Interpretación gasométrica avanzada en el paciente crítico / Advanced gasometric interpretation in critical patient / Interpretação gasométrica avançada no paciente crítico

Resumen: La interpretación gasométrica de forma rápida es muy útil en urgencias, ya que establecer de manera oportuna un diagnóstico es de suma importancia. Existen herramientas que nos permiten igualar la sensibilidad de los métodos complejos de Stewart. Evaluar la gasometría de manera tradicional, dependiendo de la escuela preferida: utilizando sólo el bicarbonato o el exceso de base; tiene baja sensibilidad diagnóstica cuando nos enfrentamos a escenarios donde existe más de un trastorno metabólico asociado. Proponemos los siguientes cinco pasos: evaluar el pH, déficit de base, anión gap, exceso de base y el índice cloro/sodio, que son importantes para identificar de manera rápida y sensible una gasometría en pacientes críticos.

Abstract: The interpretation of a gasometry of rapid form is very useful in an emergency department since to establish in an opportune way a diagnosis performs supreme importance. There exists hardware that allows us to equal the sensibility of the complex m ethods of Stewart. To evaluate the gasometry of a traditional way, depending on the favorite school: using only the bicarbonate or the base excess, it has low diagnostic sensibility when we face stages where more than one metabolic associate disorder exists. We propose the following five steps: to evaluate the pH, deficit of base, anion gap, excess of base, and the index chlorine/sodium, which are important to identify rapidly and sensitively a gasometry in critical patients.

Resumo: A interpretação gasométrica rápida é muito útil em emergências, pois é de suma importância estabelecer um diagnóstico em tempo hábil. Existem ferramentas que nos permitem igualar a sensibilidade dos métodos complexos de Stewart. Avaliar a gasometria da forma tradicional, dependendo da escola preferida: usando apenas bicarbonato ou excesso de base, tem baixa sensibilidade diagnóstica diante de cenários onde há mais de um distúrbio metabólico associado. Propomos as 5 etapas a seguir: avaliação do pH, déficit de base, lacuna aniônica, excesso de base e relação cloreto/sódio, importantes para identificar de forma rápida e sensível os gases sanguíneos em pacientes críticos.

A study on mean anion gap over 6 hours after admission as a predictor of pediatric mortality in pediatric intensive care unit

Background:The aims of the study was to correlate change in anion gap at 0 and 6 hours of admission with mortality in pediatric intensive care unit (PICU).Methods:Fifty children up to 12 years of age, admitted in PICU were included in the study. Blood gas anion gap levels were taken at 0 and 6 hours of admission and change in anion gap was calculated. Final outcome was recorded.Results:Out of 50 patients enrolled in the study, 18 (36%) patients died and 32 (64%) survived. Mortality was higher in group with increased anion gap after 6 hours of admission as compared to survived. Change in anion gap was higher in expired patient as compared to survivors.Conclusions:Mortality was higher in group with increased anion gap after 6 hours of admission

Pancreatic ketoacidosis-a rare case report

Euglycemic Pancreatic Ketoacidosis is a syndrome of high anion gap acidosis in which the high anion gap is due to elevated serum ketone bodies comprising of acetone, aceto- acetate and beta hydroxyl-butyrate, due to increased peripheral adipose tissue breakdown by elevated serum lipase as a consequence of acute pancreatitis with normal blood glucose levels. There are multiple causes for ketonuria and/or ketonemia with or without acidosis like uncontrolled diabetes mellitus, usually of the insulin dependent type (diabetic ketoacidosis), lactic acidosis, prolonged starvation (starvation ketosis), ethanol ingestion (alcoholic ketoacidosis), sepsis, pregnancy and vomiting. Our patient was not a known diabetic and his blood glucose were always within normal limits, so this ketoacidosis cannot be attributed to Diabetes Mellitus. It cannot be attributed to starvation as our patient was not fasting when he got admitted and furthermore ketoacidosis is not a frequent manifestation of starvation adding to it that we transfused adequate amount of DNS and resumed oral intake during our observation period. It cannot be attributed to vomiting as our patient had only two episodes of vomiting. Our patient does not have any liver or kidney pathology and there is no history or evidence of alcohol intoxication. But, acute pancreatitis without diabetes-mellitus, causing ketoacidosis is a very rare presentation which is caused by high levels of pancreatic lipase in the circulation.

An unusual presentation of biotinidase deficiency in infant: High anion gap metabolic acidosis and Burkholderia cepacia sepsis

Biotinidase deficiency (BD) is an inborn metabolic disorder caused by low enzyme activity giving rise to impaired biotin release from dietary proteins. The first symptoms may be seen at first week following birth until 1 year of age. The goal of the therapy is to increase biotin bioavailability by daily 5-20 mg lifelong biotin replacement. Three-month-old girl born to nonconsanguineous parents, admitted to pediatric intensive care with multiple seizures, breathing difficulty and posturing. Blood investigations showed thrombocytopenia and high anion gap metabolic acidosis (HAGMA). Enzyme assay for biotinidase revealed low activities. Urinary organic acid analysis was normal. Enzyme activity is <10% in severe cases whereas between 10-30% in partial deficiency. BD can cause metabolic ketoacidosis, Hyperammonemia and organic Aciduria. BD behaves like immunodeficiency. Rarely bacterial infection can be seen. Treatment is lifelong biotin replacement.

Evaluation of strong ion gap and other indicators on prognosis of severe pneumonia in children / 中国小儿急救医学

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.

Brecha de iones fuertes y su cinética de aclaramiento como marcador de mortalidad en pacientes con choque séptico / Strong ion gap and its clearance kinetics as a mortality marker in septic shock patients / Hiato de íons fortes e sua cinética de aclaramento como marcador da mortalidade em pacientes com choque séptico

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.

Albumin corrected anion gap is an independent risk factor for long-term mortality of patients with sepsis / 中华危重病急救医学

Objective To explore whether albumin corrected anion gap (ACAG) is associated with long-term mortality of sepsis patients.Methods Adult patients with a diagnosis of sepsis within the first 24 hours (from December 2013 to December 2014) admitted to the intensive care unit (ICU) were included via the Sepsis database of West China Hospital Sichuan University. To record their long-term survival, patients were followed up by telephone interview one year after enrollment. ACAG was calculated according to the anion gap (AG) level within the first 24 hours admitted to ICU, and patients were divided into normal ACAG group (ACAG 12-20 mmol/L) and high ACAG group (ACAG > 20 mmol/L), and clinical characteristics and 1-year mortality were compared between groups. Patients were also divided into survivors and non-survivors according to the 1-year survival outcome, and multivariate logistic regression analysis was conducted to find independent risk factors for long-term mortality of sepsis patients.Results A total of 296 sepsis patients were enrolled in the study, with 191 (64.5%) in the high ACAG group and 105 (35.5%) in the normal ACAG group. There were no significant differences in age, gender, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), sequential organ failure assessment (SOFA), Charlson cormobidity index (CCI) and other background variables between groups. Compared with the normal ACAG group, patients who suffered from multiple organ dysfunction syndrome (MODS) in the high ACAG group were more prone to develop renal and gastrointestinal injury (43.5% vs. 25.7%, 52.9% vs. 33.3%, respectively), had significantly higher serum creatinine [SCr (μmol/L): 89.0 (61.0, 148.0) vs. 67.1 (48.0, 86.0)], greater need for continuous renal replacement therapy (CRRT, 16.8% vs. 6.7%), and significantly shorter length of ICU stay and hospital stay [days: 11 (5, 22) vs. 16 (18, 31), 21 (14, 39) vs. 28 (20, 47)], with statistically significant differences (allP < 0.05). It was shown by Kaplan-Meier survival analysis that 1-year cumulative survival for the high ACAG group was significantly lower than that of the normal ACAG group (55.0% vs. 67.7%,P = 0.046). It was shown by multivariate logistic regression that ACAG [odds ratio (OR) = 1.201, 95% confidence interval (95%CI) = 1.115-1.293,P = 0.000], APACHE Ⅱ (OR = 1.053, 95%CI = 1.011-1.098, P = 0.014), the incidence of septic shock (OR = 2.203, 95%CI = 1.245-3.898,P = 0.007), fungus infection (OR = 3.107, 95%CI = 1.702-5.674,P = 0.000), acute renal failure (OR = 2.729, 95%CI = 1.134-6.567,P = 0.025) and complicated with malignancy (OR = 2.929, 95%CI = 1.395-6.148,P = 0.005) were independent risk factors contributing to increased 1-year mortality among sepsis patients.Conclusion ACAG was an independent risk factor for 1-year mortality of sepsis patients.

Nodding Episodes and High Anion Gap in a 13 Year Old Child with Nodding Syndrome: A Case Report.

Introduction: Nodding syndrome is an unknown neurological disorder affecting children in Northern Uganda, South Sudan and Southern Tanzania. The patient in our case report is, to the best of our knowledge, the first with the syndrome that has been serially followed up for more than three months and the information obtained provides important clue to the possible risk factor to the syndrome. Case Presentation: A 13-year-old boy diagnosed in Atanga Health Centre III using World Health Organization (WHO) surveillance case definition as probable Nodding syndrome was referred to Gulu Regional Referral Hospital with pyomyositis of abdominal wall muscle and head nodding which was not responding to treatment. Serial anthropometry and laboratory investigations including, haematology, clinical chemistry, biochemistry and muscle biopsy were conducted in a period of 3 months and compared to the nodding episodes. Complete blood count showed leucocytosis with immature granulocytes and atypical lymphocytes mainly during the infective phase of the pyomyositis but returned to normal as a result of the surgical procedure, Incision, Drainage and Debridement (I, D & D) of pyomyositis of the anterior abdominal wall muscle combined with administration of antibiotics and analgesics. The liver enzymes were high throughout the period of admission in Gulu Hospital. The renal parameters and serum electrolytes were within normal ranges during the nodding free periods but it was deranged during the nodding episodes. Abdominal ultrasound scan showed a focal mass on the right internal and external oblique muscles of the abdominal wall. Histology of the muscle showed a non-specific inflammation of the abdominal muscles with mass necrosis of the muscle and thrombosed blood vessels. These findings highlight the concurrent existence of pyomyositis in a child with Nodding Syndrome but whose nodding episodes were pronounced during the periods with imbalanced electrolyte pattern and with high anion gap. In conclusion: Nodding syndrome is an unknown neurological disorder affecting children whose nodding episodes are probably related to the high Anion Gap metabolic acidosis.

Evaluation of Strong Ion Gap in Patients with Acute Respiratory Failure / 医学研究杂志

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 .

¿Es la diferencia de aniones fuertes un buen marcador de mortalidad en adultos con abdomen en tabla? / Is the Strong Anion Gap a good marker of mortality in the adult with acute abdomen?

Introducción. Tradicionalmente, el ácido láctico, la proteína C reactiva y el déficit efectivo de base, se han utilizado para predecir la mortalidad en pacientes críticamente enfermos. La información es insuficiente cuando se utiliza la diferencia de aniones fuertes. En especial, no existen datos de pacientes con abdomen agudo. El objetivo de este estudio piloto fue evaluar el desempeño de la diferencia de aniones fuertes para predecir la mortalidad perioperatoria (30 días) en pacientes con abdomen en tabla, que requieren cirugía inmediata, en comparación con el ácido láctico, el déficit efectivo de base, la albúmina y la relación proteína C reactiva/albúmina. Materiales y métodos. Para evaluar las características operativas de cada uno de los factores metabólicos en relación con la mortalidad periperatoria temprana, se determinó el área bajo la curva ROC (Receiver Operating Characteristics). Una vez obtenidos los mejores puntos de corte, se evaluó la asociación entre los sobrevivientes y los no sobrevivientes, mediante la prueba de ji al cuadrado (p<0,05). Resultados. Entre los factores metabólicos analizados, los que presentaron una mejor área bajo la curva ROC, fueron el ácido láctico (0,85) y el déficit efectivo de base (0,71). El área bajo la curva de la diferencia de aniones fuertes fue inferior (0,68), así como la de la diferencia aparente (0,68) y la diferencia efectiva (0,60). La relación proteína C reactiva/albúmina mayor de 5.000 g/L demostró un área bajo la curva ROC de 0,63. Se demostró diferencia estadística para el ácido láctico por encima de 4 mmol/L, la diferencia aparente de aniones fuertes menor de 40 mmol/L, la diferencia de aniones fuertes mayor de14 mmol/L y el déficit efectivo de base mayor de 7 mmol (p<0,05), entre sobrevivientes y no sobrevivientes. Conclusión. La diferencia de aniones fuertes (fuerte, aparente y efectiva) demuestra menores características operativas en pacientes con abdomen en tabla, cuando se correlaciona con la mortalidad posoperatoria temprana, en comparación con el ácido láctico y el déficit efectivo de base. La relación proteína C reactiva/albúmina demuestra mejores características operativas que la diferencia de aniones fuertes y debe evaluarse en nuevos estudios.

Background: Historically, the lactic acid, C- reactive protein and the Base Deficit, have been used to predict mortality in critical ill patients. Bu the information is not sufficient about the Strong Ion Gap (SIG) or Strong Ion Gap Difference (SID) as predictor. As a matter of fact, there is no information available for patients with acute abdomen. The objective for this study was to evaluate the performance of SID as a predictor of perioperative mortality (30 days) in patients with acute abdomen requiring immediate surgery, in comparison with serum levels of lactic acid, base deficit, albumin, and the C- reactive protein (CRP) / albumin ratio. Methods: In order to evaluate the operative characteristics of each one of the metabolic factors related to the early perioperative mortality, an area under an ROC curve (Receiver Operating Curve) was determined. Once the best cutting points were obtained, the association between survivors and not survivors was evaluated using the Chi square test (p<0.05). Results: Once analyzed the metabolic factors, those who presented a better area under the ROC curve were lactic acid (0.85) and base deficit (0.71). The area under an ROC curve of the SID was inferior (0.68), as well as the apparent strong ion gap (SIDa) (0.68) and the Effective Strong Ion Gap (SIGe) (0.60). The RCP/albumin ratio was higher than 5000 m/l with an area under an ROC curve of 0.63. There is statistically difference over 4 mmol/L for lactic acid, below 40 mmol/L for SIDa, higher than 14 mmol/L for SID and higher than 7 mmol for base deficit ( p<0.05), between survivors and not survivors. Conclusion: The Strong Ion Gap Difference (apparent and effective) shows less operative characteristics in patients with acute abdomen, when it is correlated with early postoperative mortality, in comparison with the lactic acid and the base deficit. The RCP/ albumin demonstrate better operative characteristics than the SID, and it must be evaluated in new studies.

Una causa inusual de acidosis metabólica severa: ayuno prequirúrgico / A rare cause of severe metabolic acidosis: Presurgical fasting

Objetivos: Presentación de un caso clínico y revisión no sistemática de la literatura sobre acidosis metabólica severa por ayuno prequirúrgico, su incidencia, etiología y fisiopatología. Materiales y métodos: Con autorización del Comité de ética de nuestra institución, se presenta el caso de un paciente con acidosis metabólica severa inducida por ayuno durante una colecistectomía laparoscópica, su manejo y desenlace. La búsqueda bibliográfica se realizó en PubMed, Scielo y Bireme. Resultados: La acidosis metabólica secundaria a ayuno es subdiagnosticada y está relacionada con la búsqueda de una fuente alterna de energía en ausencia de glucosa y glucógeno. Los ácidos grasos libres constituyen esta alternativa, generando cuerpos cetónicos que, al acumularse, desencadenan una cetoacidosis. Este el primer caso en nuestra institución en un paciente no diabético. No encontramos reportes a nivel nacional. Existen en la literatura médica mundial casos asociados a ayuno secundarios a vómito durante el tercer trimestre de embarazo, trastornos psiquiátricos, dietas estrictas, disfunción de banda gástrica y abuso de alcohol. Conclusiones: El anestesiólogo debe contemplar esta posibilidad en pacientes con acidosis metabólica inducida por ayuno con valores de lactato normal y clínica de deterioro hemodinámico, que estén en los extremos de la vida, no diabéticos ni con antecedentes de abuso de alcohol. El cálculo de anión gap es una herramienta sencilla de aproximación diagnóstica. Su incidencia aumenta durante el embarazo.

Objectives: To discuss a clinical case and a non-systematic literature review on severe metabolic acidosis due to pre-surgical fasting, its incidence, etiology, and pathophysiology. Materials and methods: Discussion of a case of a patient with fasting-induced severe metabolic acidosis during a laparoscopic cholecystectomy, its management and outcomes. The Ethics Committee of our institution approved the case discussion. The literature search included Pub Med, Scielo and Bireme. Results: Fasting-induced metabolic acidosis is underdiagnosed and is related to the search for an alternate energy source in the absence of glucose and glycogen. Free fatty acids are these alternate source and generate ketone bodies that accumulate and lead to the development of acidosis. This is the first case of a non-diabetic patient at our institution. We found no other reports at the national level. There are some cases in the world literature associated with fasting from vomiting during the third trimester of pregnancy, psychiatric disorders, strict dieting, gastric band dysfunction and alcohol abuse. Conclusions: The anesthesiologist must be aware of this possibility in patients with fasting induced metabolic acidosis with normal lactate values and hemodynamic impairment that are either too young or too old, non-diabetic and with no history of alcohol abuse. The anion gap calculation tool is a simple diagnostic approach. The incidence of the condition increases during pregnancy.

High Anion Gap Metabolic Acidosis among Children with Nodding Syndrome (NS) in Northern Uganda: Case Series.

Aims: To conduct a hormonal and biochemical studies on 10 patients with diagnosis of probable Nodding Syndrome (NS). Study Design: A cross-sectional study Place and Duration of Study: Atanga Health Center III in Pader District in Northern Uganda in September 2012. Methodology: We recruited consecutively 10 children with probable Nodding Syndrome who had been admitted for symptomatic management of seizures, injuries resulting from falls and nutritional rehabilitation. History, physical examinations, biophysical measurements (anthropometry) and blood investigations including serum electrolytes, liver function tests, thyroid hormones and vitamin D assays. Ethical approval was obtained from Gulu University Institutional Review Committee. Results: All children had severely low serum calcium and bicarbonate levels and a high Anion Gap. Thyroid hormones and vitamin D assays were largely normal. Conclusion: Children with Nodding Syndrome undergoing treatment for seizure control and nutritional rehabilitation have high Anion Gap metabolic acidosis.

HIV Infection Itself may be a Cause of Hypokalemic Distal Renal Tubular Acidosis without Hypergammaglobulinemia.

Distal renal tubular acidosis (dRTA) is seen in the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) population in the setting of hypergammaglobulinemia and antiretroviral agents, whereas isolated HIV infection is rarely reported to be associated with dRTA. We report a case of a young woman with a history of untreated HIV/AIDS who presented with profound generalized weakness and refractory hypokalemia along with non-anion gap metabolic acidosis and inappropriately high urine pH. Her serum gamma-globulin level was not significantly elevated and she was not on highly active antiretroviral therapy (HAART). No other cause of dRTA was evident. Subsequently, a diagnosis of dRTA secondary to isolated HIV/AIDS was made. Distal RTA can be acquired or inherited and is caused by defects in proton pumps or pH pressure gradients. In dRTA, the potassium level can be low, normal, or even high depending upon the pathophysiologic abnormality. Early recognition and prompt treatment is imperative to avoid the serious consequences of severe electrolyte and metabolic disturbances. Our case report is a reminder to clinicians to be mindful of this rare condition when evaluating unexplained dRTA and to include HIV/AIDS as part of the differential diagnosis of dRTA even in the absence of significant hypergammaglobulinemic (IgG level was slightly elevated) state or antiretroviral agents. We believe this is the second such case to be documented.

Two Cases of Ethylene Glycol Poisoning

Ethylene glycol poisoning is treated mainly by alcohol dehydrogenase inhibition therapy and hemodialysis. Early recognition and initiation of treatment is important because toxic metabolites increase over time by hepatic metabolism; however, there is no confirmative diagnostic tool in our clinical setting. Therefore, diagnosis is dependent on history, high anion gap acidosis, high osmolal gap, etc.. Diagnosis and treatment are delayed in cases where history taking is not possible, such as a mental changed patient. Authors report on two cases of ethylene glycol poisoning by contrasting clinical outcomes, demonstrating the importance of early diagnosis and treatment for achievement of a good outcome.

Acid-base abnormalities in dogs with diabetic ketoacidosis: a prospective study of 60 cases / Distúrbios ácido-base em cães com cetoacidose diabética: estudo prospectivo de 60 casos

Diabetic ketoacidosis (DKA) is considered a typical high anion gap metabolic acidosis due to the retention of ketoanions. The objective of this study was to describe the acid-base disturbances of dogs with DKA and further characterize them, according to their frequency, adequacy of the secondary physiologic response, and occurrence of mixed disturbances. Sixty dogs with DKA were enrolled in the study. Arterial blood pH and gas tensions, plasma electrolytes, serum b-hydroxybutyrate (b-OHB), glucose, albumin and urea concentrations were determined for all dogs included in the study. All dogs were evaluated individually and systematically by the traditional approach to the diagnosis of acid-base disorders. Most of the dogs had a high anion gap acidosis, with appropriated respiratory response (n = 18; 30%) or concurrent respiratory alkalosis (n = 14; 23%). Hyperchloremic acidosis with moderated to marked increases in b-OHB was observed in 18 dogs (30%) and 7 of these patients had concurrent respiratory alkalosis. Hyperchloremic acidosis with mild increase in b-OHB was observed in 6 dogs (10%). Four dogs (7%) had a high anion gap acidosis with mild increase in b-OHB and respiratory alkalosis. Most of dogs with DKA had a high anion gap acidosis, but mixed acid-base disorders were common, chiefly high anion gap acidosis and concurrent respiratory alkalosis, and hyperchloremic acidosis with moderated to marked increases in serum b-OHB.

A cetoacidose diabética (CAD) é considerada um quadro típico de acidose metabólica e aumento do anion gap, devido à retenção de cetoânions. O objetivo deste estudo foi descrever os distúrbios ácido-base de cães com CAD e ainda caracterizá-los, de acordo com sua frequência, adequação da resposta secundária fisiológica e ocorrência de distúrbios mistos. Sessenta cães com CAD foram incluídos no estudo. O pH e hemogasometria arteriais, eletrólitos plasmáticos, glicose, b-hidroxibutirato (b-OHB), albumina e ureia séricos foram determinados para todos os cães incluídos no estudo. Todos os cães foram avaliados individualmente e de forma sistemática pela abordagem tradicional para o diagnóstico de distúrbios ácido-básicos. A maioria dos cães tinha uma acidose metabólica com aumento do anion gap, com resposta respiratória apropriada (n = 18; 30%) ou alcalose respiratória concomitante (n = 14; 23%). A acidose hiperclorêmica com aumento moderado a marcante do b-OHB sérico foi observada em 18 cães (30%) e sete desses pacientes tinham alcalose respiratória concomitante. A acidose hiperclorêmica com aumento discreto do b-OHB sérico foi observada em seis cães (10%). Quatro cães (7%) tinham acidose metabólica com aumento discreto do b-OHB e alcalose respiratória. A maioria dos cães com CAD tinha uma acidose metabólica com aumento do anion gap, mas distúrbios ácido-básicos mistos foram comuns, principalmente, acidose metabólica com aumento do anion gap e alcalose respiratória concomitante e acidose hiperclorêmica associada a um aumento de moderado a marcante do b-OHB sérico.

The incidence and types of acid-base disorder of critically ill patients in emergency / 中华急诊医学杂志

Objective To reveal the incidence and types of acid-base disorder (ABD) of critically ill patients in emergency.Methods The clinical data of critically ill patients in the resuscitation room were collected prospectively from December 1,2008 to March 31,2009.Both arterial and venous blood samples were collected to detect arterial blood gas analysis and serum electrolytes simultaneously and their ABD were analyzed.Results Of totally 766 cases,the incidence of ABD was 97.3％ (745 cases).Among ABD the simple acid-base disorder ( SA BD) was 149 cases ( 20.0％ ),dual acid-base disorder (DABD) 525 (70.5％ ) and triple acid-base disorder (TABD) 71 (9.5％ ).After calculating anion gap (AG),the incidence of TABD increased from 12 to 71 cases and the missed diagnosis rate were 83.1％ (59 cases) and after calculating potential HCO3-,the incidence of TABD increased from 8 to 71 cases and the missed diagnosis rate were 88.7％ (63 cases).The age of patients with TABD (77.9 ± 10.7 years old) was older ( P ＜ 0.01 ) than that of other two groups of SABD and DABD as well as APACHEⅡ score (25.9 ± 7.1 ) and incidence (22.5％ ) of MODS in TABD were higher (P ＜0.01 ).The mortality of patients with TABD on the first,second,third and seven day were 14.1％,23.9％,26.8％ and 38.0％ respectively and significantly higher than those in SABD and DABD (P ＜0.05 or P ＜0.01 ).Conclusions The incidence of ABD was 97.3％.Calculation of AG and potential HCO3- would help find metabolic acidosis and TABD.The age and APACHEⅡ score were key factors to poor prognosis of patients with TABD.

Analysis of Anion Gap in Premature Suffered from Hyperbilirubinemia / 中国基层医药

Objective To investigate the changes of the anion gap(AG)in the premature suffered from hyperbilirubinemia,to provide the basis for treatment.Methods The serum electrolyte,the renal function and the liver function in 94 premature babies suffered from hyperbilirubinemia were tested,and then calculated the value of AG,while the arterial blood gas analyses were done in 36 cases.Results 44 cases had high AG(46.81％),44 cases had normal AG(46.81％)and 6 cases had low AG(6.38％).The increase of AG was directly proportional to the concentration of Na+in blood,while was inversely proportion to the concentration of HCO3-.There was no close relationship between the AG and BUN,Scr in the serum.Conclusion The incidence rate of metabolic acidosis poisoning was high in premature suffered from hyperbilirubinemia with high AG,so the routine test of blood electrolyte,renal function and arterial blood gas should be done.Calculate the value of AG to guide the treatment,and to avoid correcting the acid by the alkali blindly.

Prognostic Factors for Mortality in Emergency Department Patients with Hypotension / 대한구급학회지

BACKGROUND: This study was performed to analyze the effects of differences between initial and follow up amounts of central venous oxygen saturation (Scvo2), lactate, anion gap (AG), and corrected anion gap (CAG). METHODS: Patients with systolic blood pressure that was lower than 90 mmHg participated in this study. Along with Arterial Blood Gas Analysis (ABGA), the amounts of electrolytes, albumin, and Scvo2 were initially checked and then re-checked four hours later. The patients were divided into two groups, which were survived and expired, and the differences in initial and final values were compared in both groups. RESULTS: Out of a total of 36 patients, 29 patients survived and 7 patients died. The data showed almost no difference in mean age, mean arterial pressure, heart rate, respiratory rate, and body temperature between two groups. Comparing the initial amount, there was a statistically significant variation in lactate. Comparing the final values, lactate, AG, and CAG varied significantly. However, for both groups, the differences between the initial and final values were not significant. The area under curve (AUC) of follow up lactate and follow up CAG was 0.89 and 0.88. AUC of ED-APACHEII and original ICU APACHEII was 0.74 and 0.96. CONCLUSIONS: There was no prognostic effect of Scvo2, lactate, AG, and CAG in hypotensive patients. The initial and final values of lactate and CAG were good prognostic factors for the expired group.

Características clínicas y evolución de los pacientes con intoxicación por metanol atendidos en un hospital general / Clinical characteristics and outcome of patients with methanol poisoning treated in a general hospital

Objetivo: Describir las características clínicas y la evolución de los pacientes con intoxicación por metanol. Material y métodos: Estudio descriptivo, transversal, retrospectivo, tipo serie de casos en pacientes con diagnóstico de intoxicación por metanol, atendidos en el Hospital Nacional Cayetano Heredia entre el 2004 y 2008. Resultados: Se encontraron 8 pacientes (6 varones y 2 mujeres) atendidos por intoxicación por metanol, 6 sobrevivieron. En todos los casos la vía de ingreso fue oral, 7 en forma accidental; 4 de los pacientes tenía antecedentes de dependencia alcohólica y 3 de depresión. Al ingreso, 7 presentaron alteración del nivel de conciencia, 7 visión borrosa y 4 vómitos y los niveles de metanol sérico estuvieron entre 67 a 93 mg/dL. Todos los pacientes presentaron acidosis metabólica con anión gap elevado. Los pacientes fallecidos tuvieron pH menor de 7,0. La principal complicación fue neumonía aspirativa. Conclusiones: Debido al escaso número de casos no podemos llegar a conclusiones; sin embargo, podemos decir que la intoxicación por metanol generalmente se produce por ingesta accidental, debido al consumo de licores adulterados en varones adultos de limitados recursos económicos, los síntomas más frecuentes de presentación son la alteración de la conciencia y la visión borrosa, y aparentemente el riesgo de muerte está relacionado con la severidad de la acidosis metabólica.

Objective: To describe clinical characteristics and evolution of patients with methanol poisoning. Methods: A descriptive, transversal, retrospective study, case series report of patients with methanol poisoning at the Hospital Nacional Cayetano Heredia between 2004 and 2008. Results: We found 8 patients (6 men and 2 women) with methanol poisoning, 6 survived. In all cases pathway entrance was oral, 7 were accidental; 4 patients were alcoholics and 3 had depression. At admission, 7 had consciousness disorder, 7 blurred vision, 4 vomits and serum methanol levels were between 67-93 mg/dl. All patients had metabolic acidosis with elevated anion gap. The main complication was aspiration pneumonia. Conclusions: Due to the small number of cases we can reach conclusions, but we can say methanol poisoning is usually caused by accidental ingestion, mainly from adulterated liquor consumption by adult men with limited economic resources, most common symptoms are consciousness disorder and blurred vision, and apparently risk of death is related to severity of metabolic acidosis.

Cambios electroííticos y ácido-base en el paciete sometido a nefrectomia para donación renal en el centro médico quirúrgico Boliviano-belga / Electrolyte changes and acid-base in patients undergoing nephrectomy for kidney donation in the center medic-surgical Bolivian-Belgian

Los cambios en el equilibrio acido-base causados por la infusión de solución salina isotónica (0,9%) durante el transoperatorio han sido escasamente estudiados, por lo que en el presente estudio se evaluó este fenómeno en el paciente donador renal. Se realizó un estudio prospectivo, descriptivo, observacional y longitudinal donde se incluyeron 12 pacientes sometidos a nefrectomía dentro del protocolo de transplante renal de donador vivo relacionado que se lleva a cabo en el Centro Medico Quirúrgico Boliviano - Belga en el periodo comprendido entre Septiembre - Octubre de 2008. Se tomaron muestras de sangre de la arteria radial para medir pH, PaCO2, PAO2, concentraciones de sodio, potasio, cloro y bicarbonato séricos en 3 diferentes momentos del procedimiento quirúrgico-anestésico ( basal, pinzamiento y emersión ). El anión gap se calculó con la siguiente fórmula: [Na+] - [CI-] + [HCO3]. La infusión de solución salina isotónica (0.9%) causó disminución del pH, bicarbonato sérico y déficit de base (p < 0.001 ). El anión gap se mantuvo constante y el cloro sérico se incremento ligeramente sin mostrar significancia estadística. El tiempo de infusión fue de 14±24 min. Hasta el pinzamiento del hilio renal. La infusión de 15 ± 3.7 ml/kg/H de solución salina isotónica (0.9%) condujo a acidosis metabólica que asociada a hi-percloremia y a un anión gap normal se considera como acidosis hipercloremica.

The changes in acid-base balance caused by of a (0,9%) saline solution during anesthesia and surgery are poorly char-acterized. The authors evaluated these phenomena in kitney donors. It was carried out a prospective, descriptive, ob-servational and longitudinal study where 12 patients were included to nephrectomy protocol related to live donor's transplant that is taken to I dig in the Center I Prescribe Surgical Bolivian - Belgian in the period between September -October of 2008. We took samples of blood of the radial artery to measure pH, PaCO2, PAO2, concentrations of sodium, potassium, chlorine and bicarbonate serie in 3 different moments of the procedure surgical-anesthetic (basal,clamping and emersión). The anión gap was calculated with the following formula: [Na+] - [Cl -] + [HCO3 -]. The infusión of iso-tonic saline solution (0.9%) it caused decrease of the pH, bicarbonate serie and base déficit (p <0.001). The anión gap stayed constant and the chlorine serie increment lightly without statistical significance. The time of infusión was of 14±24 min. until the clamping of the renal hilio. The infusión of 15 ± 3.7 ml/kg/H of isotonic saline solution (0.9%) lead to metabolic acidosis associated to hyper-chloremia and to an normal anión gap it is considered as acidosis hyperchloremic.