/00365513.2022.2092903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Rational treatment and thorough diagnostic classification of acid-base disorders requires quantitative understanding of the mechanisms that generate and dissipate loads of acid and base. A natural precondition for this tallying is the ability to quantify the acid content in any specified fluid. Physical chemistry defines the pH-dependent charge on any buffer species, and also on strong ions on which, by definition, the charge is pH-invariant. Based, then, on the requirement of electroneutrality and conservation of mass, it was shown in 1914 that pH can be calculated and understood on the basis of the chemical composition of any fluid. Herein we first show that this specification for [H+] of the charge-balance model directly delivers the pH-dependent buffer-capacity as defined in the literature. Next, we show how the notion of acid transport as proposed in experimental physiology can be understood as a change in strong ion difference, ΔSID. Finally, based on Brønsted-Lowry theory we demonstrate that by defining the acid content as titratable acidity, this is equal to SIDref - SID, where SIDref is SID at pH 7.4. Thereby, any chemical situation is represented as a curve in a novel diagram with titratable acidity = SIDref - SID as a function of pH. For any specification of buffer chemistry, therefore, the change in acid content in the fluid is path invariant. Since constituents of SID and titratable acidity are additive, we thereby, based on first principles, have defined a new framework for modeling acid balance across a cell, a whole organ, or the whole-body.
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Affiliation(s)
- Troels Ring
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Adrogué HJ, Tucker BM, Madias NE. Clinical Approach to Assessing Acid-Base Status: Physiological vs Stewart. Adv Chronic Kidney Dis 2022; 29:343-354. [PMID: 36175072 DOI: 10.1053/j.ackd.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Evaluation of acid-base status depends on accurate measurement of acid-base variables and their appropriate assessment. Currently, 3 approaches are utilized for assessing acid-base variables. The physiological or traditional approach, pioneered by Henderson and Van Slyke in the early 1900s, considers acids as H+ donors and bases as H+ acceptors. The acid-base status is conceived as resulting from the interaction of net H+ balance with body buffers and relies on the H2CO3/HCO3- buffer pair for its assessment. A second approach, developed by Astrup and Siggaard-Andersen in the late 1950s, is known as the base excess approach. Base excess was introduced as a measure of the metabolic component replacing plasma [HCO3-]. In the late 1970s, Stewart proposed a third approach that bears his name and is also referred to as the physicochemical approach. It postulates that the [H+] of body fluids reflects changes in the dissociation of water induced by the interplay of 3 independent variables-strong ion difference, total concentration of weak acids, and PCO2. Here we focus on the physiological approach and Stewart's approach examining their conceptual framework, practical application, as well as attributes and drawbacks. We conclude with our view about the optimal approach to assessing acid-base status.
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Affiliation(s)
- Horacio J Adrogué
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston, TX; Department of Medicine, Division of Nephrology, Houston Methodist Hospital, Houston, TX
| | - Bryan M Tucker
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston, TX; Department of Medicine, Division of Nephrology, Houston Methodist Hospital, Houston, TX
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Department of Medicine, Division of Nephrology, St Elizabeth's Medical Center, Boston, MA.
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7
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Pannu AK, Sharma R, Sharma N, Kaur J, Walia R, Kumar S. Stewart (physicochemical) approach versus conventional anion gap approach for resolution of metabolic acidosis in diabetic ketoacidosis. Int J Diabetes Dev Ctries 2021; 41:628-633. [DOI: 10.1007/s13410-021-00927-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 01/20/2021] [Indexed: 12/01/2022] Open
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8
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João Pedro AM, Marques TM, dos Santos Leal LD, Alves Santos PS, de Souza Ferreira JP, Dominguez R, da Silva SF, Story DA, Rossiter HB, Effros RM, van Schalkwyk JM. Commentaries on Viewpoint: Stewart's approach to quantitative acid-base physiology should replace traditional bicarbonate-centered models. J Appl Physiol (1985) 2021; 130:2022-2023. [PMID: 34142891 DOI: 10.1152/japplphysiol.00327.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Assis Moreira João Pedro
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Thais Melo Marques
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Ludmila Dias dos Santos Leal
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Paula Souza Alves Santos
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Joao Pedro de Souza Ferreira
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - Raul Dominguez
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Departamento de Motricidad Humana y Rendimiento Deportivo, Universidad de Sevilla, Sevilla, Spain
| | - Sandro Fernandes da Silva
- Grupo de estudo e pesquisa em respostas neuromusculares, Universidade Federal de Lavras, Lavras, Brazil,Programa de Pós-Graduação em Nutrição e Saúde Universidade Federal de Lavras, Lavras, Brazil
| | - David A Story
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Harry B Rossiter
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Richard M Effros
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
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9
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Rubin DM. Last Word on Viewpoint: Stewart's approach to quantitative acid-base physiology should replace traditional bicarbonate-centered models. J Appl Physiol (1985) 2021; 130:2024. [PMID: 34142907 DOI: 10.1152/japplphysiol.00360.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- David M Rubin
- Biomedical Engineering Research Group, University of the Witwatersrand, Johannesburg, South Africa
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10
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Cove M, Kellum JA. The End of the Bicarbonate Era? A Therapeutic Application of the Stewart Approach. Am J Respir Crit Care Med 2020; 201:757-758. [PMID: 31658424 PMCID: PMC7124708 DOI: 10.1164/rccm.201910-2003ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Matthew Cove
- Department of MedicineNational University Health SystemSingapore, Singaporeand
| | - John A Kellum
- Department of Critical Care MedicineUniversity of PittsburghPittsburgh, Pennsylvania
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11
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A Proof of Concept Study, Demonstrating Extracorporeal Carbon Dioxide Removal Using Hemodialysis with a Low Bicarbonate Dialysate. ASAIO J 2020; 65:605-613. [PMID: 30281542 DOI: 10.1097/mat.0000000000000879] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) devices remove CO2 directly from blood, facilitating ultraprotective ventilation or even providing an alternative to mechanical ventilation. However, ECCO2R is not widely available, whereas dialysis is available in most intensive care units (ICUs). Prior attempts to provide ECCO2R with dialysis, by removing CO2 in the form of bicarbonate, have been plagued by metabolic acidosis. We hypothesized that bicarbonate dialysis is feasible, provided the plasma strong ion difference is maintained. We used a mathematical model to investigate the effects of bicarbonate removal on pH and CO2 in plasma, and performed in-vitro experiments to test CO2 removal using three dialysates with different bicarbonate concentrations (0, 16, and 32 mmol·L). Our modeling predicted a reduction in partial pressures of CO2 (PCO2) and increased pH with progressive lowering of plasma bicarbonate, provided strong ion difference and plasma proteins (Atot) were maintained. In our in-vitro experiments, total CO2 removal, scaled up to an adult size filter, was highest with our dialysate containing no bicarbonate, where we removed the equivalent of 94 ml·min (±3.0) of CO2. Under the same conditions, our dialysate containing a conventional bicarbonate concentration (32 mmol·L) only removed 5 ml·min (±4; p < 0.001). As predicted, pH increased following bicarbonate removal. Our data show that dialysis using low bicarbonate dialysates is feasible and results in a reduction in plasma PCO2. When scaled up, to estimate equivalent CO2 removal with an adult dialysis circuit, the amount removed competes with existing low-flow ECCO2R devices.
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Abstract
Physicochemical models have played an important role in understanding, diagnosing, and treating acid-base disorders for more than 100 years. This review focuses on recent complex models, solved using computers, and shows how these models provide new understanding and diagnostic approaches in acid-base disorders. These advanced models use the following physicochemical principles: (1) chemical equilibrium, (2) conservation of mass, (3) electroneutrality, and (4) osmotic equilibrium to describe the steady-state distribution of H2O and ions in the four major body-fluid spaces, cells, interstitium, plasma, and erythrocytes, and show how this distribution is changed by fluid infusions and losses through renal and gastrointestinal physiological processes. Illustrations of model use with a new comprehensive diagnostic approach are the understanding of an important clinical situation, saline acidosis, and the diagnosis of a patient with diabetic ketoacidosis. This new approach predicts a patient's whole-body base excess and partitions this value into 10 individual values, producing the disorder. These data and other data produced by the diagnostic model described in this review provide much more extensive insight than previous approaches.
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Affiliation(s)
- Matthew B Wolf
- Department of Pharmacology, Physiology and Neuroscience, University of South Carolina, Columbia, SC.
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13
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Colombo R, Wu MA, Castelli A, Fossali T, Rech R, Ottolina D, Cogliati C, Catena E. The effects of severe hemoconcentration on acid-base equilibrium in critically ill patients: the forgotten role of buffers in whole blood. J Crit Care 2020; 57:177-184. [PMID: 32171088 DOI: 10.1016/j.jcrc.2020.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/09/2020] [Accepted: 02/25/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE Idiopathic Systemic Capillary Leak Syndrome (ISCLS) is a paroxysmal permeability disorder characterized by abrupt onset of shock and hemoconcentration due to massive shift of fluids and proteins from the intravascular to the interstitial compartment. We hypothesize that increased hemoglobin concentration has a pivotal role in the acid-base imbalance during life-threatening crises. MATERIALS AND METHODS Analysis of the acid-base balance fluctuations during six severe ISCLS flares admitted to ICU of a referral center for ISCLS. RESULTS Acid-base equilibrium was assessed for plasma and the whole blood by single and multicompartmental models. The acute phase of ISCLS was characterized by shock, hypoalbuminemia, severe hemoconcentration, and acidosis. The physical-chemical approach for plasma found a remarkable component of unmeasured anions (SIG) during the acute phase. After correction of the physical-chemical model for the whole blood, the SIG variations disappeared because the buffer role of hemoglobin was relevant. CONCLUSION Hemoglobin has a remarkable role in buffering metabolic acidosis during the shock phase of ISCLS. In these circumstances, the assessment of acid-base equilibrium in plasma alone may overestimate unmeasured anions. On the contrary, the physical-chemical model corrected for whole blood better explains the metabolic component of acid-base imbalance when marked shift of hemoglobin concentration occurs.
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Affiliation(s)
- Riccardo Colombo
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy.
| | - Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Antonio Castelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Tommaso Fossali
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Roberto Rech
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Davide Ottolina
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Chiara Cogliati
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Emanuele Catena
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
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14
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Changes in the SID Actual and SID Effective Values in the Course of Respiratory Acidosis in Horses With Symptomatic Severe Equine Asthma-An Experimental Study. J Equine Vet Sci 2019; 78:107-111. [PMID: 31203972 DOI: 10.1016/j.jevs.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 04/20/2019] [Accepted: 05/01/2019] [Indexed: 11/20/2022]
Abstract
Equine asthma syndrome is an allergic, inflammatory airway disease that usually affects older horses. Respiratory acidosis is an acid-base imbalance caused by alveolar hypoventilation. The acid-base balance may be assessed using the Henderson-Hasselbalch equation as well as the Stewart model. The authors hypothesized that systemic respiratory acidosis changes the ionic concentrations affecting water dissociation. The study group included 16 Warmblood, mixed breed horses of both sexes with a history of severe equine asthma, and 10 healthy horses were used as controls. Arterial and venous blood were collected from all the horses. The pH, pO2, and pCO2 and HCO3- were assessed in the arterial blood. Na, K, Cl, albumin, and Pinorganic (Pi) were assessed in the venous blood. The obtained results were used to calculate the anion gap (AG), modified AG, actual strong ion difference (SIDa), weak non-volatile acids, and effective strong ion difference (SIDe) values for all the horses. A systemic, compensatory respiratory acidosis was diagnosed in the study group. The concentration of Na in the blood serum in the study group was significantly higher, whereas the concentration of Cl was significantly lower than the values in the control group. The SIDa and SIDe values calculated in the horses from the study group were significantly higher than those in the control group. Significantly higher SIDa and SIDe values confirm the presence of ionic changes that affect water dissociation in the course of respiratory acidosis in horses. The SIDa and SIDe values may be useful in the diagnosis and treatment of respiratory acidosis in horses, which warrant further investigation.
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Olivier PY, Beloncle F, Seegers V, Tabka M, Renou de La Bourdonnaye M, Mercat A, Cales P, Henrion D, Radermacher P, Piquilloud L, Lerolle N, Asfar P. Assessment of renal hemodynamic toxicity of fluid challenge with 0.9% NaCl compared to balanced crystalloid (PlasmaLyte ®) in a rat model with severe sepsis. Ann Intensive Care 2017; 7:66. [PMID: 28616838 PMCID: PMC5471284 DOI: 10.1186/s13613-017-0286-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 06/01/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND According to international guidelines, volume expansion with crystalloids is the first-line treatment for hemodynamic management in patients with severe sepsis or septic shock. Compared to balanced crystalloids, 0.9% sodium chloride (0.9% NaCl) induces hyperchloremia and metabolic acidosis and may alter renal hemodynamics and function. We compared the effects of 0.9% NaCl to a less chloride-concentrated fluid, PlasmaLyte® (PL) in targeted fluid resuscitation in a randomized, double-blind controlled study in an experimental model of severe sepsis in rats. RESULTS A sepsis with hypotension was induced by cecal ligature and puncture (CLP) in 40 male Wistar rats (20 for each crystalloid). Rats received fluid resuscitation over a period of 200 min for a targeted mean arterial pressure of 90 mm Hg. Animals received similar volumes of 0.9% NaCl or PL. Unlike PL-resuscitated rats, 0.9% NaCl-resuscitated rats experienced hyperchloremia and metabolic acidosis, whereas systemic hemodynamics, renal hemodynamics and renal function were not significantly different between both groups. CONCLUSION In our model of rats with severe sepsis resuscitated with large amounts of crystalloids, 0.9% NaCl-induced hyperchloremic acidosis, but balanced crystalloid did not improve systemic and renal hemodynamics or renal function.
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Affiliation(s)
- Pierre-Yves Olivier
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,Medical Intensive Care Department, University Hospital, Angers, France.,BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France
| | - François Beloncle
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,Medical Intensive Care Department, University Hospital, Angers, France.,BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France
| | - Valérie Seegers
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,Statistical Department, University Hospital, Angers, France
| | - Maher Tabka
- BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France.,Faculté de médecine d'Angers, 4 rue haute de reculée, 49000, Angers, France
| | - Mathilde Renou de La Bourdonnaye
- BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France.,Faculté de médecine d'Angers, 4 rue haute de reculée, 49000, Angers, France
| | - Alain Mercat
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,Medical Intensive Care Department, University Hospital, Angers, France
| | - Paul Cales
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,HIFIH, UPRE-EA 3859, SFR 4208, LUNAM University, Angers, France
| | - Daniel Henrion
- BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France.,Faculté de médecine d'Angers, 4 rue haute de reculée, 49000, Angers, France
| | - Peter Radermacher
- Universitätsklinikum, Ulm Helmholtzstr. 8/1, 89081, Ulm, Germany.,Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | - Lise Piquilloud
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,Medical Intensive Care Department, University Hospital, Angers, France
| | - Nicolas Lerolle
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France.,Medical Intensive Care Department, University Hospital, Angers, France.,BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France
| | - Pierre Asfar
- CHU d'Angers, 4 rue Larrey, 49000, Angers, France. .,Medical Intensive Care Department, University Hospital, Angers, France. .,BNMI Laboratory, CNRS UMR 6214-INSERM U1083, Angers University, Angers, France.
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16
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May AG, Sen A, Cove ME, Kellum JA, Federspiel WJ. Extracorporeal CO 2 removal by hemodialysis: in vitro model and feasibility. Intensive Care Med Exp 2017; 5:20. [PMID: 28390055 PMCID: PMC5383917 DOI: 10.1186/s40635-017-0132-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/30/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Critically ill patients with acute respiratory distress syndrome and acute exacerbations of chronic obstructive pulmonary disease often develop hypercapnia and require mechanical ventilation. Extracorporeal carbon dioxide removal can manage hypercarbia by removing carbon dioxide directly from the bloodstream. Respiratory hemodialysis uses traditional hemodialysis to remove CO2 from the blood, mainly as bicarbonate. In this study, Stewart's approach to acid-base chemistry was used to create a dialysate that would maintain blood pH while removing CO2 as well as determine the blood and dialysate flow rates necessary to remove clinically relevant CO2 volumes. METHODS Bench studies were performed using a scaled down respiratory hemodialyzer in bovine or porcine blood. The scaling factor for the bench top experiments was 22.5. In vitro dialysate flow rates ranged from 2.2 to 24 mL/min (49.5-540 mL/min scaled up) and blood flow rates were set at 11 and 18.7 mL/min (248-421 mL/min scaled up). Blood inlet CO2 concentrations were set at 50 and 100 mmHg. RESULTS Results are reported as scaled up values. The CO2 removal rate was highest at intermittent hemodialysis blood and dialysate flow rates. At an inlet pCO2 of 50 mmHg, the CO2 removal rate increased from 62.6 ± 4.8 to 77.7 ± 3 mL/min when the blood flow rate increased from 248 to 421 mL/min. At an inlet pCO2 of 100 mmHg, the device was able to remove up to 117.8 ± 3.8 mL/min of CO2. None of the test conditions caused the blood pH to decrease, and increases were ≤0.08. CONCLUSIONS When the bench top data is scaled up, the system removes a therapeutic amount of CO2 standard intermittent hemodialysis flow rates. The zero bicarbonate dialysate did not cause acidosis in the post-dialyzer blood. These results demonstrate that, with further development, respiratory hemodialysis can be a minimally invasive extracorporeal carbon dioxide removal treatment option.
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Affiliation(s)
- Alexandra G May
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ayan Sen
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA.,Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Matthew E Cove
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University of Singapore, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - John A Kellum
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - William J Federspiel
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA. .,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA. .,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
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17
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Teloh JK, Dohle DS, Sönmez S, Tsagakis K, Verhaegh R, Petersen M, Jakob H, de Groot H. Transient dilutional acidosis but no lactic acidosis upon cardiopulmonary bypass in patients undergoing coronary artery bypass grafting. Arch Med Sci 2017; 13:585-590. [PMID: 28507572 PMCID: PMC5420618 DOI: 10.5114/aoms.2016.58144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/19/2015] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Dilutional acidosis may result from the introduction of a large fluid volume into the patients' systemic circulation, resulting in a considerable dilution of endogenous bicarbonate in the presence of a constant carbon dioxide partial pressure. Its significance or even existence, however, has been strongly questioned. Blood gas samples of patients operated on with standard cardiopulmonary bypass (CPB) were analyzed in order to provide further evidence for the existence of dilutional acidosis. MATERIAL AND METHODS Between 07/2014 and 10/2014, a total of 25 consecutive patients scheduled for elective isolated coronary artery bypass grafting with CPB were enrolled in this prospective observational study. Blood gas samples taken regularly after CPB initiation were analyzed for dilutional effects and acid-base changes. RESULTS After CPB initiation, hemoglobin concentration dropped from an average initial value of 12.8 g/dl to 8.8 g/dl. Before the beginning of CPB, the mean value of the patients' pH and base excess (BE) value averaged 7.41 and 0.5 mEq/l, respectively. After the onset of CPB, pH and BE values significantly dropped to a mean value of 7.33 (p < 0.0001) and -3.3 mEq/l (p < 0.0001), respectively, within the first 20 min. In the following period during CPB they recovered to 7.38 and -0.5 mEq/l, respectively, on average. Patients did not show overt lactic acidosis. CONCLUSIONS The present data underline the general existence of dilutional acidosis, albeit very limited in its duration. In patients undergoing coronary artery bypass grafting it seems to be the only obvious disturbance in acid-base homeostasis during CPB.
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Affiliation(s)
- Johanna Katharina Teloh
- Institute of Physiological Chemistry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Daniel-Sebastian Dohle
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Serhat Sönmez
- Institute of Physiological Chemistry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Rabea Verhaegh
- Institute of Physiological Chemistry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Miriam Petersen
- Überörtliche Berufsausübungsgemeinschaft MVZ Dr. Eberhard und Partner, Dortmund, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Herbert de Groot
- Institute of Physiological Chemistry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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18
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Abstract
The topic of intravenous (IV) fluids may be regarded as “reverse nephrology”, because nephrologists usually treat to remove fluids rather than to infuse them. However, because nephrology is deeply rooted in fluid, electrolyte, and acid-base balance, IV fluids belong in the realm of our specialty. The field of IV fluid therapy is in motion due to the increasing use of balanced crystalloids, partly fueled by the advent of new solutions. This review aims to capture these recent developments by critically evaluating the current evidence base. It will review both indications and complications of IV fluid therapy, including the characteristics of the currently available solutions. It will also cover the use of IV fluids in specific settings such as kidney transplantation and pediatrics. Finally, this review will address the pathogenesis of saline-induced hyperchloremic acidosis, its potential effect on outcomes, and the question if this should lead to a definitive switch to balanced solutions.
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Affiliation(s)
- Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus Medical Center, Room D-438, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
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19
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Mioni R, Marega A, Lo Cicero M, Montanaro D. Old and new approaches to the interpretation of acid-base metabolism, starting from historical data applied to diabetic acidosis. Scand J Clin Lab Invest 2016; 76:520-543. [PMID: 27410514 DOI: 10.1080/00365513.2016.1204660] [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: 01/18/2016] [Accepted: 06/19/2016] [Indexed: 06/06/2023]
Abstract
The approach to acid-base chemistry in medicine includes several methods. Currently, the two most popular procedures are derived from Stewart's studies and from the bicarbonate/BE-based classical formulation. Another method, unfortunately little known, follows the Kildeberg theory applied to acid-base titration. By using the data produced by Dana Atchley in 1933, regarding electrolytes and blood gas analysis applied to diabetes, we compared the three aforementioned methods, in order to highlight their strengths and their weaknesses. The results obtained, by reprocessing the data of Atchley, have shown that Kildeberg's approach, unlike the other two methods, is consistent, rational and complete for describing the organ-physiological behavior of the hydrogen ion turnover in human organism. In contrast, the data obtained using the Stewart approach and the bicarbonate-based classical formulation are misleading and fail to specify which organs or systems are involved in causing or maintaining the diabetic acidosis. Stewart's approach, despite being considered 'quantitative', does not propose in any way the concept of 'an amount of acid' and becomes even more confusing, because it is not clear how to distinguish between 'strong' and 'weak' ions. As for Stewart's approach, the classical method makes no distinction between hydrogen ions managed by the intermediate metabolism and hydroxyl ions handled by the kidney, but, at least, it is based on the concept of titration (base-excess) and indirectly defines the concept of 'an amount of acid'. In conclusion, only Kildeberg's approach offers a complete understanding of the causes and remedies against any type of acid-base disturbance.
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Affiliation(s)
- Roberto Mioni
- a Division of Nephrology , Civil and University Hospital , Santa Maria Della Misericordia , Udine , Italy
| | - Alessandra Marega
- a Division of Nephrology , Civil and University Hospital , Santa Maria Della Misericordia , Udine , Italy
| | - Marco Lo Cicero
- a Division of Nephrology , Civil and University Hospital , Santa Maria Della Misericordia , Udine , Italy
| | - Domenico Montanaro
- a Division of Nephrology , Civil and University Hospital , Santa Maria Della Misericordia , Udine , Italy
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20
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Abstract
OBJECTIVES Hyperchloremia is frequently observed in critically ill patients in the ICU. Our study aimed to examine the association of serum chloride (Cl) levels with hospital mortality in septic ICU patients. DESIGN Retrospective cohort study. SETTING Urban academic medical center ICU. PATIENTS ICU adult patients with severe sepsis or septic shock who had Cl measured on ICU admission were included. Those with baseline estimated glomerular filtration rate less than 15 mL/min/1.73 m or chronic dialysis were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,940 patients included in the study, 615 patients (31.7%) had hyperchloremia (Cl ≥ 110 mEq/L) on ICU admission. All-cause hospital mortality was the dependent variable. Cl on ICU admission (Cl0), Cl at 72 hours (Cl72), and delta Cl (ΔCl = Cl72 - Cl0) were the independent variables. Those with Cl0 greater than or equal to 110 mEq/L were older and had higher cumulative fluid balance, base deficit, and Sequential Organ Failure Assessment scores. Multivariate analysis showed that higher Cl72 but not Cl0 was independently associated with hospital mortality in the subgroup of patients with hyperchloremia on ICU admission (adjusted odds ratio for Cl72 per 5 mEq/L increase = 1.27; 95% CI, 1.02-1.59; p = 0.03). For those who were hyperchloremic on ICU admission, every within-subject 5 mEq/L increment in Cl72 was independently associated with hospital mortality (adjusted odds ratio for ΔCl 5 mEq/L = 1.37; 95% CI, 1.11-1.69; p = 0.003). CONCLUSIONS In critically ill septic patients manifesting hyperchloremia (Cl ≥ 110 mEq/L) on ICU admission, higher Cl levels and within-subject worsening hyperchloremia at 72 hours of ICU stay were associated with all-cause hospital mortality. These associations were independent of base deficit, cumulative fluid balance, acute kidney injury, and other critical illness parameters.
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21
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Havlin J, Schück O, Charvat J, Slaby K, Horackova M, Klaboch J, Sagova M, Vankova S, Matousovic K. Acid-base disorders associated with serum electrolyte patterns in patients on hemodiafiltration. Nephrol Ther 2015; 11:551-7. [PMID: 26475666 DOI: 10.1016/j.nephro.2015.04.008] [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] [Received: 03/03/2015] [Revised: 04/10/2015] [Accepted: 04/29/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Metabolic acidosis (MAC) is a common aspect of dialysis-dependent patients. It is definitely caused by acid retention; however, the influence of other plasma ions is unclear. Understanding the mechanism of MAC and its correction is important when choosing the dialysis solution. Therefore, we assessed the relationship between intradialytic change of acid-base status and serum electrolytes. METHODS We studied 68 patients on post-dilution hemodiafiltration, using dialysate bicarbonate concentration 32mmol/L. The acid-base disorders were evaluated by the traditional Siggaard-Anderson and modern Stewart approaches. RESULTS The mean pre-dialysis pH was 7.38, standard base excess (SBE) -1.5, undetermined anions (UA(-)) 7.5, sodium-chloride difference (Diff(NaCl)) 36.2mmol/L. MAC was present in 34% of patients, of which 83% had an increased UA(-) as a major cause of MAC. The mean nPCR was 0.99g/kg/day and correlated negatively with SBE. After dialysis, metabolic alkalosis predominated in 81%. The mean post-dialysis pH was 7.45, SBE 4, UA(-) 2.6, Diff(NaCl) 36.9mmol/L. ΔSBE significantly correlated with ΔUA(-), but not with ΔDiff(NaCl) or ΔCl(-). CONCLUSIONS MAC in patients on hemodiafiltration is mainly caused by acid retention and is associated with higher protein intake. We did not prove the effect of sodium or chloride on acid-base balance. Even though we used a relatively low concentration of dialysate bicarbonate, we recorded a high proportion of post-dialysis alkalosis caused by the excessive decrease of undetermined anions, which had been completely replaced by bicarbonate and indicated the elimination of undesirable anions, as well as of normal endogenous anions.
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Affiliation(s)
- Jan Havlin
- Department of medicine, 2nd Medical Faculty of Charles University and Faculty hospital Motol, V Úvalu 84, 150 06, Prague 5, Czech Republic; B. Braun Avitum Praha Nusle Dialysis Center, Táborská 325/57, 140 00, Prague 4, Czech Republic.
| | - Otto Schück
- Department of medicine, 2nd Medical Faculty of Charles University and Faculty hospital Motol, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Charvat
- Department of medicine, 2nd Medical Faculty of Charles University and Faculty hospital Motol, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Krystof Slaby
- Department of rehabilitation and sports medicine, 2nd Medical Faculty of Charles University and Faculty hospital Motol, Prague, Czech Republic
| | - Miroslava Horackova
- Department of medicine, 2nd Medical Faculty of Charles University and Faculty hospital Motol, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Jan Klaboch
- Department of medicine I, Charles University Medical school and teaching hospital, Pilsen, Czech Republic
| | - Michaela Sagova
- Fresenius medical care DS, Dialysis centre Motol, Prague, Czech Republic
| | - Svetlana Vankova
- B. Braun Avitum Praha Nusle Dialysis Center, Táborská 325/57, 140 00, Prague 4, Czech Republic
| | - Karel Matousovic
- Department of medicine, 2nd Medical Faculty of Charles University and Faculty hospital Motol, V Úvalu 84, 150 06, Prague 5, Czech Republic
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22
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Olivier PY, Beloncle F, Asfar P. Recommandations hémodynamiques de la Surviving Sepsis Campaign : où en sommes-nous aujourd’hui ? MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1036-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Masevicius FD, Dubin A. Has Stewart approach improved our ability to diagnose acid-base disorders in critically ill patients? World J Crit Care Med 2015; 4:62-70. [PMID: 25685724 PMCID: PMC4326765 DOI: 10.5492/wjccm.v4.i1.62] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/29/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
Abstract
The Stewart approach-the application of basic physical-chemical principles of aqueous solutions to blood-is an appealing method for analyzing acid-base disorders. These principles mainly dictate that pH is determined by three independent variables, which change primarily and independently of one other. In blood plasma in vivo these variables are: (1) the PCO2; (2) the strong ion difference (SID)-the difference between the sums of all the strong (i.e., fully dissociated, chemically nonreacting) cations and all the strong anions; and (3) the nonvolatile weak acids (Atot). Accordingly, the pH and the bicarbonate levels (dependent variables) are only altered when one or more of the independent variables change. Moreover, the source of H+ is the dissociation of water to maintain electroneutrality when the independent variables are modified. The basic principles of the Stewart approach in blood, however, have been challenged in different ways. First, the presumed independent variables are actually interdependent as occurs in situations such as: (1) the Hamburger effect (a chloride shift when CO2 is added to venous blood from the tissues); (2) the loss of Donnan equilibrium (a chloride shift from the interstitium to the intravascular compartment to balance the decrease of Atot secondary to capillary leak; and (3) the compensatory response to a primary disturbance in either independent variable. Second, the concept of water dissociation in response to changes in SID is controversial and lacks experimental evidence. In addition, the Stewart approach is not better than the conventional method for understanding acid-base disorders such as hyperchloremic metabolic acidosis secondary to a chloride-rich-fluid load. Finally, several attempts were performed to demonstrate the clinical superiority of the Stewart approach. These studies, however, have severe methodological drawbacks. In contrast, the largest study on this issue indicated the interchangeability of the Stewart and conventional methods. Although the introduction of the Stewart approach was a new insight into acid-base physiology, the method has not significantly improved our ability to understand, diagnose, and treat acid-base alterations in critically ill patients.
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25
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Lindner G, Doberer D, Schwarz C, Schneeweiss B, Funk GC. Evaporation of free water causes concentrational alkalosis in vitro. Wien Klin Wochenschr 2013; 126:201-7. [PMID: 24343045 DOI: 10.1007/s00508-013-0486-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/01/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The development of metabolic alkalosis was described recently in patients with hypernatremia. However, the causes for this remain unknown. The current study serves to clarify whether metabolic alkalosis develops in vitro after removal of free water from plasma and whether this can be predicted by a mathematical model. MATERIALS AND METHODS Ten serum samples of healthy humans were dehydrated by 29 % by vacuum centrifugation corresponding to an increase of the contained concentrations by 41 %. Constant partial pressure of carbon dioxide at 40 mmHg was simulated by mathematical correction of pH [pH(40)]. Metabolic acid-base state was assessed by Gilfix' base excess subsets. Changes of acid-base state were predicted by the physical-chemical model according to Watson. RESULTS Evaporation increased serum sodium from 141 (140-142) to 200 (197-203) mmol/L, i.e., severe hypernatremia developed. Acid-base analyses before and after serum concentration showed metabolic alkalosis with alkalemia: pH(40): 7.43 (7.41 to 7.45) vs 7.53 (7.51 to 7.55), p = 0.0051; base excess: 1.9 (0.7 to 3.6) vs 10.0 (8.2 to 11.8), p = 0.0051; base excess of free water: 0.0 (- 0.2 to 0.3) vs 17.7 (16.8 to 18.6), p = 0.0051. The acidifying effects of evaporation, including hyperalbuminemic acidosis, were beneath the alkalinizing ones. Measured and predicted acid-base changes due to serum evaporation agreed well. CONCLUSIONS Evaporation of water from serum causes concentrational alkalosis in vitro, with good agreement between measured and predicted acid-base values. At least part of the metabolic alkalosis accompanying hypernatremia is independent of renal function.
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Affiliation(s)
- Gregor Lindner
- Department of Internal Medicine, Inselspital,University Hospital Bern, Bern, Switzerland
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26
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Abstract
This paper describes the interactions between ventilation and acid-base balance under a variety of conditions including rest, exercise, altitude, pregnancy, and various muscle, respiratory, cardiac, and renal pathologies. We introduce the physicochemical approach to assessing acid-base status and demonstrate how this approach can be used to quantify the origins of acid-base disorders using examples from the literature. The relationships between chemoreceptor and metaboreceptor control of ventilation and acid-base balance summarized here for adults, youth, and in various pathological conditions. There is a dynamic interplay between disturbances in acid-base balance, that is, exercise, that affect ventilation as well as imposed or pathological disturbances of ventilation that affect acid-base balance. Interactions between ventilation and acid-base balance are highlighted for moderate- to high-intensity exercise, altitude, induced acidosis and alkalosis, pregnancy, obesity, and some pathological conditions. In many situations, complete acid-base data are lacking, indicating a need for further research aimed at elucidating mechanistic bases for relationships between alterations in acid-base state and the ventilatory responses.
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Affiliation(s)
- Michael I Lindinger
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada.
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27
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Acid-base changes after fluid bolus: sodium chloride vs. sodium octanoate. Intensive Care Med Exp 2013; 1:23. [PMID: 26266792 PMCID: PMC4797930 DOI: 10.1186/2197-425x-1-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/10/2013] [Indexed: 02/06/2023] Open
Abstract
Objectives This study aims to test the hypothesis that fluid loading with sodium chloride (150 mmol Na and 150 mmol Cl) or sodium octanoate (150 mmol Na, 100 mmol Cl, and 50 mmol octanoate) would lead to different acid–base changes. Design We performed a double-blind crossover experimental study. Setting The study was done at a University Physiology Laboratory. Subjects Eight Merino ewes were used as subjects. Measurements and main results We randomly assigned animals to a rapid intravenous infusion (1 L over 30 min) of either normal saline (NS) or sodium octanoate solution (OS). We collected blood samples at 0.5, 1, 2, 4, and 6 h after the start of the infusion for blood gas analyses and biochemistry. We calculated strong ion difference apparent (SIDa), effective strong ion difference, and strong ion gap (SIG). Animals in the NS group developed metabolic acidification immediately after fluid administration (pH 7.49 to 7.42, base excess 3.0 to -1.6 mEq/L), while the OS group did not (pH 7.47 to 7.51, base excess 1.1 to 1.4 mEq/L; P < 0.001). Additionally, the OS group had higher SIDa (36.2 vs. 33.2 mEq/L) and SIG (7.4 vs. 6.2 mEq/L) at the end of the infusion. Conclusions Our findings provide further evidence that acidification induced by intravenous fluid loading is dependent on fluid composition and challenges the paradigm of the so-called dilutional acidosis. Electronic supplementary material The online version of this article (doi:10.1186/2197-425X-1-4) contains supplementary material, which is available to authorized users.
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28
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Wolf MB. Whole body acid-base and fluid-electrolyte balance: a mathematical model. Am J Physiol Renal Physiol 2013; 305:F1118-31. [PMID: 23884137 DOI: 10.1152/ajprenal.00195.2013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A cellular compartment was added to our previous mathematical model of steady-state acid-base and fluid-electrolyte chemistry to gain further understanding and aid diagnosis of complex disorders involving cellular involvement in critically ill patients. An important hypothesis to be validated was that the thermodynamic, standard free-energy of cellular H(+) and Na(+) pumps remained constant under all conditions. In addition, a hydrostatic-osmotic pressure balance was assumed to describe fluid exchange between plasma and interstitial fluid, including incorporation of compliance curves of vascular and interstitial spaces. The description of the cellular compartment was validated by close comparison of measured and model-predicted cellular pH and electrolyte changes in vitro and in vivo. The new description of plasma-interstitial fluid exchange was validated using measured changes in fluid volumes after isoosmotic and hyperosmotic fluid infusions of NaCl and NaHCO3. The validated model was used to explain the role of cells in the mechanism of saline or dilutional acidosis and acid-base effects of acidic or basic fluid infusions and the acid-base disorder due to potassium depletion. A module was created that would allow users, who do not possess the software, to determine, for free, the results of fluid infusions and urinary losses of water and solutes to the whole body.
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Abstract
Commercial 0.9% saline solution for infusion has a pH around 5.5. There are many reasons for this acidity, some of them still obscure. It is also true that infusion of normal saline can lead to metabolic acidaemia, yet the link between the acidity of saline solution and the acidaemia it can engender is not straightforward. This commentary draws together the known and putative sources of acidity in saline solutions: it turns out that the acidity of saline solution is essentially unrelated to the acidaemia complicating saline infusion.
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Affiliation(s)
- Benjamin A J Reddi
- Intensive Care Unit, Royal Adelaide Hospital; Clinical Senior Lecturer, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
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Park CM, Chun HK, Jeon K, Suh GY, Choi DW, Kim S. Factors related to post-operative metabolic acidosis following major abdominal surgery. ANZ J Surg 2012; 84:574-80. [PMID: 22985420 DOI: 10.1111/j.1445-2197.2012.06235.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Metabolic acidosis is frequently observed in perioperative patients, especially those who undergo major surgery. The aim of this study was to evaluate the factors related to post-operative metabolic acidosis and to attempt to identify the clinical effect of metabolic acidosis following major abdominal surgery. METHODS We included 172 patients admitted to a surgical intensive care unit (ICU) following major abdominal surgery. All cases were divided into either the acidosis or the normal group using immediate post-operative standard base excess (SBE). The following clinical data were retrospectively obtained from the chart and ICU database: basic clinical characteristics, operative data, type and volume of fluid infused during the operation, post-operative arterial blood gas analysis, lactate, and central venous oxygen saturation. RESULTS The predominant intraoperative fluid was either 0.9% saline or lactated Ringer's solution. The operation length, estimated blood loss, total fluid infused, total saline infused, lactate and corrected chloride were significantly higher in the acidosis group; however, central venous oxygen saturation was lower in the normal group. Among these factors, total infused saline and lactate level were independent factors related to metabolic acidosis. The comparison between the types of fluid revealed that the saline group had a significantly lower SBE, strong ion difference and higher corrected chloride. SBE was significantly correlated with lactate and total infused saline. ICU and hospital length of stay were significantly longer in the acidosis group. CONCLUSIONS Post-operative metabolic acidosis following major abdominal surgery was closely related to both hyperchloremic acidosis associated with large saline infusion and lactic acidosis caused by lactataemia.
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Affiliation(s)
- Chi-Min Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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In vivo conditioning of acid–base equilibrium by crystalloid solutions: an experimental study on pigs. Intensive Care Med 2012; 38:686-93. [DOI: 10.1007/s00134-011-2455-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
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Partitioning standard base excess: a new approach. J Clin Monit Comput 2011; 25:349-52. [DOI: 10.1007/s10877-011-9324-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 11/09/2011] [Indexed: 10/15/2022]
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Dennhardt N, Schoof S, Osthaus WA, Witt L, Bertram H, Sümpelmann R. Alterations of acid-base balance, electrolyte concentrations, and osmolality caused by nonionic hyperosmolar contrast medium during pediatric cardiac catheterization. Paediatr Anaesth 2011; 21:1119-23. [PMID: 21966960 DOI: 10.1111/j.1460-9592.2011.03706.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This prospective clinical observational study was conducted to investigate the effects of contrast medium on acid-base balance, electrolyte concentrations, and osmolality in children. BACKGROUND For pediatric cardiac catheterization, high doses of nonionic hyperosmolar contrast medium are widely used. METHODS Forty pediatric patients (age 0-16 years) undergoing cardiac angiography with more than 3 ml·kg(-1) of nonionic hyperosmolar contrast medium (Iomeprol) were enrolled, and the total amount of the contrast agent given was documented. Before and after contrast medium administration, a blood sample was collected to analyze electrolytes, acid-base parameters, osmolality, hemoglobin, and hematocrit. RESULTS After cardiac catheterization, pH, hemoglobin, hematocrit, bicarbonate, base excess, sodium, chloride, calcium, anion gap and strong ion difference decreased, whereas osmolality increased significantly (base excess -1.8 ± 1.8 vs -3.4 ± 2.3, sodium 138 ± 2.9 vs 132 ± 4.1 mm, osmolality 284 ± 5.7 vs 294 ± 7.6 mosmol·kg(-1), P < 0.01). Seventy-eight percent of the children developed hyponatremia (sodium <135 mm). No changes were seen in pCO(2) , lactate, and potassium levels. CONCLUSIONS Regarding the differential diagnosis of metabolic disturbances after pediatric cardiac catheterization, low-anion gap metabolic acidosis and hyponatremia should be considered as a possible side effect of the administered contrast medium.
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Affiliation(s)
- Nils Dennhardt
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany.
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Kofranek J, Matousek S, Rusz J, Stodulka P, Privitzer P, Matejak M, Tribula M. The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2011; 104:143-153. [PMID: 21232813 DOI: 10.1016/j.cmpb.2010.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 09/30/2010] [Accepted: 12/09/2010] [Indexed: 05/30/2023]
Abstract
The paper is a presentation of the current state of development for the Atlas of Physiology and Pathophysiology (Atlas). Our main aim is to provide a novel interactive multimedia application that can be used for biomedical education where (a) simulations are combined with tutorials and (b) the presentation layer is simplified while the underlying complexity of the model is retained. The development of the Atlas required the cooperation of many professionals including teachers, system analysts, artists, and programmers. During the design of the Atlas, tools were developed that allow for component-based creation of simulation models, creation of interactive multimedia and their final coordination into a compact unit based on the given design. The Atlas is a freely available online application, which can help to explain the function of individual physiological systems and the causes and symptoms of their disorders.
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Affiliation(s)
- Jiri Kofranek
- Charles University in Prague, First Faculty of Medicine, Department of Pathological Physiology, U nemocnice 5, 128 53 Praha 2, Czech Republic.
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Wolf MB, DeLand EC. A mathematical model of blood-interstitial acid-base balance: application to dilution acidosis and acid-base status. J Appl Physiol (1985) 2011; 110:988-1002. [DOI: 10.1152/japplphysiol.00514.2010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We developed mathematical models that predict equilibrium distribution of water and electrolytes (proteins and simple ions), metabolites, and other species between plasma and erythrocyte fluids (blood) and interstitial fluid. The models use physicochemical principles of electroneutrality in a fluid compartment and osmotic equilibrium between compartments and transmembrane Donnan relationships for mobile species. Across the erythrocyte membrane, the significant mobile species Cl−is assumed to reach electrochemical equilibrium, whereas Na+and K+distributions are away from equilibrium because of the Na+/K+pump, but movement from this steady state is restricted because of their effective short-term impermeability. Across the capillary membrane separating plasma and interstitial fluid, Na+, K+, Ca2+, Mg2+, Cl−, and H+are mobile and establish Donnan equilibrium distribution ratios. In each compartment, attainment of equilibrium by carbonates, phosphates, proteins, and metabolites is determined by their reactions with H+. These relationships produce the recognized exchange of Cl−and bicarbonate across the erythrocyte membrane. The blood submodel was validated by its close predictions of in vitro experimental data, blood pH, pH-dependent ratio of H+, Cl−, and HCO3−concentrations in erythrocytes to that in plasma, and blood hematocrit. The blood-interstitial model was validated against available in vivo laboratory data from humans with respiratory acid-base disorders. Model predictions were used to gain understanding of the important acid-base disorder caused by addition of saline solutions. Blood model results were used as a basis for estimating errors in base excess predictions in blood by the traditional approach of Siggaard-Andersen (acid-base status) and more recent approaches by others using measured blood pH and Pco2values. Blood-interstitial model predictions were also used as a basis for assessing prediction errors of extracellular acid-base status values, such as by the standard base excess approach. Hence, these new models can give considerable insight into the physicochemical mechanisms producing acid-base disorders and aid in their diagnoses.
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Affiliation(s)
- Matthew B. Wolf
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina, Columbia, South Carolina; and
| | - Edward C. DeLand
- Department of Surgery, University of California at Los Angeles, Westwood, California
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The acid-base effects of free water removal from and addition to oxygenated and deoxygenated whole blood: an in vitro model of contraction alkalosis and dilutional acidosis. Transl Res 2011; 157:29-37. [PMID: 21146148 DOI: 10.1016/j.trsl.2010.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 11/22/2022]
Abstract
This study was conducted to describe the acid-base effects of hydration and dehydration of oxygenated and deoxygenated whole blood. Whole blood samples from goats were equilibrated in a tonometer to a partial pressure of carbon dioxide of 40 mm Hg and oxygen (PO₂) of 100 mm Hg or 30 mm Hg. Contraction alkalosis was achieved by evaporating blood samples to 80% of the original volume. Dilutional acidosis was achieved by increasing the blood sample volume by 20% by addition of sterile water. Acid-base, electrolyte, hemoglobin, lactate, albumin, and phosphorus concentrations were measured at baseline and after dehydration or hydration. A 20% dehydration of whole blood caused a 22% increase in sodium concentration and a significant increase in base excess of +3 mEq/L (P < 0.01); bicarbonate concentration increased only 7% to 9%. A concurrent increase was found in phosphorus, albumin, hemoglobin, and lactate concentrations. A 20% dilution of whole blood caused a 21% decrease in sodium concentration and a significant decrease in base excess of -5 mEq/L (P < 0.01) with an 11% to 15% decrease in bicarbonate concentration. A concurrent decrease was found in phosphorus, albumin, and hemoglobin concentrations. No significant difference was observed between the acid-base effects on oxygenated versus deoxygenated blood in any experiment. Dilutional acidosis and contraction alkalosis of whole blood are complex acid-base disorders resulting from direct changes in bicarbonate concentration in combination with changes in the concentration of weak plasma acids and buffering reactions. Therefore, bicarbonate concentration does not change to the same degree as the magnitude of contraction or dilution.
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Guidet B, Soni N, Della Rocca G, Kozek S, Vallet B, Annane D, James M. A balanced view of balanced solutions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:325. [PMID: 21067552 PMCID: PMC3219243 DOI: 10.1186/cc9230] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The present review of fluid therapy studies using balanced solutions versus isotonic saline fluids (both crystalloids and colloids) aims to address recent controversy in this topic. The change to the acid-base equilibrium based on fluid selection is described. Key terms such as dilutional-hyperchloraemic acidosis (correctly used instead of dilutional acidosis or hyperchloraemic metabolic acidosis to account for both the Henderson-Hasselbalch and Stewart equations), isotonic saline and balanced solutions are defined. The review concludes that dilutional-hyperchloraemic acidosis is a side effect, mainly observed after the administration of large volumes of isotonic saline as a crystalloid. Its effect is moderate and relatively transient, and is minimised by limiting crystalloid administration through the use of colloids (in any carrier). Convincing evidence for clinically relevant adverse effects of dilutional-hyperchloraemic acidosis on renal function, coagulation, blood loss, the need for transfusion, gastrointestinal function or mortality cannot be found. In view of the long-term use of isotonic saline either as a crystalloid or as a colloid carrier, the paucity of data documenting detrimental effects of dilutional-hyperchloraemic acidosis and the limited published information on the effects of balanced solutions on outcome, we cannot currently recommend changing fluid therapy to the use of a balanced colloid preparation.
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Affiliation(s)
- Bertrand Guidet
- Inserm, Unité de Recherche en Épidémiologie Systèmes d'Information et Modélisation (U707), Paris F-75012, France.
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Doberer D, Loerting T, Kirchner K, Funk GC. The many faces of “evidence” for dependent and independent variables in the ‘Stewart approach’: reply to Lang. Intensive Care Med 2010. [DOI: 10.1007/s00134-010-1899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Peter Stewart: reconciliation of terminology, calculations, and conclusions? Intensive Care Med 2010; 36:1628-9. [DOI: 10.1007/s00134-010-1930-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2010] [Indexed: 11/26/2022]
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Comment on: “A critique of Stewart’s approach: the chemical mechanism of dilutional acidosis”. Intensive Care Med 2010; 36:1624-5; author reply 1626-7. [DOI: 10.1007/s00134-010-1897-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2010] [Indexed: 10/19/2022]
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The standard strong ion difference, standard total titratable base, and their relationship to the Boston compensation rules and the Van Slyke equation for extracellular fluid. J Clin Monit Comput 2010; 24:177-88. [DOI: 10.1007/s10877-010-9231-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 03/09/2010] [Indexed: 11/27/2022]
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control. Intensive Care Med 2010; 36:196-209. [PMID: 20057995 PMCID: PMC2816797 DOI: 10.1007/s00134-009-1742-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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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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Mixing bicarbonates: dilution acidosis from first principles. Intensive Care Med 2009; 35:2183-4; author reply 2185-6. [PMID: 19774362 DOI: 10.1007/s00134-009-1668-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2009] [Indexed: 10/20/2022]
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The Stewart approach to acid-base analysis: not disqualified yet. Intensive Care Med 2009; 35:2181-2; author reply 2185-6. [PMID: 19774363 DOI: 10.1007/s00134-009-1667-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2009] [Indexed: 10/20/2022]
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