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1.
BJOG ; 127(3): 405-413, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31762140

RESUMO

OBJECTIVE: To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress. DESIGN: Prospective observational study. SETTING: University hospital. SAMPLE: CBG from 97 VDs and 124 CDs without fetal distress. METHODS: Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs. MAIN OUTCOME MEASURES: Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO2 ), partial pressure of carbon dioxide (pCO2 ), pH, and postpartum haemorrhage. RESULTS: Arterial cord blood pH, bicarbonate ( HCO 3 - , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO 3 -  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO 3 -  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO2 increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit. CONCLUSIONS: After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs. TWEETABLE ABSTRACT: By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively.


Assuntos
Acidose , Cesárea , Parto Obstétrico , Sangue Fetal/metabolismo , Complicações do Trabalho de Parto , Cordão Umbilical/cirurgia , Acidose/sangue , Acidose/diagnóstico , Acidose/etiologia , Gasometria/métodos , Cesárea/efeitos adversos , Cesárea/métodos , Cesárea/estatística & dados numéricos , Constrição , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Itália/epidemiologia , Masculino , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/etiologia , Gravidez , Resultado da Gravidez/epidemiologia , Tempo para o Tratamento
3.
Medicine (Baltimore) ; 98(41): e17434, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593098

RESUMO

RATIONALE: Preoperative prolonged fasting may cause starvation ketoacidosis. Herein, we report of a case of starvation ketoacidosis due to long-term fasting before surgery. PATIENT CONCERNS: We report of a case of metabolic acidosis due to prolonged fasting in a previously healthy 44-year-old woman during a total laparoscopic hysterectomy. Hyperventilation was observed to occur when the surgery was completed. Metabolic acidosis and hypoglycemia were demonstrated by blood gas analysis of the radial artery. DIAGNOSIS: Metabolic acidosis. INTERVENTIONS: The patient received sodium bicarbonate and 5% glucose fluid at the end of the surgery. OUTCOMES: The tracheal tube was successfully removed when the tidal volume of the patient returned to normal after the therapy. However, the patient suffered pulmonary edema when she was transferred to the intensive care unit (ICU). With treatments with furosemide and sodium bicarbonate, acidosis and pulmonary edema were completely corrected at 8 hours after the surgery. On the second day after the surgery, the patient suffered nausea and vomiting. Nausea and vomiting were not completely relieved on the sixth day after the operation; therefore, the patient was transferred to the Department of Gastroenterology for further therapy. LESSONS: This case suggests that although the concept of enhanced recovery after surgery (ERAS) has been adopted by most physicians because of its positive outcomes, the issue of prolonged fasting still exists, and such patients may be exposed to the risk of starvation ketoacidosis.


Assuntos
Acidose/etiologia , Jejum/efeitos adversos , Inanição/complicações , Adulto , Feminino , Humanos , Histerectomia , Período Pré-Operatório
5.
Clin Nephrol ; 92(5): 258-262, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31347495

RESUMO

BACKGROUND: Falsely low or even unmeasurable serum bicarbonate has been described in patients with severe hypertriglyceridemia or paraproteinemia. This phenomenon, known as pseudo-hypobicarbonatemia, is believed to be due to interference by these components when the commonly used enzymatic assay is utilized for serum bicarbonate measurement. The calculated bicarbonate derived from blood gas machines is not affected. This can lead to a misdiagnosis of a severe anion gap metabolic acidosis along with an extensive and expensive work-up. CASE PRESENTATIONS: We review a series of 5 patients with severe hypertriglyceridemia who presented with pseudo-hypobicarbonatemia and an elevated anion gap metabolic acidosis. Membrane-based therapeutic plasma exchange was utilized. RESULTS: Following aggressive lowering of the triglycerides, there was an immediate resolution of the pseudo-hypobicarbonatemia and anion gap metabolic acidosis. CONCLUSION: Recognition of lipemic serum in the setting of an otherwise unexplained anion gap metabolic acidosis should prompt the clinician to obtain a blood gas sample for true determination of the acid-base status. Doing so may avoid an extensive and expensive metabolic work-up.


Assuntos
Acidose , Hipertrigliceridemia/complicações , Troca Plasmática , Equilíbrio Ácido-Base/fisiologia , Acidose/sangue , Acidose/diagnóstico , Acidose/etiologia , Acidose/terapia , Análise Química do Sangue/normas , Erros de Diagnóstico , Humanos , Hipertrigliceridemia/sangue
6.
Medicine (Baltimore) ; 98(30): e16504, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31348261

RESUMO

RATIONALE: Autosomal recessive distal renal tubular acidosis (dRTA) is a rare condition, most cases of which are caused by genetic mutations. Several loss-of-function mutations in the ATP6V0A4 gene have been recently reported. PATIENT CONCERNS: A 2-month, 24-day-old Chinese girl presenting with vomiting and diarrhea. DIAGNOSIS: dRTA was established by metabolic acidosis and hypokalemia. Mutational analysis of the ATP6V0A4 gene revealed a homozygous deletion of exons 13 and 14. The father was found to have a heterozygous loss of both exons, whereas the mother was normal. INTERVENTIONS: Patient was treated with potassium citrate. OUTCOMES: The patient has shown normal pH and potassium levels. LESSONS: This is the first case of a homozygous deletion in ATP6V0A4 reported in the literature. Although the initial auditory screening was normal in this case, this patient will nevertheless undergo long-term auditory testing.


Assuntos
Acidose Tubular Renal/genética , Acidose/tratamento farmacológico , Acidose/etiologia , Acidose Tubular Renal/complicações , Acidose Tubular Renal/diagnóstico , China , Feminino , Homozigoto , Humanos , Hipopotassemia/tratamento farmacológico , Hipopotassemia/etiologia , Lactente , Citrato de Potássio/uso terapêutico , Deleção de Sequência
7.
Ann R Coll Surg Engl ; 101(6): e131-e132, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31155884

RESUMO

A 52-year-old man was admitted with diarrhoea and faecaluria and referred recurrent urinary tract infections for over 20 years. He also reported a two-week hospital admission more than 20 years ago for right iliac fossa pain, which was managed conservatively. Computed tomography showed a fistulous tract extending from the bladder with an unclear connection to the bowel. Cystoscopy confirmed the presence of a vesical fistula and biopsy of the tract confirmed colonic mucosa. Flexible sigmoidoscopy was negative. A cystogram was requested as an outpatient procedure and the patient was discharged after antibiotic treatment. A few days after discharge the patient was readmitted as an emergency to critical care for severe hyperchloraemic hypokalaemic acidosis and a Glasgow Coma Score of 6/15. He was intubated and ventilated and his metabolic derangement was treated. As soon as his conditions improved, he underwent emergency laparotomy, which revealed the presence of a fistula between the caecal fundus and the bladder. The fistula was repaired and the patient recovered swiftly and completely and was discharged on postoperative day 5. At 12-month follow up the patient was completely symptoms-free, his bowel habits were normal and he has not had any urinary infection. Appendicovesical fistula is a rare and potentially lethal condition due to its metabolic consequences. Past history of right iliac fossa pain treated conservatively, diarrhoea and recurrent urinary tract infection must raise suspicion.


Assuntos
Acidose/diagnóstico , Apêndice , Fístula Intestinal/diagnóstico , Fístula da Bexiga Urinária/diagnóstico , Acidose/etiologia , Apêndice/diagnóstico por imagem , Cloretos/sangue , Humanos , Hipopotassemia/etiologia , Fístula Intestinal/complicações , Fístula Intestinal/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , Fístula da Bexiga Urinária/complicações , Fístula da Bexiga Urinária/diagnóstico por imagem
8.
Lancet ; 394(10196): 396-406, 2019 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-31248662

RESUMO

BACKGROUND: Metabolic acidosis, a complication of chronic kidney disease, causes protein catabolism and bone demineralisation and is associated with adverse kidney outcomes and mortality. Veverimer, a non-absorbed, counterion-free, polymeric drug candidate selectively binds and removes hydrochloric acid from the gastrointestinal lumen. METHODS: We did a multicentre, randomised, blinded, placebo-controlled, 40-week extension of a 12-week parent study at 29 sites (hospitals and specialty clinics) in seven countries (Bulgaria, Georgia, Hungary, Serbia, Slovenia, Ukraine, and the USA). Eligible patients were those with chronic kidney disease (estimated glomerular filtration rate 20-40 mL/min per 1·73 m2) and metabolic acidosis (serum bicarbonate 12-20 mmol/L), who had completed the 12-week parent study, for which they were randomly assigned (4:3) to veverimer (6 g/day) or placebo as oral suspensions in water with food. Participants in the extension continued with the same treatment assignment as in the parent study. The primary endpoint was safety; the four secondary endpoints assessed the long-term effects of veverimer on serum bicarbonate concentration and physical functioning. The safety analysis set was defined as all patients who received any amount of study drug. This trial is registered at ClinicalTrials.gov, number NCT03390842, and has now completed. FINDINGS: Participants entered the study between Dec 20, 2017, and May 4, 2018. Of the 217 patients randomly assigned to treatment in the parent study (124 to veverimer and 93 to placebo), 196 patients (114 veverimer and 82 placebo) continued on their blinded randomised treatment assignment into this 40-week extension study. Compared with placebo, fewer patients on veverimer discontinued treatment prematurely (3% vs 10%, respectively), and no patients on veverimer discontinued because of an adverse event. Serious adverse events occurred in 2% of veverimer-treated patients and in 5% of placebo patients (two of whom died). Renal system adverse events were reported in 8% and 15% in the veverimer and placebo groups, respectively. More patients on veverimer than placebo had an increase in bicarbonate (≥4 mmol/L or normalisation) at week 52 (63% vs 38%, p=0·0015) and higher bicarbonate concentrations were observed with veverimer than placebo at all timepoints starting at week 1 (p<0·001). Veverimer resulted in improved patient-reported physical functioning (Kidney Disease and Quality of Life-Physical Function Domain) versus placebo with a mean placebo-subtracted change at end of treatment of 12·1 points (SE 3·3; p<0·0001). Time to do the repeat chair stand test improved by 4·3 s (1·2) on veverimer versus 1·4 s (1·2) on placebo (p<0·0001). INTERPRETATION: In patients with chronic kidney disease and metabolic acidosis, veverimer safely and effectively corrected metabolic acidosis and improved subjective and objective measures of physical function. FUNDING: Tricida.


Assuntos
Acidose/tratamento farmacológico , Polímeros/administração & dosagem , Insuficiência Renal Crônica/complicações , Acidose/etiologia , Acidose/metabolismo , Administração Oral , Idoso , Bicarbonatos/metabolismo , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polímeros/efeitos adversos , Insuficiência Renal Crônica/metabolismo , Resultado do Tratamento
9.
Adv Neonatal Care ; 19(3): 198-204, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30969944

RESUMO

BACKGROUND: Any maternal history of blood loss, ABO or Rh incompatibility, and hydrops fetalis often leads to suspicion of neonatal anemia postnatally. When maternal history consists only of decreased fetal movement, recognition of neonatal anemia can be problematic. CLINICAL FINDINGS: This case was a transported late preterm neonate who presented initially with persistent hypoxia unresponsive to usual respiratory support. On examination, mild paleness was noted. PRIMARY DIAGNOSIS: Anemia caused by fetal-maternal hemorrhage was the ultimate diagnosis confirmed by a Kleihauer-Betke test on maternal serum examining fetal cells. INTERVENTIONS: Neonatal resuscitation included positive pressure ventilation, oxygen, and intubation. However, oxygenation did not improve prompting consultation with the neonatologist. Sedation and a paralytic were given. A chest radiograph ruled out pneumothoraces and pleural effusions as causative. Initiation of inhaled nitric oxide produced a mild response. Eventually, the transport nurse obtained a complete blood count indicating severe anemia, which prompted an emergent blood transfusion. The accepting neonatology team consulted with the obstetrician and a Kleihauer-Betke test was performed on mother's blood confirming a large fetal-maternal hemorrhage. OUTCOMES: This neonate responded well to blood transfusions, a pressor, and respiratory support and was discharged home at 7 days of life. PRACTICE RECOMMENDATIONS: Recognition of postnatal anemia is vital to sustaining life and this can occur in the transport environment. When maternal history is nonspecific and a neonate is hypoxic, uncommon causes of hypoxia can be identified with consultation and a complete blood count.


Assuntos
Anemia Neonatal/diagnóstico , Transfusão Feto-Materna/diagnóstico , Acidose/etiologia , Anemia Neonatal/etiologia , Anemia Neonatal/terapia , Gasometria , Transfusão de Sangue , Feminino , Transfusão Feto-Materna/complicações , Humanos , Hipovolemia/etiologia , Hipóxia/etiologia , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Transferência de Pacientes , Gravidez , Respiração Artificial , Vasoconstritores/uso terapêutico
10.
J Med Case Rep ; 13(1): 79, 2019 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-30853027

RESUMO

BACKGROUND: Insulin autoimmune syndrome is a rare cause of hyperinsulinemic hypoglycemia characterized by autoantibodies to human insulin without previous insulin use. We report a case of a patient with hyperinsulinemic hypoglycemia possibly caused by insulin antibodies induced by insulin analogs and a novel therapeutic measure for this condition. CASE PRESENTATION: An 84-year-old Japanese man with a 28-year history of type 2 diabetes and chronic kidney disease, treated with biphasic insulin aspart 30, experienced persistent early morning hypoglycemia with daytime hyperglycemia. Despite discontinuation of biphasic insulin aspart 30, the condition persisted even after the patient ate small, frequent meals. Sodium bicarbonate was administered to correct the chronic metabolic acidosis, which then rectified the early morning glucose level. CONCLUSIONS: We believe this to be the first published case of a therapeutic approach to the treatment of hyperinsulinemic hypoglycemia associated with insulin antibodies that factors in blood pH and the correction of acidosis using sodium bicarbonate, which physicians could consider.


Assuntos
Acidose/tratamento farmacológico , Álcalis/uso terapêutico , Doenças Autoimunes/tratamento farmacológico , Hiperinsulinismo/tratamento farmacológico , Hipoglicemia/tratamento farmacológico , Anticorpos Anti-Insulina/efeitos adversos , Bicarbonato de Sódio/uso terapêutico , Acidose/etiologia , Idoso de 80 Anos ou mais , Doenças Autoimunes/fisiopatologia , Humanos , Hiperinsulinismo/fisiopatologia , Hipoglicemia/fisiopatologia , Masculino , Síndrome
11.
Curr Opin Anaesthesiol ; 32(3): 384-391, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30925513

RESUMO

PURPOSE OF REVIEW: The composition and type of intravenous fluids during paediatric anaesthesia have been subjects of debates for decades. Errors in perioperative fluid management in children may lead to serious complications and a negative outcome. Therefore, in this review, historical and recent developments and recommendations for perioperative fluid management in children are presented, based on physiology and focused on safety and efficacy. RECENT FINDINGS: Optimized fasting times and liberal clear fluid intake until 1 h improve patient comfort and metabolic and haemodynamic condition after induction of anaesthesia. Physiologically composed balanced isotonic electrolyte solutions are safer than hypotonic electrolyte solutions or saline 0.9% to protect young children against the risks of hyponatraemia and hyperchloraemic acidosis. For intraoperative maintenance infusion, addition of 1-2% glucose is sufficient to avoid hypoglycaemia, lipolysis or hyperglycaemia. Modified fluid gelatine or hydroxyethyl starch in balanced electrolyte solution can safely be used to quickly normalize blood volume in case of perioperative circulatory instability and blood loss. SUMMARY: Physiologically composed balanced isotonic electrolyte solutions are beneficial for maintaining homeostasis, shifting the status more towards the normal range in patients with preexisting imbalances and have a wide margin of safety in case of accidental hyperinfusion.


Assuntos
Anestesia/métodos , Eletrólitos/administração & dosagem , Hidratação/métodos , Soluções Isotônicas/administração & dosagem , Assistência Perioperatória/métodos , Acidose/etiologia , Acidose/prevenção & controle , Anestesia/efeitos adversos , Criança , Jejum/fisiologia , Hidratação/normas , Homeostase/fisiologia , Humanos , Hiponatremia/etiologia , Hiponatremia/prevenção & controle , Infusões Intravenosas , Assistência Perioperatória/normas
12.
BMC Pregnancy Childbirth ; 19(1): 104, 2019 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-30922264

RESUMO

BACKGROUND: This study was to evaluate the impact of different preoperative fasting conditions on women and neonates through a retrospective analysis. METHODS: A total of 1599 women were divided into 5 groups according to different preoperative fasting times: group A: solid food ≥8 h; clear fluids ≥6 h; B: solid food ≥8 h; clear fluids ≥2 h < 6 h; C: solid food ≥6 h < 8 h; clear fluids < 2 h; D: solid food ≥2 h < 6 h; clear fluids < 2 h; E: solid food < 2 h; clear fluids < 2 h. RESULTS: Incidence rate of vomiting of women was lower in group C (solid food ≥6 h < 8 h and clear fluids < 2 h) than other groups (P <  0.05). Compared with the fasting for a long time (groups A and B: solid food > 8 h and clear fluids > 2 h at least), the incidence rate of hypoglycemia and acidosis of neonates in group C displayed a certain decrease (P <  0.05). Although shorter fasting times (solid food < 6 h at least) reduced the incidence of hypoglycemia and acidosis in neonates, it increased the risk of vomiting of women. CONCLUSION: The preoperative fasting of solid food ≥6 h < 8 h and clear fluids < 2 h reduces the incidence of vomiting in women's anesthesia and the risk of hypoglycemia and acidosis in neonates.


Assuntos
Cesárea/efeitos adversos , Jejum/efeitos adversos , Doenças do Recém-Nascido/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios/métodos , Vômito/epidemiologia , Acidose/epidemiologia , Acidose/etiologia , Adulto , Feminino , Humanos , Hipoglicemia/epidemiologia , Hipoglicemia/etiologia , Incidência , Recém-Nascido , Doenças do Recém-Nascido/etiologia , Complicações Pós-Operatórias/etiologia , Gravidez , Cuidados Pré-Operatórios/efeitos adversos , Estudos Retrospectivos , Fatores de Tempo , Vômito/etiologia
13.
J Pediatr Endocrinol Metab ; 32(4): 335-340, 2019 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-30862760

RESUMO

Background Thiamine deficiency is commonly reported in patients with diabetes especially during diabetic ketoacidosis (DKA) that could attribute to myocardial dysfunction in those patients. However, there is limited data regarding its relation to myocardial function among those patients. This study aimed to explore the association between myocardial function and serum thiamine levels in children with type 1 diabetes mellitus (DM). Methods This cross-sectional comparative study included 25 patients with DKA. Clinical data assessment, echocardiographic examination and measurement of serum high-sensitive troponin T (hs-cTnT) and thiamine levels were done. We also assessed the association between troponin levels, echocardiographic ventricular systolic and diastolic function and serum thiamine. Results Twenty-four percent of children with DKA had thiamine deficiency. DKA children with thiamine deficiency had significant acidosis and higher serum troponin levels and significant impairment of diastolic function than those without thiamine deficiency. The serum thiamine level had a significant positive correlation with the echocardiographic indices of diastolic function but negative correlation with troponin levels. Conclusions Thiamine deficiency is a common finding during the treatment of children with DKA, and this deficiency may be associated with myocardial dysfunction.


Assuntos
Acidose/etiologia , Biomarcadores/sangue , Cardiomiopatias/sangue , Cardiomiopatias/etiologia , Cetoacidose Diabética/fisiopatologia , Deficiência de Tiamina/complicações , Tiamina/sangue , Acidose/sangue , Acidose/patologia , Adolescente , Cardiomiopatias/patologia , Criança , Pré-Escolar , Estudos Transversais , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Deficiência de Tiamina/epidemiologia
14.
Lancet ; 393(10179): 1417-1427, 2019 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-30857647

RESUMO

BACKGROUND: Patients with advanced chronic kidney disease lose the capacity to fully excrete endogenous acid, resulting in chronic metabolic acidosis that increases the risk of disease progression and causes muscle catabolism and bone resorption. Veverimer, a non-absorbed, counterion-free, polymeric drug, selectively binds and removes hydrochloric acid from the gastrointestinal lumen, unlike current oral sodium bicarbonate therapy for metabolic acidosis that only neutralises accumulated acid. We assessed the efficacy and safety of veverimer as a treatment for metabolic acidosis in patients with chronic kidney disease. METHODS: We did a multicentre, parallel, randomised, double-blind, placebo-controlled study at 37 sites (hospitals and specialty clinics) in Bulgaria, Croatia, Georgia, Hungary, Serbia, Slovenia, Ukraine, and the USA. Eligible participants were patients aged 18-85 years with non-dialysis-dependent chronic kidney disease (estimated glomerular filtration rate of 20-40 mL/min per 1·73 m2) and metabolic acidosis (serum bicarbonate concentration of 12-20 mmol/L). Patients were randomly assigned (4:3) to veverimer 6 g/day or placebo for 12 weeks while they consumed their typical diet. Both drugs were taken as oral suspensions in water with lunch. Randomisation was done by study site personnel with a computer-generated randomisation code with balanced permuted blocks (block size of seven) and stratified by baseline bicarbonate (≤18 mmol/L vs >18 mmol/L). Patients and investigators were masked to treatment allocation; however, because the appearance of placebo differed from veverimer, a non-masked site staff member who had no other role in the study dispensed, prepared, and supervised dosing of the study drugs. The composite primary efficacy endpoint was the difference (veverimer-placebo) in the proportion of patients achieving at week 12 either an increase of 4 mmol/L or more from baseline in serum bicarbonate concentration or serum bicarbonate in the normal range of 22-29 mmol/L, assessed in the modified intention-to-treat population (all patients with a baseline and at least one post-baseline serum bicarbonate value). Patients fasted for at least 4 h (consuming only water) before measurements of bicarbonate. Safety was assessed in all patients who received any amount of study drug. This trial is registered with ClinicalTrials.gov, number NCT03317444. FINDINGS: Between Sept 26, 2017, and Feb 9, 2018, we randomly assigned 124 participants to veverimer and 93 to placebo. The composite primary endpoint was met by 71 (59%) of 120 patients in the veverimer group versus 20 (22%) of 89 patients in the placebo group (a difference of 37%, 95% CI 23-49; p<0·0001). The most common body system in which adverse events in the veverimer group occurred was gastrointestinal; of these, non-treatment limiting diarrhoea was the most common event (11 [9%] vs three [3%] in the veverimer and placebo groups, respectively). The most common treatment-related adverse events were gastrointestinal (diarrhoea, flatulence, nausea, and constipation) occurring in 16 (13%) patients with veverimer and five (5%) patients with placebo. Two deaths occurred during the study, both in the placebo group (unstable angina and pneumonia). INTERPRETATION: Veverimer effectively and safely corrected metabolic acidosis. Longer-term studies are warranted to assess the effects of veverimer on physical functioning and to assess other deleterious consequences of metabolic acidosis including progression of chronic kidney disease and bone health. FUNDING: Tricida.


Assuntos
Acidose/tratamento farmacológico , Ácido Gástrico , Polímeros/uso terapêutico , Insuficiência Renal Crônica/complicações , Acidose/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bicarbonatos/sangue , Reagentes para Ligações Cruzadas/química , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polímeros/química , Resultado do Tratamento
15.
Am J Trop Med Hyg ; 100(2): 275-279, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30734693

RESUMO

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.


Assuntos
Acidose/epidemiologia , Anemia/epidemiologia , Coinfecção/epidemiologia , Malária Vivax/epidemiologia , Insuficiência de Múltiplos Órgãos/epidemiologia , Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Trombocitopenia/epidemiologia , Acidose/etiologia , Acidose/mortalidade , Acidose/parasitologia , Adolescente , Adulto , Idoso , Anemia/etiologia , Anemia/mortalidade , Anemia/parasitologia , Criança , Pré-Escolar , Coinfecção/complicações , Coinfecção/mortalidade , Coinfecção/parasitologia , Feminino , Humanos , Índia/epidemiologia , Lactente , Recém-Nascido , Malária Falciparum , Malária Vivax/complicações , Malária Vivax/mortalidade , Malária Vivax/parasitologia , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Insuficiência de Múltiplos Órgãos/parasitologia , Plasmodium falciparum/crescimento & desenvolvimento , Plasmodium falciparum/patogenicidade , Plasmodium vivax/crescimento & desenvolvimento , Plasmodium vivax/patogenicidade , Prevalência , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Síndrome do Desconforto Respiratório do Adulto/parasitologia , Índice de Gravidade de Doença , Análise de Sobrevida , Trombocitopenia/etiologia , Trombocitopenia/mortalidade , Trombocitopenia/parasitologia
16.
Artif Organs ; 43(8): 719-727, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30706485

RESUMO

Low flow extracorporeal veno-venous CO2 removal (ECCO2 R) therapy is used to remove CO2 while reducing ventilation intensity. However, the use of this technique is limited because efficiency of CO2 removal and potential beneficial effects on pulmonary hemodynamics are not precisely established. Moreover, this technique requires anticoagulation that may induce severe complications in critically ill patients. Therefore, our study aimed at determining precise efficiency of CO2 extraction and its effects on right ventricular (RV) afterload, and comparing regional anticoagulation with citrate to systemic heparin anticoagulation during ECCO2 R. This study was performed in an experimental model of severe hypercapnic acidosis performed in two groups of three pigs. In the first group (heparin group), pigs were anticoagulated with a standard protocol of unfractionated heparin while citrate was used for ECCO2 R device anticoagulation in the second group (citrate group). After sedation, analgesia and endotracheal intubation, pigs were connected to a volume-cycled ventilator. Severe hypercapnic acidosis was obtained by reducing tidal volume by 60%. ECCO2 R was started in both groups when arterial pH was lower than 7.2. Pump Assisted Lung Protection (PALP, Maquet, Rastatt, Germany) system was used to remove CO2 . CO2 extraction, arterial pH, PaCO2 as well as systemic and pulmonary hemodynamic were continuously followed. Mean arterial pH was normalized to 7.37 ± 1.4 at an extracorporeal blood flow of 400 mL/min, coming from 7.11 ± 1.3. RV end-systolic pressure increased by over 30% during acute hypercapnic acidosis and was normalized in parallel with CO2 removal. CO2 extraction was not significantly increased in citrate group as compared to heparin group. Mean ionized calcium and MAP were significantly lower in the citrate group than in the heparin group during ECCO2 R (1.03 ± 0.20 vs. 1.33 ± 0.19 and 57 ± 14 vs. 68 ± 15 mm Hg, respectively). ECCO2 R was highly efficient to normalize pH and PaCO2 and to reduce RV afterload resulting from hypercapnic acidosis. Regional anticoagulation with citrate solution was as effective as standard heparin anticoagulation but did not improve CO2 removal and lead to more hypocalcemia and hypotension.


Assuntos
Acidose/terapia , Anticoagulantes/uso terapêutico , Dióxido de Carbono/isolamento & purificação , Citratos/uso terapêutico , Oxigenação por Membrana Extracorpórea/métodos , Hipercapnia/terapia , Acidose/etiologia , Animais , Feminino , Heparina/uso terapêutico , Hipercapnia/complicações , Masculino , Respiração Artificial/métodos , Suínos
17.
World Neurosurg ; 125: e972-e977, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30763747

RESUMO

OBJECTIVE: We created a neck trauma model by injecting blood into the sheath of rabbits' carotid bodies (CBs). Then we determined the relationship between neuronal degeneration of the CB due to hemorrhage of this organ and its clinical effects such as blood pH and heart rhythm. METHODS: The present study included 24 adult male New Zealand rabbits. The animals were divided into 3 groups: control (n = 5); sham (0.5 mL saline injected into CBs; n = 5); and study (CB trauma model; n = 14). pH values and heart rhythms were recorded before the experiment to determine the values under normal conditions, and measurements were repeated thrice in the days following the experiment. The number of normal and degenerated neuron density of CBs was counted. The relationship between the blood pH values, heart rhythms, and degenerated neuron densities was analyzed. RESULTS: Heart rhythms were 218 ± 20 in the control group, 197 ± 16 in the sham group (P = 0.09), and 167 ± 13 in the study group (P < 0.0005). pH values were 7.40 ± 0.041 in the control group, 7.321 ± 0.062 in the sham group (P = 0.203), and 7.23 ± 0.02 in study group (P < 0.0005). Degenerated neuron densities were 12 ± 4/mm3 in the control group, 430 ± 74/mm3 in the sham group (P < 0.005), and 7434 ± 810/mm3 in the study group (P < 0.0001). CONCLUSIONS: A high degenerate neuron density in the CB can decrease blood pH and hearth rhythm after neck trauma, and there might be a close relationship between the number of degenerated neurons and clinical findings (such as heart rhythm and blood pH). This relationship suggests that injury to the glossopharyngeal nerve-CB network can cause acidosis by disturbing the breathing-circulating reflex and results in respiratory acidosis.


Assuntos
Acidose/etiologia , Corpo Carotídeo/fisiopatologia , Traumatismos do Nervo Glossofaríngeo/etiologia , Lesões do Pescoço/complicações , Degeneração Neural/etiologia , Animais , Traumatismos do Nervo Glossofaríngeo/fisiopatologia , Frequência Cardíaca/fisiologia , Concentração de Íons de Hidrogênio , Masculino , Lesões do Pescoço/fisiopatologia , Degeneração Neural/fisiopatologia , Coelhos
18.
Eur Radiol ; 29(8): 4096-4104, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30666450

RESUMO

OBJECTIVES: To assess whether increases in amide proton transfer (APT)-weighted signal reflect the effects of tissue recovery from acidosis using transient rat middle cerebral artery occlusion (MCAO) models, compared to permanent occlusion models. MATERIALS AND METHODS: Twenty-four rats with MCAO (17 transient and seven permanent occlusions) were prepared. APT-weighted signal (APTw), apparent diffusion coefficient (ADC), cerebral blood flow (CBF), and MR spectroscopy were evaluated at three stages in each group (occlusion, reperfusion/1 h post-occlusion, and 3 h post-reperfusion/4 h post-occlusion). Deficit areas showing 30% reduction to the contralateral side were measured. Temporal changes were compared with repeated measures of analysis of variance. Relationship between APTw and lactate concentration was calculated. RESULTS: Both APTw and CBF values increased and APTw deficit area reduced at reperfusion (largest p = .002) in transient occlusion models, but this was not demonstrated in permanent occlusion. No significant temporal change was demonstrated with ADC at reperfusion. APTw deficit area was between ADC and CBF deficit areas in transient occlusion model. APTw correlated with lactate concentration at occlusion (r = - 0.49, p = .04) and reperfusion (r = - 0.32, p = .02). CONCLUSIONS: APTw values increased after reperfusion and correlated with lactate content, which suggests that APT-weighted MRI could become a useful imaging technique to reflect tissue acidosis and its reversal. KEY POINTS: • APT-weighted signal increases in the tissue reperfusion, while remains stable in the permanent occlusion. • APTw deficit area was between ADC and CBF deficit areas in transient occlusion model, possibly demonstrating metabolic penumbra. • APTw correlated with lactate concentration during ischemia and reperfusion, indicating tissue acidosis.


Assuntos
Acidose/diagnóstico , Acidose/etiologia , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/patologia , Imagem por Ressonância Magnética/métodos , Acidose/patologia , Amidas , Animais , Circulação Cerebrovascular , Modelos Animais de Doenças , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Masculino , Prótons , Ratos , Ratos Wistar
19.
J Diabetes Investig ; 10(4): 1116-1117, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30659759

RESUMO

A patient with mitochondrial diabetes mellitus developed diabetic ketoacidosis. During insulin treatment, although diabetic ketoacidosis improved, lactic acidosis unexpectedly worsened. This clinical course, named "switched metabolic acidosis," could reflect the unique pathophysiology of the mitochondrial disorder.


Assuntos
Acidose/etiologia , Complicações do Diabetes/etiologia , Diabetes Mellitus/fisiopatologia , Doenças Mitocondriais/complicações , Acidose/tratamento farmacológico , Idoso , Complicações do Diabetes/tratamento farmacológico , Feminino , Humanos , Prognóstico
20.
Rev Bras Anestesiol ; 69(2): 200-203, 2019.
Artigo em Português | MEDLINE | ID: mdl-30651202

RESUMO

BACKGROUND AND OBJECTIVES: A prompt and effective management of trauma patient is necessary. The aim of this case report is to highlight the importance of intraoperative echocardiography as a useful tool in patients suffering from refractory hemodynamic instability no otherwise explained. CASE REPORT: A 41 year-old woman suffered a car accident. At the emergency department, no abnormalities were found in ECG or chest X-ray. Abdominal ultrasound revealed the presence of abdominal free liquid and the patient was submitted to urgent exploratory laparotomy. Nevertheless, she persisted suffering arterial hypotension and metabolic acidosis. Looking for the reason of her hemodynamic instability, intraoperative transthoracic echocardiography was performed, finding out the presence of pericardial effusion. Once the cardiac surgeon extracted pericardial clots, patient's situation improved clinically and analytically. CONCLUSION: Every anesthesiologist should be able to use the intraoperative echocardiography as an effective tool in order to establish the appropriate measures to promote the survival of patients suffering severe trauma.


Assuntos
Ecocardiografia/métodos , Hemodinâmica , Derrame Pericárdico/diagnóstico por imagem , Ultrassonografia/métodos , Acidentes de Trânsito , Acidose/etiologia , Adulto , Feminino , Humanos , Hipotensão/etiologia , Cuidados Intraoperatórios/métodos
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