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Objective:To investigate the correlation between strong ion gap (SIG) and prognosis of adult hospitalized patients who experienced cardiac arrest (CA).Methods:A retrospective cohort study was conducted on adult CA patients (≥18 years old) who were admitted to the intensive care unit (ICU) for the first time from the Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) database from 2001 to 2012. The patients were divided into 3 groups based on the tertiles of serum SIG value. The clinical baseline characteristics and related data of CA patients were compared. Kaplan-Meier method was used to draw the 28- and 90-day cumulative survival curves of CA patients. Meanwhile, the log-rank test was used to compare the differences in the survival curves among different groups, and Cox proportional hazard regression model was established to analyze whether SIG was an independent predictor of all-cause mortality in CA patients.Results:Six hundred and six adult CA patients were eligible for final analysis. The patients were divided into 3 groups based on the tertiles of serum SIG value [<3.91 mmol/L ( n=202), 3.91~7.32 mmol/L ( n=202) and >7.32 mmol/L ( n=202)]. The mean age was (66.91±15.95) years and 382 patients (63.04%) were male. The all-cause mortality rates of ICU, 28 days and 90 days were 36.47%, 49.17% and 56.93%, respectively. There were significant differences in SOFA score, SIG, anion gap, pH, lactic acid, white blood cells, prothrombin time, creatinine, blood potassium, blood phosphorus, hypertension, coronary heart disease, cardiogenic shock, and ICU, 28-day and 90-day all-cause mortality among the 3 groups (all P<0.05). The Kaplan-Meier survival curves showed that the 28- and 90-day cumulative survival rates of CA patients decreased gradually with the increase of SIG level, and the differences were statistically significant among the 3 groups (all P<0.001). Multivariate Cox proportional hazard models showed that the increase of SIG level (>7.32 mmol/L) was an independent risk factor for 28-day ( HR=1.610, 95% CI: 1.177-2.203, P=0.003) and 90-day all-cause mortality ( HR=1.506, 95% CI: 1.123-2.019, P=0.006) among CA patients, after adjusting for the related confounders. Conclusions:The elevated SIG level (>7.32 mmol/L) is an independent predictor of 28- and 90-day all-cause mortality in CA patients. The calculation of SIG level in these patients is helpful for early identification of patients with poor prognosis.
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Objective To investigate the value of strong ion gap (SIG) for predicting acute heart failure (AHF) after acute myocardial infarction. Methods A total of 189 patients with acute myocardial infarction were enrolled from July 2015 to December 2016 in the First Affiliated Hospital of Soochow University. Based on AHF occurrence, the patients were divided into the AHF group (n=76) and the non-AHF group (n=113). General clinical data and laboratory tests were compared between the two groups. The univariate analysis and multivariate logistic regression analysis were performed to estimate the contribution of clinical risk factors to triggering AHF after acute myocardial infarction. Spearman correlation analysis was performed to estimate the correlation between SIG and Killip classification. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of ALB, anion gap (AG) and SIG in AHF after acute myocardial infarction. Results Age, proportion of history of diabetes, the serum level of C-reactive protein (CRP), AG and SIG of the AHF group were higher than those of the non-AHF group (P<0.05). Meanwhile, the serum level of albumin (ALB) of the AHF group were lower than those of the non-AHF group (P<0.05). Univariate analysis showed AHF after acute myocardial infarction was closely associated with age, history of diabetes, serum ALB, AG and SIG (P<0.05). Multivariate logistic regression analysis showed that history of diabetes (OR=2.034, 95％CI:1.075-4.113, P<0.05) and SIG (OR=2.445, 95％CI: 1.538-4.297, P<0.05) were significantly correlated with AHF after acute myocardial infarction. The ROC analysis revealed SIG (AUC=0.837,95％CI:0.781-0.893) had a large area under curve compared to ALB (AUC=0.671,95％CI: 0.593-0.750) and AG (AUC=0.728,95％CI: 0.654-0.802). The optimal diagnostic intercept value was 5.24 mmol/L, and the sensitivity and specificity were 76.32％ and 78.36％, respectively. Conclusions SIG could be used as an independent predictor for AHF secondary to acute myocardial infarction, and was significantly correlated with severity of AHF.
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Objective To investigate the value of strong ion gap (SIG) in predicting the severity of acute pancreatitis (AP) based on the revised Atlanta classification. Methods A total of 133 patients with AP admitted from January, 2015 to December, 2016 were enrolled. Of them, there were 55 with mild AP (MAP), 52 with moderately severe AP (MSAP) and 26 with severe AP (SAP). All patients with AP conformed to the diagnostic criteria of Guidelines or Diagnosis and Treatment of Acute Pancreatitis set in 2014 in China. Patients with other underlying diseases that might influence the clinical outcome were excluded, including those with diabetic ketoacidosis, chronic renal failure and other disorders. The changes in blood SIG levels in each group were observed. The correlations between SIG and acute physiology, chronic health evaluation (APACHE) Ⅱ score, Ranson score and length of hospital stay were analyzed. The receiver operating characteristic curves (ROC) were plotted to determine the efficiency of SIG, Scr, APACHE Ⅱ score, and Ranson score for predicting the severity of acute pancreatitis. Results The level of SIG in the SAP group was the highest, followed by the MSAP group and the lowest in the MAP group.There were significant differences in pairwise comparisons (P<0.01). The correlations between SIG and APACHE Ⅱ score (r=0.567, P<0.01), Ranson score (r=0.502, P<0.01), and length of hospital stay were positive (r=0.589, P<0.01). There was no statistical difference in the area under curve (AUC) between SIG and APACHE Ⅱ score (0.874±0.029 vs.0.895±0.025, P>0.05) and as well as Ranson score (0.874±0.029 vs. 0.890±0.027, P>0.05) for predicting moderately-severe acute pancreatitis, but SIG was superior to Scr (0.874±0.029 vs. 0.735±0.043, P<0.01). There was a significant difference in AUC between SIG and Scr (0.910±0.030 vs. 0.755±0.054, P<0.01), but no statistical differences between SIG and APACHE Ⅱ score (0.910±0.030 vs. 0.867±0.034, P>0.05) and Ranson score (0.910±0.030 vs. 0.871±0.032, P>0.05) for predicting severe acute pancreatitis. Conclusion SIG has important clinical significance for predicting the severity of acute pancreatitis.
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Objective To investigate the value of strong ion gap (SIG),anion gap (AG),and the anionic gap corrected by albumin (ACAG) and lactate in evaluating the prognosis of severe pneumonia in children. Methods Pediatric patients with severe pneumonia hospitalized in the Affiliated Hospital of North Sichuan Medical College from June 2014 to June 2017 were selected as study subjects. A total of 20 death pa-tients (death group) and 59 survivors (survival group) were analyzed respectively according to their progno-sis. The data of Na + ,K + ,Cl - ,HCO -3 ,Mg2 + ,Ca2 + ,pH,PaCO2 ,P,albumin and lactate were obtained from blood gas analysis and blood biochemistry. Based on these data,ACAG was calculated by the Henderson-hasselbalach formula and SIG was calculated by the Stewart-Figge formula. Results There were significant differences in ACAG,SIG,and lactate levels between death group and survival group(P < 0. 05). The area under the ROC curve of ACAG was 0. 756,and the area under the ROC curve of SIG was 0. 936,which were larger than the area under the diagnostic reference line (P < 0. 05),the results were statistically significant. The sensitivity and specificity of ACAG was 79. 7％ and 70. 0％ respectively,and the cut off was 12. 7. The sensitivity and specificity of SIG was 81. 4％ and 95. 5％ respectively,and the cut off was 2. 7. Conclusion SIG,ACAG and lactate have the guiding value in assessing the prognosis of children with severe pneumonia. Meanwhile,SIG has a greater guiding significance for the assessment of the prognosis of children with severe pneumonia.
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Resumen: Introducción: Existe evidencia clínica de que la brecha de iones fuertes obtenida por el método de Stewart de equilibrio ácido-base es mejor predictora de mortalidad que los parámetros tradicionales en algunos pacientes críticamente enfermos. Objetivo: Evaluar la cinética de depuración de la brecha de iones fuertes en individuos con choque séptico durante las primeras 48 horas de estancia en la unidad de cuidados intensivos. Material y métodos: Se trata de un estudio retrospectivo observacional, con datos obtenidos del expediente clínico, realizado en una unidad de cuidados intensivos adultos en un hospital privado de la ciudad de Monterrey, Nuevo León. Se evaluaron variables demográficas, así como datos obtenidos de gasometrías y química sanguínea al ingreso, a las 24 y 48 horas posteriores, para calcular parámetros tradicionales del equilibrio ácido-base y los obtenidos por el método de Stewart. Se calculó también la cinética de eliminación de dichos parámetros para evaluar sus cambios a través del tiempo y su relación con la mortalidad. Resultados: Se estudiaron 91 personas con choque séptico entre junio de 2014 y junio de 2016, con una mortalidad de 28.6%. La depuración de lactato, brecha aniónica corregida y brecha de iones fuertes a 48 horas no fueron capaces de predecir mortalidad, aunque sí los niveles individuales de dichos parámetros a las 48 horas. El mejor predictor de mortalidad fue AGCOR a 48, con un área bajo la curva ROC de 0.71805, contrario a la brecha de iones fuertes (SIG por sus siglas en inglés) a 48 horas, con un área bajo la curva ROC de 0.67367. Conclusiones: Los cambios a través de las primeras 48 horas de la brecha de iones fuertes son asociados a mortalidad, pero no aportan mayor beneficio que los parámetros tradicionales en sujetos con choque séptico.
Abstract: Introduction: There is clinical evidence that the strong ion gap obtained by Stewart's acid-base approach is a better predictor of mortality than those obtained by the traditional approach in some critically ill patients. Objective: To evaluate the strong ion gap clearance kinetics in patients with septic shock during the first 48 hours in the intensive care unit. Material and methods: A retrospective, observational study obtained from a patient database in a private intensive care unit in Monterrey, Nuevo León. Patient's demographics were analyzed, along with data collected from their laboratory work at admission and at 24 and 48 hours to calculate traditional acid-base parameters and parameters obtained by the Stewart's method. Clearance at 48 hours was also calculated to track their changes over time and to evaluate their relation to patient mortality. Results: Data from 91 patients with septic shock admitted between June 2014 and June 2016 were studied, with a 28.6% mortality rate. Lactate clearance, corrected anion gap clearance and strong ion gap clearance at 48 hours were not related to patient mortality, although their individual values at 48 hours were able to predict mortality. The best predictor of mortality was AGCOR at 48, with an area under the ROC curve of 0.71805, compared with an area under the ROC curve of 0.67367 for SIG at 48 hours. Conclusions: Strong ion gap changes over the first 48 hours were associated with mortality; however, they do not offer any advantage over traditional acid-base parameters in patients with septic shock.
Resumo: Introdução: Existe evidência clínica que o hiato de íons fortes, obtido pelo método de Stewart de ácido-base, é melhor preditor de mortalidade que os parâmetros tradicionais em alguns pacientes graves. Objetivo: Avaliar a cinética de depuração do hiato de íons fortes em pacientes com choque séptico durante as primeiras 48 horas de estadia na unidade de terapia intensiva. Material e métodos: Um estudo retrospectivo, observacional com dados obtidos a partir do prontuário médico. Realizado na UTI de um hospital particular na cidade de Monterrey, em Nuevo León. Foram avaliadas as variáveis demográficas e os dados obtidos a partir da gasometria e química sanguínea na admissão, 24 horas e 48 horas posteriores para calcular os parâmetros tradicionais do equilíbrio ácido-base e os obtidos pelo método de Stewart. Calculou-se também as cinéticas de eliminação destes parâmetros e assim avaliar as alterações ao longo do tempo e a sua relação com a mortalidade. Resultados: Foram estudados 91 pacientes com choque séptico entre junho de 2014 e junho de 2016, com uma taxa de mortalidade de 28.6%. A depuração de lactato, hiato aniônico corrigido e hiato de íons fortes às 48 horas não foram capazes de prever a mortalidade, se bem que previram os níveis individuais de estes parâmetros às 48 horas. O melhor preditor de mortalidade foi AGCOR às 48 com uma área sob a curva ROC de 0.71805, contrário ao SIG às 48 horas com uma área sob a curva ROC de 0.67367. Conclusões: As alterações através das primeiras 48 horas do hiato de íons fortes está associada com a mortalidade, mas não fornecem maior benefício que os parâmetros tradicionais em pacientes com choque séptico.
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Objective To evaluate the probability that strong ion gap was selected as predictive factor of mortality in patients with a -cute respiratory failure.Methods SIG was calculated with the Stewart -Figge model, after determination of blood gas ,blood pH,serum electrolytes.Results ①The incidence of acute respiratory distress syndrome and source pulmonary edema was 26% respectively in pa-tients with ARF.②There was a significant difference in the values of K +、Cl-、HCO3-、AG、pH、ALB、SIG、Cr,lactic acid,PaCO2 and PaO2 between group T 1 and control .However , there was no significant difference between recovery group T 2 and control .③There was a signifi-cant difference in the value of AG and SIG between the recovery group T 1 and death group T 1 from the patients with ARF .④SIG was a better predictor than AG by the evaluation of ROC curve .Conclusions AG and SIG can reflect the worse condition of acid -base disturb-ance in patients with ARF sensitively at the first beginning .Meanwhile , SIG may be served as a predictor for risk of mortality in patients with ARF better than AG .
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Objective To compare the strong ion gap (SIG) and liver and kidney function index predicting the prognosis of acute paraquat poisoning patients.Methods Retrospective study with a total of 148 cases from 2006 to 2013 who were diagnosed by paraquat poisoning,according to the prognosis they are divided into survival group and death group.Compared with the early SIG,ALT,AST,Cr,BUN index level to analyze with the odds ratio (ORs) and established ROC curve to conform which is more effective on the prognosis of patients with paraquat poisoning.Results The abnormal index of glutamic pyruvic transaminase (ALT) (x2=10.257,P =0.001),glutamic oxalacetic transaminase (AST) (x2=9.109,P =0.003),creatinine (Cr) (x2=10.257,P =0.021),blood urea nitrogen (BUN) (x2=10.257,P ＜ 0.01) indicated a higher risk of death than the normal index,SIG showed higher ORs for fatality than ALT,AST,Cr,BUN (P ＜ 0.05).In the ROC curve,the area under the curve of the SIG,ALT,AST,Cr,BUN on the prognosis of fatality were 0.822,0.708,0.724,0.603,0.625.Conclusions With early SIG and ALT,AST,Cr,BUN level increased,the risk of death will increase in paraquat poisoning patients,and SIG is a more effective marker than index of kidney and liver function on the prognosis of death.
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Objective To investigate the clinical application value of strong ion gap(SIG)generated by the third generation equa-tion following pH and the anion gap(AG)in critically ill patients.Methods On the basis of the determination results of blood gas and blood biochemistry,the equation in the Stewart-Figge methodology was adopted to calculate SIG.Results (1)There were sta-tistically significant differences in K+ ,Na+ ,HCO3 - ,AG,pH,PO4 3 - ,ALB,SIG and Cr between the critical illness groups and the control group(P <0.05).(2)The SIG mean value ratio the death group to non-death group was 3.04,the difference was the big-gest,P <0.05,AG and Cr took the second place.Conclusion SIG as a new indicator in combination with other biochemical and blood gas indicators,such as the HCO3 - ,AG,pH,PO4 3 - ,Cr and lactic acid can reflect the situation of the acid-base disorders in critically ill patients and plays a strong indicative role in predicting the disease development trends.
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BACKGROUND: Intraoperative acid-base imbalance frequently occurs during liver transplantation (LT). The purpose of this study was to compare the acid-base changes between cadaveric whole LT and a LT from a living relative using a strong ion approach. METHODS: Twenty-four patients undergoing LT were allocated to a group receiving a LT from a brain dead donor (BD group, n = 12) or a LT from a living, related donor (LD group, n = 12) according to the surgical technique required. Acid-base parameters such as PaCO2, pH, base excess, and serum concentrations of bicarbonate, albumin, lactate, phosphate, and other electrolytes were measured at 30 min after skin incision (T1), 30 min after reperfusion (T2), and 1 h after the arrival at the intensive care unit (T3). The apparent strong ion difference (SIDa), the effective strong ion difference (SIDe), and the strong ion gap (SIG) were calculated using the Stewart equation. RESULTS: There were no significant differences in pH, PaCO2, base excess, SIDa, and SIG between the two groups throughout the entire period of investigation. pH was decreased from T1 to T2, and increased significantly from T2 to T3 in both groups. The serum concentration of lactate was significantly increased from T1 to T2 and T3 in both groups without any intergroup differences. The strong ion gap was significantly increased from T1 to T2 only in the BD group. CONCLUSIONS: During LT from both cadaveric and living related donors, there is a biphasic acid-base change that is characterized by an initial metabolic acidosis and then a metabolic alkalosis, with no significant intergroup differences in acid-base variables.
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Humans , Acid-Base Equilibrium , Acid-Base Imbalance , Acidosis , Alkalosis , Brain Death , Cadaver , Electrolytes , Hydrogen-Ion Concentration , Intensive Care Units , Lactic Acid , Liver , Liver Transplantation , Reperfusion , Skin , Tissue DonorsABSTRACT
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.