Alcoholic ketoacidosis evaluated with a point-of-care capillary beta-hydroxybutyrate measurement device.

BACKGROUND: The diagnosis of alcoholic ketoacidosis (AKA) has traditionally been made based only on clinical history and the presence of severe metabolic acidosis with a high anion gap (AG); however, the concentration of beta-hydroxybutyrate (BOHB), a pivotal ketone body in AKA, is not evaluated in most cases. The aim of this study was to clarify the clinical spectrum of AKA in terms of the severity of ketoacidosis by using a point-of-care capillary BOHB measurement device. METHODS: This retrospective case series was conducted at a Japanese private teaching hospital. Patients with suspected AKA, based on their clinical history, who underwent BOHB measurement using a point-of-care capillary measurement device in the emergency department, were included. Data on their clinical presentations, blood tests, and treatments were collected, described, and compared between patients with a BOHB concentration higher than 3.0 mmol/L (H-BOHB) and those with a concentration less than 3.0 mmol/L (L-BOHB). RESULTS: A total of 83 patients were included in this study. Sixty-eight patients were categorized as having H-BOHB and 15 as having L-BOHB. Nausea (71%), vomiting (71%), tachycardia (76%), and tachypnea (46%) were commonly observed at presentation. Hyponatremia (46%), hypokalemia (34%), hypomagnesemia (42%), and hyperphosphatemia (41%) were frequent electrolyte abnormalities upon presentation. Rehydration with balanced crystalloids and glucose-containing intravenous fluids, electrolyte supplementation, and thiamine replacement were the major treatments. The mean length of stay in the ICU and hospital were 4.4 and 7.0 days, respectively, with low overall mortality (1%). The H-BOHB and L-BOHB groups did not differ in terms of clinical data. Seventy percent of patients with L-BOHB had severe metabolic acidosis with a high AG due to hyperlactatemia (mean lactate concentration: 8.5 mmol/L). CONCLUSIONS: We described the clinical features of AKA measured by using a point-of-care capillary BOHB measurement device. Although certain patients diagnosed with AKA based only on their clinical history had predominant lactic acidosis with minor elevations in BOHB concentration, the BOHB concentration had no effect on the clinical spectrum of AKA in this study.

Pneumococcal meningitis in a patient with severe COVID-19 on dexamethasone and tocilizumab: A case report.

Although various therapeutic agents have been tried for coronavirus disease-2019 (COVID-19) and evidence has accumulated, the risk of secondary infection is increased by underlying disease and immunosuppressive drugs. We report a case of pneumococcal meningitis in a patient with severe COVID-19 who was receiving dexamethasone and tocilizumab. The patient's symptoms improved with appropriate diagnosis and antimicrobial therapy, and she fortunately returned to society without any neurological sequelae of meningitis.

Intermittent Hemodialysis for Managing Metabolic Acidosis During Resuscitation of Septic Shock: A Descriptive Study.

Septic shock is often complicated by severe metabolic acidosis, for which renal replacement therapy may be considered. However, little is known about the use of intermittent hemodialysis to manage this condition. The aim of this study was to compare physiologic and biochemical variables and vasopressor requirements before and after intermittent hemodialysis among patients who received intermittent hemodialysis to manage metabolic acidosis during resuscitation of septic shock. DESIGN: This retrospective, cross-sectional study was conducted between April 2014 and September 2015. SETTINGS: The ICU of a non-university-affiliated teaching hospital. PATIENTS: Patients who were admitted to the ICU with septic shock and underwent intermittent hemodialysis to manage metabolic acidosis within 48 hours after the diagnosis of septic shock. MEASUREMENTS AND MAIN RESULTS: The main outcomes were mean arterial pressure, minute ventilator volume, norepinephrine requirement, bicarbonate and pH before and after intermittent hemodialysis. Of 1,190 patients screened, 34 were included, and 33 accomplished a planned session of intermittent hemodialysis. After intermittent hemodialysis, an increased mean arterial pressure (+9.0 mm Hg; 95% CI, 6-13; p < 0.001), decreased minute ventilatory volume (-2.0 L/min; 95% CI, -3.3 to 0.8; p = 0.002), decreased norepinephrine requirement (-0.07 µg/kg/min; 95% CI, -0.12 to -0.02; p = 0.009), increased bicarbonate level (+7.2 mmol/L; 95% CI, 6.1-8.3; p < 0.001), and increased pH (+0.17; 95% CI, 0.13-0.21; p < 0.001) were observed in comparison to those before intermittent hemodialysis. CONCLUSIONS: In conclusion, intermittent hemodialysis appeared to be feasible and to stabilize hemodynamic and respiratory conditions in patients with septic shock complicated by metabolic acidosis during resuscitation.