Acidosis metabólica neonatal por síndrome de enterocolitis inducido por proteína de alimentos: reporte de caso / Neonatal metabolic acidosis caused by food proteininduced enterocolitis syndrome: a case report

El síndrome de enterocolitis inducido por proteínas de los alimentos (FPIES, por su sigla en inglés) es una reacción alérgica no mediada por inmunoglobulina E (IgE) con síntomas gastrointestinales, como vómitos y diarrea. El diagnóstico se basa en criterios clínicos y en una prueba de provocación para confirmarlo. Es una enfermedad desconocida en las unidades neonatales, debido a la inespecificidad de los síntomas en los recién nacidos. La cifra de metahemoglobina elevada es una opción sencilla de aproximación diagnóstica. Se describe el caso clínico de un recién nacido que ingresa al servicio de urgencias por deshidratación, letargia, vómitos, diarrea y acidosis metabólica grave con elevación de metahemoglobina, con mejora clínica y recuperación total tras el inicio del aporte de fórmula elemental. La sospecha diagnóstica se confirmó tras la prueba de provocación positiva.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated allergic reaction with gastrointestinal symptoms, such as vomiting and diarrhea. FPIES diagnosis is based on clinical criteria and on a food challenge test. It is an unknown disease in neonatal units due to its nonspecific symptoms in newborn infants. An elevated methemoglobin level is a simple way to approach diagnosis. Here we describe a clinical case of a newborn admitted to the emergency department because of dehydration, lethargy, vomiting, diarrhea, severe metabolic acidosis, and a high methemoglobin level. Clinical improvement and complete recovery was achieved after initiation of elemental formula. The diagnostic suspicion was confirmed after a positive challenge test.

Diagnosing sub-acute rumen acidosis in cows in the post-calving period with digital technologies / [Diagnóstico de acidose ruminal subaguda em vacas no período pós-parto usando tecnologias digitais]

This study aims to determine the relationship between indicators of the motor activity, pH factor, rumen and rectal temperature within 10 days after calving and to analyze the possibility of using the studied parameters as prognostic signs for diagnosing sub-acute rumen acidosis (SARA). The measurements were taken using bolus with sensors designed to monitor cow health. The motor activity, pH factor and ruminal temperature of 10 cows were measured during 10 days at a measurement interval of every 60 seconds. Next, the researchers calculated the average values of the obtained readings, which were divided into 2 groups according to a measurement interval of every 12 hours. Rectal temperature was measured using a veterinary thermometer every 12 hours (at 8 a.m. and at 8 p.m.). As a result, 200 measurements were obtained. Descriptive sampling statistics were calculated using the SPSS Statistics program. An increase in motor activity reduces the pH level of the rumen environment. Lowering the pH factor of the rumen environment leads to an increase in ruminal temperature. There is a positive statistically significant correlation between ruminal and rectal temperature. The nosology of SARA can be predicted by measuring the motor activity and rectal temperature of dairy cows.(AU)

Este estudo visa determinar a relação entre indicadores de atividade motora, fator de pH, temperatura ruminal e retal em até 10 dias após o parto e analisar a possibilidade de utilizar os parâmetros estudados como sinais prognósticos para o diagnóstico de acidose ruminal subaguda (SARA). As medições foram feitas usando bolus com sensores projetados para monitorar a saúde das vacas. A atividade motora, o fator de pH e a temperatura ruminal de 10 vacas foram medidos durante 10 dias em intervalos de medição de 60 segundos. A seguir, os pesquisadores calcularam os valores médios das leituras obtidas, que foram divididos em 2 grupos de acordo com um intervalo de medição a cada 12 horas. A temperatura retal foi medida com um termômetro veterinário a cada 12 horas (às 8h e às 20h). Como resultado, foram obtidas 200 medições. As estatísticas de amostragem descritiva foram calculadas usando o programa SPSS Statistics. Um aumento na atividade motora reduz o nível de pH do ambiente ruminal. A redução do fator de pH do ambiente ruminal leva a um aumento da temperatura ruminal. Existe uma correlação positiva estatisticamente significativa entre a temperatura ruminal e retal. A nosologia com SARA pode ser prevista medindo a atividade motora e a temperatura retal de vacas leiteiras.(AU)

Analytical calculation and acid-base analysis for detection of mixed disorders in critical care medicine.

Aim: The purpose of the study was to validate the systematic six-step arterial blood gas (ABG) analysis in critically ill patients to diagnose mixed ABG disorders. Materials and method: The study was conducted in the ICU of a tertiary care hospital (between 1 June and 30 September, 2007) for 4 months. A total of 560 ABG samples were evaluated from 183 patients. 50 samples were randomly picked and evaluated by single step, quick look method and six-step approaches for detecting mixed ABG disorders. Results: Single, quick and six-step methods when applied on same data, revealed higher number of mixed disorders with systematic six-step approach. Quick-step method revealed only 48% mixed disorders while six-step analysis confirmed 62% having mixed disorders, from the samples which initially appeared to be single disorder. Metabolic acidosis with respiratory acidosis (26%) was the commonest disorder. Metabolic acidosis with respiratory alkalosis (20%), respiratory alkalosis with metabolic alkalosis (6%), metabolic alkalosis with respiratory acidosis (4%), metabolic acidosis with NGMA (4%) and metabolic acidosis with metabolic alkalosis (2%) were the other mixed disorders seen. Conclusion: Mixed disorders as suspected on clinical grounds can only be validated after complete analysis by six-step approach in critically ill patients. pH, PaCO2, and HCO3 – allow determination of primary disorder, but it is only the inequality between predicted and actual compensatory response for simple acid-base disorders which reveals a mixed disorder.

Cloreto e status hidroeletrolítico e ácido-básico: importância clínica da determinação laboratorial / Chloride and hydroelectrolytic and acid base status: clinical importance of laboratorial determination

Apesar de o cloreto ser um exame amplamente disponível e solicitado em instituições de saúde, a maior pane dos médicos crê ser difícil interpretar seus resultados, estabelecer correlações com outros parâmetros laboratoriais associados e tomar decisões terapêuticas baseadas no mesmo. Devido à complexidade de sua homeostase e à intrincada correlação com o status hidroeletrolítico e ácido-básico, poucos médicos se sentem efetivamente aptos a aproveitar a valiosa informação clínica que ele pode revelar. Isto é agravado pela rarefeita bibliografia objetiva sobre o tema. Os autores desta revisão não foram capazes de encontrar nenhum capítulo especificamente dedicado ao cloreto nos principais livros-texto de Fisiologia, Clínica Médica e Nefrologia, disponíveis, à exceção de três revisões bibliográficas no Medline. Não obstante, tentamos organizar a informação tão claramente quanto possível, com o objetivo de tornar o cloreto uma ferramenta útil aos nossos colegas profissionais de saúde.

Even though chloride is a widely available and requested test in health institutions, most part of physicians find it difficult to interpret its results, establish correlations with other laboratory linked parameters and take therapeutic decisions based on it. Due to the complexity of its homeostatic balance and intrincated correlation to hydroelectrolytic and acid base status, few doctors feel actually able to fully profit from the valuable clinical information it can unfold. This is aggravated by the scarce objective bibliography on the issue. The authors of this review were not able to find any chapters specifically dedicated to chloride on major Physiology, Internal Medicine and Nephrology textbooks, but only three reviews on Medline. Nevertheless, we managed to organize the information as clearly as possible with the aim of making chloride test an useful tool to our fellow health professionals.

Isoniazid Toxicity Presenting As Status Epilepticus and Severe Metabolic Acidosis.

Isoniazid (INH) is an integral component of treatment of tuberculosis. An acute overdose is potentially fatal and is characterized by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. The diagnosis of INH overdose should be considered in any patient who presents to emergency medical services (EMS) with the triad. We report a patient presenting with multiple generalised tonic clonic (GTC) convulsions with severe metabolic acidosis as a manifestation of INH toxicity. ©

Routine laboratory investigations in infants and children presenting with fever and seizures at the University Hospital of the West Indies / Investigaciones de rutina en el laboratorio en relación con infantes y niños que se presentan con fiebre y convulsiones en el Hospital Universitario de West Indies

A retrospective chart review of the case notes of all children aged 6 months to 8 years presenting with fever and seizures to the University Hospital of the West Indies (UHWI) between January 2000 and December 2004 was conducted. Descriptive analyses were performed. Fifty-nine children (median age 1.58 years, range 0.58 to 6.83 years) were entered into the study. The main laboratory abnormalities were metabolic acidosis (23%), anaemia (10%), leukocytosis (35%) and hypomagnesaemia (3%). These were not significantly associated with meningitis or an underlying bacterial infection. There were no significant episodes of hyponatraemia, hypocalcaemia or hypoglycaemia. Meningitis was uncommon and occurred in only two (3.4%) children both younger than 16 months of age and who had other abnormal clinical signs. This study demonstrated that routine performance of haematological and biochemical investigations in children presenting with seizures and fever were of limited value. Lumbar punctures in children older than age 18 months with no other abnormal clinical signs were also found to be of low yield. Current American Academy of Paediatrics (AAP) recommendations that serum electrolytes, calcium, phosphate, magnesium, complete blood count and blood glucose should not be performed routinely in a child with a first simple febrile seizure can be safely applied to this study population.

Se llevó a cabo un estudio retrospectivo de las historias clínicas en busca de notas sobre los casos de todos los niños de 6 meses a 8 años de edad que se presentaron con fiebre y convulsiones en el Hospital Universitario de West Indies (HUWI) entre enero de 2000 y diciembre de 2004. Se realizaron análisis descriptivos. Cincuenta y nueve niños (edad mediana (1.58 años, rango 0.58 a 6.83 años) formaron parte de este estudio. Las principales anormalidades halladas mediante el laboratorio fueron: acidosis metabólica (23%), anemia (10%), leucocitosis (35%), e hipomagnesemia (3%). Éstas no estuvieron significativamente asociadas con meningitis o alguna infección bacteriana subyacente. No hubo episodios significativos de hiponatremia, hipocalcemia o hipoglicemia. La meningitis fue poco común, ocurriendo sólo en dos niños (3.4%), ambos con menos de 16 meses de edad y con otros signos clínicos anormales. Este estudio demostró que el trabajo de rutina realizado en las investigaciones hematológicas y bioquímicas en los niños que se presentaron con fiebre y convulsiones, tuvo un valor limitado. También se halló que las punciones lumbares realizadas a niños de más de 18 meses sin ningún otro signo clínico anormal, tuvieron poco valor. Las recomendaciones actuales de la Academia Americana de Pediatría (AAP) en cuanto a que las pruebas de electrolitos en suero, las mediciones de calcio, fosfato, magnesio, el conteo sanguíneo completo, y la prueba de glucosa en sangre, no deben ser realizadas rutinariamente en un niño con una primera simple convulsión febril, pueden ser aplicadas con seguridad a esta población bajo estudio.

Clinical utility of standard base excess in the diagnosis and interpretation of metabolic acidosis in critically ill patients

The aims of this study were to determine whether standard base excess (SBE) is a useful diagnostic tool for metabolic acidosis, whether metabolic acidosis is clinically relevant in daily evaluation of critically ill patients, and to identify the most robust acid-base determinants of SBE. Thirty-one critically ill patients were enrolled. Arterial blood samples were drawn at admission and 24 h later. SBE, as calculated by Van Slyke's (SBE VS) or Wooten's (SBE W) equations, accurately diagnosed metabolic acidosis (AUC = 0.867, 95 percentCI = 0.690-1.043 and AUC = 0.817, 95 percentCI = 0.634-0.999, respectively). SBE VS was weakly correlated with total SOFA (r = -0.454, P < 0.001) and was similar to SBE W (r = -0.482, P < 0.001). All acid-base variables were categorized as SBE VS <-2 mEq/L or SBE VS <-5 mEq/L. SBE VS <-2 mEq/L was better able to identify strong ion gap acidosis than SBE VS <-5 mEq/L; there were no significant differences regarding other variables. To demonstrate unmeasured anions, anion gap (AG) corrected for albumin (AG A) was superior to AG corrected for albumin and phosphate (AG A+P) when strong ion gap was used as the standard method. Mathematical modeling showed that albumin level, apparent strong ion difference, AG A, and lactate concentration explained SBE VS variations with an R² = 0.954. SBE VS with a cut-off value of <-2 mEq/L was the best tool to diagnose clinically relevant metabolic acidosis. To analyze the components of SBE VS shifts at the bedside, AG A, apparent strong ion difference, albumin level, and lactate concentration are easily measurable variables that best represent the partitioning of acid-base derangements.

Evaluation of the correlation between fetal well being tests with APGAR score and pH of umbilical artery in high risk pregnant women

Acidosis-hypoxic phenomenon is a valid indicator to determine fetal distress and is defined by mearuring the blood pH of umbilical cord. None of the present screening tests for evaluation of pregnant mothers have acceptable clinical accuracy to assess fetal acidosis. We decided to evaluate the relationshop between fetal well being tests Non-Stress Test [NST], Oxytocin Challenge Test [OCT] and Biophysical Profile [BPP] with APGAR score and the blood pH of umbilical cord. In this case-control study, we enrolled 50 high-risk pregnant women [BPP test positive, OCT positive or non reactive NST] as cases and 50 pregnant women without fetal risk factors as control group. The umbilical cord blood sample was taken immediately after delivery. Some variables such as maternal age, gestational age, parity, NST, OCT, BPP, blood pH of umbilical cord, neonatal weight, sex and APGAR score were evaluated and the data was analyzed by SPSS software. Discrimination between NST with acidosis [P<0.01] was significant in the case and control groups, but in case of OCT with acidosis it was not significant. NST and OCT had low sensitivity [58.3 and 46.5 respectively]. Besides, the relationship between BPP and blood pH of umbilical cord was significant in the case and control groups [P<0.02]. APGAR score of the cases were lower than the control group [P<0.0001]. In evaluation of fetal acidosis, the BPP test is the best screening test comparing to NST and OCT

Estudo da capacidade alcalinizante de tampões metabolizáveis em bovinos sadios / The alkalinizing effects of different metabolizable buffers in healthy steers

Seis novilhos mestiços, com cerca de 250kg e um ano de idade, foram infundidos, no decorrer de quatro horas, com cinco litros de diferentes soluções isotônicas de sais sódicos, com 150mM/l de bicarbonato, acetato, propionato, lactato L, lactato racêmico e cloreto (controle), em delineamento em quadrado latino (6x6). Análises hemogasométricas e do pH urinário foram determinadas no decorrer da infusão - zero, primeira e quatro horas - e após o seu término, na oitava hora. O pH do sangue foi maior nos animais infundidos com os tampões que nos infundidos com cloreto; teores mais elevados de bicarbonato e de excesso de ácido-base sanguíneos foram obtidos na quarta e oitava hora nos infundidos com bicarbonato e lactato; o mesmo ocorreu com a pressão de CO2 na oitava hora. Os resultados indicam que os tratamentos com Bicarbonato e lactato proporcionam acúmulo de tampões no sangue e geram discreta alcalose metabólica, compensada organicamente por leve retenção de CO2. a infusão com bicarbonato de sódio causa elevação do pH urinário

Six healthy crossbred yearling 250kg steers were infused intravenously, during four hours, with five liters of each of the six different isotonic solutions of sodium salts containing 150 mMol/l of the bicarbonate, acetate, propionate, L-lactate, D and L-lactate and chloride in a 6 x 6 latin square experimental design. Blood was collected from the jugular vein, anaerobically, for blood gas analysis, samples were obtained at different times throughout the infusion (zero, 1st, 4th and 8th h ). Urine was collect for determining the pH at the same schedule. Higher blood pH was found in cattle infused with all buffers than the chloride infused animals; higher level of blood bicarbonate and base excess were obtained at 4th and 8th h with bicarbonate and L-lactate, as well as with pCO2 at the 8th h. These results show that treatments with B and L lead to a slight accumulation of buffers in the blood, and generate a discrete metabolic alkalosis compensated organically by a small retention of CO2. Best alkalinizing effects are obtained by bicarbonate and L-lactato infusions. Bicarbonate infusions causes a high urinary pH

Seguimiento pre y post natal de gastrosquisis: reporte de un caso clínico / Monitoring of pre and post natal gastroschisis: a case clinical report

Exposición de viceras con gran superficie de evaporación que puede llevar a producir hipotermia, hipovolemia, hipoxia y acidosis y la cantidad de intestinos y viceras que se encuentran en el saco y de si existe en el abdomen un espacio para introducirlas ya que si esta masa es excesiva puede producir compromiso respiratorios por compresión, obturación de vena cava con la consecuente reducción del retorno venoso.

Delta gap changes should guide therapy in different cases of metabolic acidosis

Metabolic acidosis is associated with serious morbidities and mortality. Its diagnosis is difficult because it is frequently associated with mixed acid-base disorders and its clinical manifestations are often non specific or subclinical, which means that its diagnosis is made from laboratory and other diagnostic tests. The aim of this study was to use the delta gap for accurate interpretation of normal anion gap [AG] acidosis, high AG acidosis and if there was a coexisted metabolic disorders associated with the metabolic acidosis. Such diagnosis is beneficial in the management of each type of these metabolic disorders. Forty hundred and seventy nine measurements of acid-base changes were drawn from 479 ICU critically ill patients and patients with metabolic acidosis were selected. They were divided according to the aetiology of their acidotic condition into a renal failure group [n = 23] and a sepsis group [n= 26]. Arterial blood gases [ABG] were analyzed and the anion gap [AG] was calculated by arterial blood gas analyzer. In the renal failure group the incidence of metabolic acidosis was: normal AG acidosis 9%, mixed [normal and high] AG acidosis 48% and high AG acidosis 43%, but there was no associated metabolic alkalosis. In sepsis group, 23% of the patients had normal AG acidosis, 42% of patients had mixed [normal and high] AG acidosis, 12% of patients had high AG acidosis and the remaining cases [23%] had an associated metabolic alkalosis. In conclusion, AG is important for differential diagnosis between normal and high AG metabolic acidosis. Delta gap is an important tool for diagnosing the mixed acid-base disorders associated with the metabolic acidosis. Such diagnosis is important as a guide to know when to use bicarbonates [HCO[3]] to treat metabolic acidosis

Acidemia propionica no periodo neonatal / Propionic acidemia in the neonatal period

A acidemia propionica e uma desordem do metabolismo de acidos organicos caracterizada por um amplo espectro de variacao clinica e laboratorial. Muitas vezes ja se manifesta no periodo neonatal, quando a mortalidade e elevada e as sequelas neurologicas sao graves nos sobreviventes. O caso apresentado refere-se a um recem-nascido do sexo masculino, saudavel ate 49 horas de vida, quando iniciou quadro de recusa alimentar, gemencia e hipotermia. Evoluiu com piora clinica progressiva atingindo estado de neurotoxicidade importante. Desenvolveu acidose metabolica grave e a deteccao de elevados niveis de acido 3-hidroxi-propionico, 2-metil-3-hidroxibutirico e metil-citrico na urina, confirmou o diagnostico de acidemia propionica

Acidosis metabólica inducida por metanol administrado por vía cutánea en un niño de 9 meses de edad / Metabolic acidosis induced by methanol administered per cutaneous acoute in a 9 month infant

Se presenta el caso de un niño de 9 meses de edad con intoxicación accidental por metanol. El paciente desarrolló las siguientes alteraciones clínicas y bioquímicas: Hiperventilación, convulsiones, acidosis metabólica y aumento del anion gap. Fue tratado con infusión de bicarbonato, ventilación mecánica y etanol. Se revisa la fisiopatología, diagnóstico y tratamiento de esta intoxicación