Predictores de mortalidad precoz en pacientes con trauma complejo hemorrágico / Early mortality predictors in patients with complex hemorrhagic trauma

RESUMEN Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino (85 %), con 60 años y menos (83 %), con trauma contuso (57.5 %) y politraumatizados (42.5 %). Predominaron también los que presentaron acidosis metabólica (66.7 %), coagulopatía aguda (44.4 %), hipotermia (41.5 %). El 30 % de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 %, una especificidad de 97.2 % y un porcentaje global de pronóstico correcto del 92.8 %. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante.

ABSTRACT Background: Complex trauma is a worldwide health problem and when hemorrhagic, mortality is higher than other types of complex trauma. Objective: To determine predictive variables of early mortality in hospitalized patients with complex hemorrhagic trauma in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for 6 years. 207 patients were included. The variables were grouped into sociodemographic, associated chronic diseases, injury mechanism, type of trauma, topographic location, time between hospital admission, diagnosis and treatment, early complications, medical and surgical treatment, and early mortality. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality due to complex hemorrhagic trauma. Results: Male patients (85 %), 60 years and younger (83 %), with blunt trauma (57.5 %) and polytraumatized patients (42.5 %) predominated. Those who presented metabolic acidosis (66.7 %), acute coagulopathy (44.4 %), and hypothermia (41.5 %) also predominated. 30 % of patients died early. The decision tree had a sensitivity of 82.3 %, a specificity of 97.2 % and an overall percentage of correct forecast of 92.8 %. Four variables that predicted mortality were identified: hypothermia, metabolic acidosis, acute coagulopathy, and penetrating trauma. Conclusions: The highest probability of early dying during a complex hemorrhagic trauma occurs among patients with hypothermia, metabolic acidosis, acute coagulopathy and penetrating trauma.

Effects of oral alkali drug therapy on clinical outcomes in pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis.

BACKGROUND: Metabolic acidosis accelerates the progression of chronic kidney disease (CKD) and increases the mortality rate. Whether oral alkali drug therapy benefits pre-dialysis CKD patients is controversial. We performed a meta-analysis of the effects of oral alkali drug therapy on major clinical outcomes in pre-dialysis CKD patients. METHODS: We systematically searched MEDLINE using the Ovid, EMBASE, and Cochrane Library databases without language restriction. We included all eligible clinical studies that involved pre-dialysis CKD adults and compared those who received oral alkali drug therapy with controls. RESULTS: A total of 18 eligible studies, including 14 randomized controlled trials and 4 cohort studies reported in 19 publications with 3695 participants, were included. Oral alkali drug therapy led to a 55% reduction in renal failure events (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.25-0.82), a rate of decline in the estimated glomerular filtration rate (eGFR) of 2.59 mL/min/1.73 m2 per year (95% CI, 0.88-4.31). There was no significant effect on decline in eGFR events (RR: 0.34; 95% CI: 0.09-1.23), proteinuria (standardized mean difference: -0.32; 95% CI: -1.08 to 0.43), all-cause mortality events (RR: 0.90; 95% CI: 0.40-2.02) and cardiovascular (CV) events (RR: 1.03; 95% CI: 0.32-3.37) compared with the control groups. CONCLUSION: Based on the available and low-to-moderate certainty evidence, oral alkali drug therapy might potentially reduce the risk of kidney failure events, but no benefit in reducing all-cause mortality events, CV events, decline in eGFR and porteninuria.

Laboratory Markers of Acidosis and Mortality in Cardiogenic Shock: Developing a Definition of Hemometabolic Shock.

BACKGROUND: Acidosis and higher lactate predict worse outcomes in cardiogenic shock (CS) patients. We sought to determine whether overall acidosis severity on admission predicted in-hospital mortality in CS patients. METHODS: This retrospective descriptive analysis included CS patients admitted to a single academic tertiary cardiac intensive care unit from 2007 to 2015. Admission arterial pH, base excess, and anion gap values were used to generate a Composite Acidosis Score (range 0-5, with a score ≥2 defining Severe Acidosis). Adjusted in-hospital mortality was analyzed using multivariable logistic regression. RESULTS: We included 1,065 patients with median age of 68.9 (59.0, 77.2) years (36.4% females). Concomitant diagnoses included cardiac arrest in 38.1% and acute coronary syndrome in 59.1%. Severe Acidosis was present in 35.2%, and these patients had worse shock and more organ failure. In-hospital mortality occurred in 34.1% and was higher among patients with Severe Acidosis (54.9% vs. 22.4%, adjusted odds ratio [OR] 2.01, 95% CI 1.43-2.83, P < 0.001). Increasing Composite Acidosis Score was associated with higher in-hospital mortality (adjusted OR 1.25 per point, 95% CI 1.11-1.40, P < 0.001). Severe Acidosis was associated with higher hospital mortality at every level of shock severity and organ failure (all P < 0.05). Admission lactate level had equivalent discrimination for in-hospital mortality as the Composite Acidosis Score (0.69 vs. 0.66; P = 0.32 by De Long test). CONCLUSION: Given its incremental association with higher in-hospital mortality among CS patients beyond shock severity and organ failure, we propose Severe Acidosis as a marker of hemometabolic shock. Lactate levels performed as well as a composite measure of acidosis for predicting mortality.

Predictores de mortalidad precoz en pacientes con trauma complejo hemorrágico / Early mortality predictors in patients with complex hemorrhagic trauma

Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino, con 60 años y menos, con trauma contuso (57.5 porciento) y politraumatizados (42.5 porciento). Predominaron también los que presentaron acidosis metabólica , coagulopatía aguda, hipotermia. El 30 %porciento de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 porciento, una especificidad de 97.2 porciento y un porcentaje global de pronóstico correcto del 92.8 porciento. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante [AU]

Prognostic dynamic nomogram integrated with metabolic acidosis for in-hospital mortality and organ malperfusion in acute type B aortic dissection patients undergoing thoracic endovascular aortic repair.

BACKGROUND: Organ malperfusion is a lethal complication in acute type B aortic dissection (ATBAD). The aim of present study is to develop a nomogram integrated with metabolic acidosis to predict in-hospital mortality and organ malperfusion in patients with ATBAD undergoing thoracic endovascular aortic repair (TEVAR). METHODS: The nomogram was derived from a retrospectively study of 286 ATBAD patients who underwent TEVAR from 2010 to 2017 at a single medical center. Model performance was evaluated from discrimination and calibration capacities, as well as clinical effectiveness. The results were validated using a prospective study on 77 patients from 2018 to 2019 at the same center. RESULTS: In the multivariate analysis of the derivation cohort, the independent predictors of in-hospital mortality and organ malperfusion identified were base excess, maximum aortic diameter ≥ 5.5 cm, renal dysfunction, D-dimer level ≥ 5.44 µg/mL and albumin amount ≤ 30 g/L. The penalized model was internally validated by bootstrapping and showed excellent discriminatory (bias-corrected c-statistic, 0.85) and calibration capacities (Hosmer-Lemeshow P value, 0.471; Brier Score, 0.072; Calibration intercept, - 0.02; Slope, 0.98). After being applied to the external validation cohort, the model yielded a c-statistic of 0.86 and Brier Score of 0.097. The model had high negative predictive values (0.93-0.94) and moderate positive predictive values (0.60-0.71) for in-hospital mortality and organ malperfusion in both cohorts. CONCLUSIONS: A predictive nomogram combined with base excess has been established that can be used to identify high risk ATBAD patients of developing in-hospital mortality or organ malperfusion when undergoing TEVAR.

Correlation Of Severity Of Metabolic Acidosis At Admission And Outcome In Asphyxiated Neonates.

BACKGROUND: Blood gases can provide information about the perinatal, natal and postnatal condition of newborn. Severity of metabolic acidosis has deleterious effect on the outcome of babies. When the cord blood gases are not available the arterial blood gases are used for interpreting the status of newborn. The purpose of study was to determine the relationship between severity of metabolic acidosis at admission with the stage of hypoxic ischemic encephalopathy, and its outcome in asphyxiated neonates. METHODS: This was descriptive cross-sectional study of 384 neonates born at ≥35 weeks to <42 weeks from June to December 2018, admitted in Neonatology department of the Children's hospital & the Institute of Child Health, Lahore within first 6 hours of birth. The neonates with history of delayed cry at birth and arterial pH ≤7.30 and base deficit ≥10 were included in the study. The pH and base deficit of babies was analyzed in relation to the stage of HIE, duration of stay and death or discharge of the babies using SPSS-20. The p-value was calculated using chi-square test. RESULTS: Total of 470 neonates were eligible. Eighty-four neonates were excluded. Finally, 384 neonates were included and analyzed for the outcome variables. With severe metabolic acidosis pH <7.01, all the babies developed HIEII/III. Majority (82.1%) of the babies expired and 27.9% had prolonged hospital stay. CONCLUSIONS: Increasing severity of metabolic acidosis at admission increases the likelihood of adverse outcome in asphyxiated neonates.

The Strongest Risk Factor for Operative Mortality in Acute Type A Aortic Dissection is Acidosis: Validation of Risk Model.

Multiple risk factors for operative mortality in the setting of acute type A aortic dissection (ATAAD) have been described. Recently, the combination of severe acidosis and malperfusion was found to significantly impact operative mortality following surgery for ATAAD and a treatment algorithm was proposed. The purpose of this study is to validate these findings in our institution. A retrospective chart review was performed for patients who underwent ATAAD repair between Feb 1997 and Jan 2018. Preoperative nadir pH, bicarbonate, base deficit, organ malperfusion, and other relevant parameters were collected. Multivariable logistic regression was performed to evaluate operative mortality. A total of 298 patients underwent ATAAD repair. The highest operative mortality (18/49; 37%) was noted in patients with severe acidosis (base deficit ≤ -10). There were 96 patients (32%) with malperfusion. In patients with abdominal malperfusion, this trend is even more pronounced. Multivariable logistic regression showed that severe acidosis is associated with higher operative mortality, odds ratio of 13.9 (P = 0.001). The presence of diabetes and advanced age were also associated with higher operative mortality. These findings validate the previously reported findings that severe acidosis is a strong predictor of operative mortality, and risk increases with associated organ malperfusion. This supports the suggestion that base deficit, which is easily performed at the bedside, should be used clinically to predict operative mortality and should be collected in aortic dissection databases.

The US military experience with THAM.

BACKGROUND: Acidosis, a part of the lethal trauma triad, occurs frequently after major combat trauma. Tris-hydroxymethyl aminomethane (THAM) has been used to effectively treat acidosis in injured casualties. No research has been conducted assessing the safety of THAM in the military combat setting. We sought to describe the US military experience with THAM administration to battlefield injury subjects. METHODS: We conducted a retrospective descriptive cohort study reviewing the trauma data from the Department of Defense Trauma Registry. US military personnel with an injury severity score greater than 15, between September 2001 and December 2014, were analyzed. Our primary outcome was the 30-day all-cause mortality among cohort treated with THAM versus those who were not. Differences between the cohort were examined using a student t-test (continuous variables), Wilcoxon Rank Sum test (ordinal variables), and chi-squared test (nominal variables). RESULTS: 4558 subjects met the inclusion criteria. 69 received THAM and 4489 did not. Casualties receiving THAM had higher mean ISS scores (33 vs. 27, p < 0.001), and required significantly higher amounts of packed red blood cells (RBCs, 37 vs. 10, p < 0.001). THAM cohort had longer ventilator and intensive care unit (ICU) days with an overall lower survival to hospital discharge. On univariable analysis, THAM was associated with lower odds of survival (OR 0.18, 95% CI 0.11-0.31) but on multivariable analysis, when controlling for confounders, THAM use was not associated with a worse odds of survival (OR 0.83, 95% CI 0.21-3.24). CONCLUSIONS: Within our combat trauma population, we were unable to detect worse 30 day mortality associated with THAM administration. Prospective investigations are needed to validate its use in critically injured combat casualties.

Associations between early intra-arrest blood acidaemia and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study.

BACKGROUND: Resuscitation guidelines list acidaemia as a potentially reversible cause of cardiac arrest without specifying the threshold defining acidaemia. We examined the association between early intra-arrest arterial blood gas (ABG) data and outcomes of in-hospital cardiac arrest (IHCA). METHODS: This single-centred retrospective study reviewed patients with IHCA between 2006 and 2015. Early intra-arrest ABG data were measured within 10 min of initiating cardiopulmonary resuscitation. The ABG analysis included measurements of blood pH, PaCO2, and HCO3-. RESULTS: Among the 1065 included patients, 60 (5.6%) achieved neurologically intact survival. Mean blood pH was 7.2. Mean PaCO2 and HCO3- levels were 59.7 mmHg and 22.1 mmol/L, respectively. A blood pH of 7.2 was identified by a generalised additive models plot to define severe acidaemia. The PaCO2 level was higher in patients with severe acidaemia (mean: 74.5 vs. 44.1 mmHg) than in those without. Multivariable logistic regression analyses indicated that blood pH > 7.2 was associated with a favourable neurological recovery (odds ratio [OR]: 2.79, 95% confidence interval [CI]: 1.43-5.46; p-value = 0.003) and blood pH was positively associated with survival at hospital discharge (OR: 5.80, 95% CI: 1.62-20.69; p-value = 0.007). CONCLUSION: Early intra-arrest blood pH was associated with IHCA outcomes, while levels of PaCO2 and HCO3- were not. A blood pH of 7.2 could be used as the threshold defining severe acidaemia during arrest and help profile patients with IHCA. Innovative interventions should be developed to improve the outcomes of patients with severe acidaemia, such as novel ventilation methods.

Bicarbonate use and mortality outcome among critically ill patients with metabolic acidosis: A meta analysis.

BACKGROUND: The use of sodium bicarbonate in the treatment of metabolic acidosis in critically ill subjects has long been a subject of debate. Despite empiric use in the setting of severe acidemia in critically ill patients, there is little data looking into the role of sodium bicarbonate in the treatment of severe metabolic acidosis in the intensive care unit (ICU) setting. METHODS: We conducted a comprehensive search of Pubmed and Cochrane Central Register of Controlled Trials addressing bicarbonate use in the metabolic acidosis in the intensive care unit (ICU) setting. We examined mortality as end point. Pooled odds ratios (OR) and their 95% confidence intervals (CI) were calculated for all outcomes using a random-effect model. RESULTS: The final search yielded 202 articles of which all were screened individually. A total of 11 studies were identified but 6 studies were excluded due to irrelevance in mortality outcome and methodology. Analysis was done separately for observational studies and randomized controlled trials. The pooled OR [95% CI] for mortality with bicarbonate use in the observational studies was 1.5 [0.62-3.67] with heterogeneity of 67%, while pooled OR for mortality in the randomized trials was 0.72 [0.49-1.05] (figure 2). In combining all studies, the pooled odds ratio was 0.93 95% [0.69-1.25] but with heterogeneity of 63%. After sensitivity analysis with removing the study done by Kim et al. 2013, heterogeneity was 0% with OR 0.8 [0.59-1.10]. CONCLUSION: There is no significant difference in mortality in the use of bicarbonate among critically ill patients with high anion gap metabolic acidosis predominantly driven by lactic acidosis.

Metabolic acidosis in critically ill patients with cirrhosis: Epidemiology and short-term mortality risk factors.

BACKGROUND/AIMS: Metabolic acidosis is a common complication in patients with cirrhosis at the intensive care units (ICUs) and associated with increased mortality. The aim of our research was to explore the epidemiology and risk factors of metabolic acidosis in critically ill patients with cirrhosis. MATERIALS AND METHODS: A total of 975 patients with cirrhosis were selected into our study, and all participants were followed up for at least 28 days. Cox regression model and machine-learning algorithm were used to identify the importance of different risk factors, respectively. Finally, an improved prognostic model as Model for End-stage Liver Disease and metabolic acidosis (MELD-MA) was developed. RESULTS: Among the 975 patients with liver cirrhosis, 506 had metabolic acidosis, including 257 patients who had decompensated metabolic acidosis at ICU admission. The 28-day mortality was 41% (206/506) in patients with metabolic acidosis. Bilirubin (hazard ratio (HR): 1.023, 95% confidence interval (CI): 1.011-1.036), international normalized ratio (HR: 1.527, 95% CI: 1.332-1.750), pH (HR: 0.173, 95% CI: 0.047-0.640), BE-Lac (HR: 0.907, 95% CI: 0.868-0.948), and BE-Na (HR: 0.923, 95% CI: 0.859-0.991) were considered as independent prognostic parameters for 28-day mortality. MELD-NA had significantly higher discrimination (area under the receiver operating characteristic curve 0.79) than MELD and Child-Pugh score. CONCLUSION: Critically ill patients with cirrhosis have a high mortality rate and poor prognosis because of the high prevalence of metabolic acidosis. Lactic acidosis is the worst prognosis of all types of metabolic acidosis. MELD-MA performs well on the short-term mortality assessment in critically ill patients with cirrhosis and metabolic acidosis.

Comparison of early warning scores in patients with COPD exacerbation: DECAF and NEWS score.

BACKGROUND: The National Early Warning Score 2 (NEWS2) includes two oxygen saturation scales; the second adjusts target saturations to 88%-92% for those with hypercapnic respiratory failure. Using this second scale in all patients with COPD exacerbation ('NEWS2All COPD') would simplify practice, but the impact on alert frequency and prognostic performance is unknown. Admission NEWS2 score has not been compared with DECAF (dyspnoea, eosinopenia, consolidation, acidaemia, atrial fibrillation) for inpatient mortality prediction. METHODS: NEWS, NEWS2 and NEWS2All COPD and DECAF were calculated at admission in 2645 patients with COPD exacerbation attending consecutively to one of six UK hospitals, all of whom met spirometry criteria for COPD. Alert frequency and appropriateness were assessed for all NEWS iterations. Prognostic performance was compared using the area under the receiver operating characteristic (AUROC) curve. Missing data were imputed using multiple imputation. FINDINGS: Compared with NEWS, NEWS2 reclassified 3.1% patients as not requiring review by a senior clinician (score≥5). NEWS2All COPD reduced alerts by 12.6%, or 16.1% if scoring for injudicious use of oxygen was exempted. Mortality was low in reclassified patients, with no patients dying the same day as being identified as low risk. NEWS2All COPD was a better prognostic score than NEWS (AUROC 0.72 vs 0.65, p<0.001), with similar performance to NEWS2 (AUROC 0.72 vs 0.70, p=0.090). DECAF was superior to all scores (validation cohort AUROC 0.82) and offered a more clinically useful range of risk stratification (DECAF=1.2%-25.5%; NEWS2=3.5%-15.4%). CONCLUSION: NEWS2All COPD safely reduces the alert frequency compared with NEWS2. DECAF offers superior prognostic performance to guide clinical decision-making on admission, but does not replace repeated measures of NEWS2 during hospitalisation to detect the deteriorating patient.

Sodium bicarbonate therapy for critically ill patients with metabolic acidosis: A scoping and a systematic review.

PURPOSE: We aimed to assess the biochemical and physiological effects, clinical efficacy, and safety, of intravenous NaHCO3 therapy in critically ill patients with acute metabolic acidosis. METHODS: We conducted a scoping review concerning the biochemical and physiological effects of NaHCO3 (PART A), and a systematic review regarding clinical efficacy (PART B). We searched MEDLINE in Part A and MEDLINE, EMBASE, Cochrane, the National Institute of Health Clinical Trials Register, and the WHOICTRP for randomised controlled trials in Part B. RESULTS: Twelve studies in Part A and two trials in Part B fulfilled the eligibility criteria. Intravenous NaHCO3 increased blood pH, base excess, serum bicarbonate, sodium, and PaCO2 during and after administration and decreased anion gap and potassium value. For clinical efficacy, only one study contributed to the effect estimate. The risk ratio (RR) for all-cause mortality was 0.83 (95% confidence interval, 0.68 to 1.02), and the risk of hypocalcaemia was increased in the bicarbonate group (RR 1.65, 95% confidence interval 1.09 to 2.50). There were inadequate data on hemodynamic indices. CONCLUSIONS: Given the lack of data on the effects of intravenous NaHCO3 therapy to support its clinical use and the frequency of bicarbonate therapy, a program of investigation appears justified.

Malaria Severity in Mangaluru City in the Southwestern Coastal Region of India.

Dakshina Kannada district in the Southwestern region of Karnataka state, India, including Mangaluru city is endemic to malaria. About 80% of malaria infections in Mangaluru and its surrounding areas are caused by Plasmodium vivax and the remainder is due to Plasmodium falciparum. Malaria-associated clinical complications significantly occur in this region. Here, we report the pathological conditions of 41 cases of fatal severe malaria, admitted to the district government hospital in Mangaluru city during January 2013 through December 2016. The results of clinical, hematological, and biochemical analyses showed that most of these severe malaria cases were associated with thrombocytopenia, anemia, metabolic acidosis, acute respiratory distress, and single or multi-organ dysfunction involving liver, kidney, and brain. Of the 41 fatal malaria cases, 24, 10, and seven patients had P. vivax, P. falciparum, and P. vivax and P. falciparum mixed infections, respectively. These data suggest that besides P. falciparum that is known to extensively cause severe and fatal malaria illnesses, P. vivax causes fatal illnesses substantially in this region, an observation that is consistent with recent findings in other regions.

Persistent acidosis after reperfusion-A prognostic indicator of increased 30-day and in-hospital postoperative mortality in liver transplant recipients.

During liver transplantation, the patient is at risk of developing progressive lactic acidosis. Following reperfusion, correction of acidosis may occur. In some patients, acidosis will worsen, a phenomenon referred to as persistent acidosis after reperfusion (PAAR). We compared postoperative outcomes in patients who manifested PAAR vs those that did not. All adult patients undergoing liver transplantation from 2002 to 2015 were included. PAAR is defined by the presence of a significant negative slope coefficient for base excess values measured after hepatic artery anastomosis through 72 hours postoperatively. Primary outcome was a composite of 30-day and in-hospital mortality. Secondary outcomes included: ICU LOS, total hospital LOS, and re-transplantation rate within 7 days. PAAR occurred in 10% of the transplant recipients. Patients with PAAR had higher MELD, BMI, and eGFR and demonstrated a longer median ICU LOS and hospital median LOS with a trend toward mortality difference. But, after propensity matching, the mortality rate difference became significantly higher in patients with PAAR compared with matched controls while the ICU LOS differences disappeared. The re-transplantation rates were similar also between the PAAR and no PAAR groups. The cohort with PAAR had a significant 30-day and in-hospital increase in mortality after propensity score matching.

Serum electrolyte imbalance and prognostic factors of postoperative death in adult traumatic brain injury patients: A prospective cohort study.

Electrolyte imbalances are common in traumatic brain injury. It shares the cause of perioperative morbidity and mortality. Types of intravenous fluid resuscitation, osmotic diuretics, massive blood loss, and intracranial pathology were considered as the potential factors to worsen electrolyte abnormalities in these patients. The aims of this study were to report the incidence of electrolyte imbalance in traumatic brain injured patients and to assess the association between electrolyte imbalance and other prognostic factors to death within 24 hours of the injury.The study was carried out in the northern university, tertiary-care hospital of Thailand. The patients aged from 18 to 65 years old, presented with traumatic brain injury, and needed for emergency craniotomy were included. We excluded the patients who had minor neurosurgical procedures, pregnancy, and undergone cardiopulmonary resuscitation from the Emergency Department.Among 145 patients recruited, 101 (70%) had Glasgow Coma Scale (GCS) score ≤ 8, 25 (17%) had GCS score 9 to 12, and 19 (13%) had GCS score 13 to 15. The most common diagnosis were subdural hematoma and epidural hematoma, 51% and 36%, respectively. Hypokalemia was the most common electrolyte imbalance at 65.5%. The results of the use of a multivariable logistic regression model show that the odds of postoperative death in TBI patients were increased with high levels of blood glucose, hypernatremia, and acidosis.Hypokalemia was the most common electrolyte imbalance in TBI patients. Hypernatremia, acidosis, and hyperglycemia significantly increased the odds ratio of death in the first 24 hours post TBI.

[CME: Ethylene Glycol Intoxication]. / CME: Ethylenglykol-Intoxikation.

CME: Ethylene Glycol Intoxication Abstract. Ethylene glycol is a sweet-tasting alcohol used in common antifreeze and other industrial solutions. Without appropriate therapy, intoxication with ethylene glycol can result in severe metabolic acidosis, acute renal failure, and in death. After gastrointestinal resorption, hepatic metabolism starts with oxidation by alcohol dehydrogenase and results in severe anion gap metabolic acidosis. Other metabolic products are calcium oxalate crystals, which can deposit in several tissues like the kidneys and lead to acute tubular necrosis with reversible renal failure. The crucial therapeutic step is rapid inhibition of alcohol dehydrogenase with fomepizole or ethanol to avoid the formation of toxic metabolites. Additionally, haemodialysis is the most effective way to eliminate ethylene glycol as well as its toxic metabolites. If therapy is initiated rapidly, prognosis is favorable.

Acid base variables predict survival early in the course of treatment with continuous venovenous hemodiafiltration.

Metabolic acid-base disorders, especially metabolic acidosis, are common in critically ill patients who require renal replacement therapy. Continuous veno-venous hemodiafiltration (CVVHDF) achieves profound changes in acid-base status, but metabolic acidosis can remain unchanged or even deteriorate in some patients. The objective of this study is to understand the changes of acid-base variables in critically ill patients with septic associated acute kidney injury (SA-AKI) during CVVHDF and to determine how they relate to clinical outcome.Observational study of 200 subjects with SA-AKI treated with CVVHDF for at least 72 hours. Arterial blood gases and electrolytes and other relevant acid-base variables were analyzed using quantitative acid-base chemistry.Survivors and nonsurvivors had similar demographic characteristics and acid-base variables on day one of CVVHDF. However, during the next 48 hours, the resolution of acidosis was significantly different between the 2 groups, with an area under the ROC curve for standard base excess (SBE) and mortality of 0.62 (0.54-0.70), this was better than APACHE II score prediction power. Quantitative physicochemical analysis revealed that the majority of the change in SBE was due to changes in Cl and Na concentrations.Survivors of SA-AKI treated with CVVHDF recover hyperchloremic metabolic acidosis more rapidly than nonsurvivors. Further study is needed to determine if survival can be improved by measures to correct acidosis more rapidly.

Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis.

OBJECTIVE: Although sodium bicarbonate (SB) solution has been widely used in clinical practice, its effect on mortality when administered to a large population of patients with acidosis is not known. The study aimed to investigate the effectiveness of SB infusion in septic patients with metabolic acidosis. METHODS: Septic patients with metabolic acidosis were identified from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score (PS) was used to account for the baseline differences in the probability to receive SB or not. The marginal structural Cox model (MSCM) was employed to adjust for both baseline and time-varying confounding factors. MAIN RESULTS: A total of 1718 septic patients with metabolic acidosis were enrolled in the study, including 500 in the SB group and 1218 in the non-SB group. Both pH [7.16 (standard deviation (SD): 0.10) vs. 7.22 (SD: 0.07); p < 0.001] and bicarbonate concentration (BC) [11.84 (SD: 3.63) vs. 14.88 (SD: 3.36) mmol/l; p < 0.001] were significantly lower in the SB than that in the non-SB group. While there was no significant mortality effect in the overall population [hazard ratio (HR): 1.04; 95% CI 0.86-1.26; p = 0.67], SB was observed to be beneficial in patients with acute kidney injury (AKI) stage 2 or 3 and pH < 7.2 (HR 0.74; 95% CI 0.51-0.86; p = 0.021). Similar results were replicated with the MSCM. CONCLUSION: Our study observed that SB infusion was not associated with improved outcome in septic patients with metabolic acidosis, but it was associated with improved survival in septic patients with AKI stage 2 or 3 and severe acidosis. The results need to be verified in randomized controlled trials.