Faculty Opinions recommendation of Acetazolamide-mediated decrease in strong ion difference accounts for the correction of metabolic alkalosis in critically ill patients.

Crystalloids in critical illness

10.1093/med/9780199600830.003.0057 ◽

2016 ◽

Author(s):

Karthik Raghunathan ◽

Andrew Shaw

Keyword(s):

Critical Illness ◽

Critically Ill ◽

Critically Ill Patients ◽

Endothelial Glycocalyx ◽

Strong Ion Difference ◽

Negative Consequences ◽

Negative Effects ◽

Randomized Controlled Studies ◽

Preload Responsiveness ◽

Saline Solutions

‘Crystalloid’ refers to solutions of crystalline substances that can pass through a semipermeable membrane and are distributed widely in body fluid compartments. The conventional Starling model predicts transvascular exchange based on the net balance of opposing hydrostatic and oncotic forces. Based on this model, colloids might be considered superior resuscitative fluids. However, observations of fluid behaviour during critical illness are not consistent with such predictions. Large randomized controlled studies have consistently found that colloids offer no survival advantage relative to crystalloids in critically-ill patients. A revised Starling model describes a central role for the endothelial glycocalyx in determining fluid disposition. This model supports crystalloid utilization in most critical care settings where the endothelial surface layer is disrupted and lower capillary pressures (hypovolaemia) make volume expansion with crystalloids effective, since transvascular filtration decreases, intravascular retention increases and clearance is significantly reduced. There are important negative consequences of both inadequate and excessive crystalloid resuscitation. Precise dosing may be titrated based on functional measures of preload responsiveness like pulse pressure variation or responses to manoeuvres such as passive leg raising. Crystalloids have variable electrolyte concentrations, volumes of distribution, and, consequently variable effects on plasma pH. Choosing balanced crystalloid solutions for resuscitation may be potentially advantageous versus ‘normal’ (isotonic, 0.9%) saline solutions. When used as the primary fluid for resuscitation, saline solutions may have adverse effects in critically-ill patients secondary to a reduction in the strong ion difference and hyperchloraemic, metabolic acidosis. Significant negative effects on immune and renal function may result as well.

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Low bicarbonate replacement fluid normalizes metabolic alkalosis during continuous veno-venous hemofiltration with regional citrate anticoagulation

Annals of Intensive Care ◽

10.1186/s13613-021-00850-4 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Paul Köglberger ◽

Sebastian J. Klein ◽

Georg Franz Lehner ◽

Romuald Bellmann ◽

Andreas Peer ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Metabolic Alkalosis ◽

Base Excess ◽

Kidney Injury ◽

Regional Citrate Anticoagulation ◽

Citrate Anticoagulation ◽

Future Studies ◽

Replacement Fluid ◽

Retrospective Comparative Study

Abstract Background Metabolic alkalosis is a frequently occurring problem during continuous veno-venous hemofiltration (CVVH) with regional citrate anticoagulation (RCA). This study aimed to evaluate the effectiveness of switching from high to low bicarbonate (HCO3−) replacement fluid in alkalotic critically ill patients with acute kidney injury treated by CVVH and RCA. Methods A retrospective-comparative study design was applied. Patients who underwent CVVH with RCA in the ICU between 09/2016 and 11/2017 were evaluated. Data were available from the clinical routine. A switch of the replacement fluid Phoxilium® (30 mmol/l HCO3−) to Biphozyl® (22 mmol/l HCO3−) was performed as blood HCO3− concentration persisted ≥ 26 mmol/l despite adjustments of citrate dose and blood flow. Data were collected from 72 h before the switch of the replacement solutions until 72 h afterwards. Results Of 153 patients treated with CVVH during that period, 45 patients were switched from Phoxilium® to Biphozyl®. Forty-two patients (42 circuits) were available for statistical analysis. After switching the replacement fluid from Phoxilium® to Biphozyl® the serum HCO3− concentration decreased significantly from 27.7 mmol/l (IQR 26.9–28.9) to 25.8 mmol/l (IQR 24.6–27.7) within 24 h (p < 0.001). Base excess (BE) decreased significantly from 4.0 mmol/l (IQR 3.1–5.1) to 1.8 mmol/l (IQR 0.2–3.4) within 24 h (p < 0.001). HCO3− and BE concentration remained stable from 24 h till the end of observation at 72 h after the replacement fluid change (p = 0.225). pH and PaCO2 did not change significantly after the switch of the replacement fluid until 72 h. Conclusions This retrospective analysis suggests that for patients developing refractory metabolic alkalosis during CVVH with RCA the use of Biphozyl® reduces external HCO3− load and sustainably corrects intracorporeal HCO3− and BE concentrations. Future studies have to prove whether correcting metabolic alkalosis during CVVH with RCA in critically ill patients is of relevance in terms of clinical outcome.

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Rising serum sodium levels are associated with a concurrent development of metabolic alkalosis in critically ill patients

Intensive Care Medicine ◽

10.1007/s00134-012-2753-3 ◽

2012 ◽

Vol 39 (3) ◽

pp. 399-405 ◽

Cited By ~ 14

Author(s):

Gregor Lindner ◽

Christoph Schwarz ◽

Heidelinde Grüssing ◽

Nikolaus Kneidinger ◽

Andreas Fazekas ◽

...

Keyword(s):

Critically Ill ◽

Serum Sodium ◽

Critically Ill Patients ◽

Metabolic Alkalosis ◽

Concurrent Development

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The use of sodium-chloride difference and chloride-sodium ratio as strong ion difference surrogates in the evaluation of metabolic acidosis in critically ill patients

Journal of Critical Care ◽

10.1016/j.jcrc.2010.02.003 ◽

2010 ◽

Vol 25 (3) ◽

pp. 525-531 ◽

Cited By ~ 29

Author(s):

Danielle Nagaoka ◽

Antonio Paulo Nassar Junior ◽

Alexandre Toledo Maciel ◽

Leandro Utino Taniguchi ◽

Danilo Teixeira Noritomi ◽

...

Keyword(s):

Metabolic Acidosis ◽

Sodium Chloride ◽

Critically Ill ◽

Critically Ill Patients ◽

Strong Ion Difference

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Prediction of mortality with unmeasured anions in critically ill patients on mechanical ventilation

Vojnosanitetski pregled ◽

10.2298/vsp1410936n ◽

2014 ◽

Vol 71 (10) ◽

pp. 936-941 ◽

Cited By ~ 5

Author(s):

Milos Novovic ◽

Jasna Jevdjic

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Metabolic Acidosis ◽

Mortality Rate ◽

Critically Ill ◽

Critically Ill Patients ◽

Apache Ii ◽

Strong Ion Difference ◽

Acid Base ◽

Prediction Of Mortality

Background/Aim. Acid-base disorders are common within critically ill patients. Physicochemical approach described by Stewart and modified by Figge gives precise quantification method of metabolic acidosis and insight into its main mechanisms, as well as influence of unmeasured anion on metabolic acidosis. The aims of this study were to determine whether the conventional acid-base variables are connected with survival rate of critically ill patients at Intensive care unit; whether strong ion difference/strong ion gap (SID/SIG) is a better predictor of mortality rate comparing to conventional acid-base variables; to determine all significant predictable parameters for the 28-day mortality rate at intensive care units. Methods. This retrospective observational analytic study included 142 adult patients requiring mechanical ventilation, survivors (n = 68) and nonsurvivors (n = 74). Apparent strong ion difference (SIDapp), effective strong ion difference (SIDeff) and SIG values were calculated with the Stewart-Figge?s quantitative biophysical method. Descriptive and analytical statistical methods were used in the study [t-test, Mann-Whitney U test, ?2-test, binary logistic regression, Reciever operating characteristic (ROC) curves, calibration]. Results. Age, Na+, acute physiology and chronic health evaluation (APACHE II), Cl-, albumin, SIG, SID app, SIDeff, and aninon gap (AG) were statistically significant predictors. AG represented a model with imprecise calibration, i.e. a model with little predictive power. APACHE II had p-value more than 0.05 if it was near it, and therefore it could be considered potentially unreliable for outcome prediction. SIDeff and SIG represented models with well-defined calibration. ROC analysis results showed that APACHE II, Cl-, albumin, SIDeff, SIG i AG had the largest area bellow the curve. By creation of logistic models with calibration methods, we found that outcome depends on SIG and APACHE II score. Conclusion. Based on our data, unmeasured anions provide prediction of mortality of critically ill patients on mechanical ventilation, unlike the traditional acid-base variables which are not accurate predictors of the 28-day mortality rate.

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