Alterações hidroeletrolíticas em pessoas com cirrose / Hydroelectrolytic alterations in cirrhotic patients

O objetivo deste estudo foi evidenciar e discutir as principais alterações hidroeletrolíticas em pessoas com cirrose. Trata-se de uma revisão integrativa, de natureza qualitativa. Os artigos foram selecionados por meio da plataforma Medical Literature Analysis and Retrievel System Online. Os principais achados identificados a partir dos artigos selecionados foram a ocorrência de hiponatremia, o mau prognóstico diante da presença de distúrbios hidroeletrolíticos em relação à sobrevida em pessoas com cirrose e a importância da albumina. Indivíduos com cirrose são suscetíveis ao desenvolvimento de distúrbios hidroeletrolíticos devido às mudanças fisiopatológicas da doença e às condições clínicas apresentadas. A hiponatremia e a hipocalemia são os mais recorrentes, destacando, porém, a necessidade de atenção aos demais distúrbios. (AU)

The objective of this study was to show and discuss the main hydroelectrolytic alterations in cirrhotic patients. This is an integrative review, a qualitative study, in which articles were selected at the Medical literature Analysis and Retrieval System Online. The main findings identified in the articles selected were the occurrence of hyponatremia, the poor prognostic, due to the presence of hydroelectrolytic disorders, regarding cirrhotic individuals survival and the importance of albumin. Individuals with cirrhosis are susceptible to the development of hydroelectrolytic disorders due to the pathophysiological alterations of the disease and because of the clinical status presented. Hyponatremia and hypokalemia are the most recurrent, but attention shall be given to the other disorders too. (AU)

Distúrbios ácido-base nas doenças hepáticas / Acid-base disorders in liver diseases

O objetivo deste artigo foi abordar as controvérsias científicas acerca dos distúrbios ácido-base nas doenças hepáticas. Nos estágios avançados da doença hepática, os distúrbios ácido-base atuam de forma complexa, comprometendo a qualidade de vida do paciente e desafiando o manejo clínico. A literatura apresenta a alcalose respiratória como uma das principais alterações, porém há uma longa discussão sobre o mecanismo fisiopatológico; em especial, citam-se a hipóxia, a hipocapnia e o nível de progesterona. Nas desordens metabólicas, com destaque para a acidose, os estudos apontam principalmente o lactato, os unmeasured ions ou íons não medidos e as alterações hidroeletrolíticas, mas cada componente desse sobressai-se dependendo da fase da doença estudada, compensada ou descompensada. As controvérsias dos distúrbios ácido-base nas doenças hepáticas devem-se ora à complexidade da fisiopatologia da própria doença, ora à necessidade de mais estudos esclarecedores.

The aim of this study is to address the scientific controversy about acid-base disorders in liver diseases. In the end stage of liver diseases, the acid-base disorder has a complex performance, impairing the patient's quality of life and challenging the clinic management. Although the literature shows respiratory alkalosis as one of the main alterations, there is a long discussion about the pathophysiological mechanism, specially regarding hypoxia, hypocapnia, and progesterone level. In metabolic disorders, especially acidosis, the studies mainly indicate the lactate, unmeasured ions, and hydroelectrolytic alterations, but, depending on the disease phase, either compensated or decompensated, each element has a particular action. The controversy about acid-base disorders in liver diseases is associated with the complexity of this condition, as well as with the necessity of more specialized research.

Categorização de suplementos nutricionais para o doente renal crônico dialítico / Categorization of nutritional supplements for chronic renal dialysis patient

Introdução: Pacientes em tratamento hemodialítico apresentam perdas nutricionais e alterações metabólicas importantes, necessitando de acompanhamento nutricional e, muitas vezes, de suplementos. O objetivo deste estudo foi analisar e comparar os diferentes suplementos quanto aos teores de macro e micronutrientes: potássio, cálcio, fósforo e ferro, destinados aos doentes renais crônicos em hemodiálise, assim como ao custo e a forma de acesso desses. Método: A pesquisa foi realizada em sites e folders de fornecedores. Os cálculos foram realizados para 100 mL dos suplementos e, para a análise nutricional, utilizaram-se as informações contidas nos rótulos dos mesmos. Resultados: Foram encontrados 4 suplementos, os quais apresentaram variações importantes quanto aos teores de macro e micronutrientes analisados, assim como ao custo. O local de acesso não se mostrou diferente entre eles. Conclusão: Não existe um suplemento que se sobressaia em relação aos demais. Todos apresentam suas vantagens e desvantagens, sendo necessária uma conduta profissional individualizada conforme as especificidades de cada paciente.

Sobrecarga hídrica em crianças submetidas à ventilação mecânica / Fluid overload in children undergoing mechanical ventilation

RESUMO Os pacientes admitidos em uma unidade de terapia intensiva estão sujeitos à sobrecarga fluídica acumulada e recebem volume endovenoso pela ressuscitação agressiva, preconizada nas recomendações de tratamento do choque séptico, além de outras fontes de líquidos relacionadas às medicações e ao suporte nutricional. A estratégia liberal de oferta hídrica tem sido associada a maiores morbidade e mortalidade. Apesar de haver poucos estudos prospectivos pediátricos, novas estratégias estão sendo propostas. Esta revisão não sistemática discute a fisiopatologia da sobrecarga fluídica, suas consequências e as estratégias terapêuticas disponíveis. Durante a síndrome da resposta inflamatória sistêmica, o glicocálice endotelial é danificado, favorecendo o extravasamento fluídico, traduzido em edema intersticial. O extravasamento para o terceiro espaço se traduz em maior tempo de ventilação mecânica, maior necessidade de terapia de substituição renal e mais tempo de internação na unidade de terapia intensiva e no hospital, entre outros. A monitorização hemodinâmica adequada, bem como a infusão cautelosa de fluídos, pode minimizar estes danos. Uma vez instalada a sobrecarga fluídica acumulada, o tratamento com o uso crônico de diuréticos de alça pode levar a uma resistência ao uso destas medicações. A utilização precoce de vasopressores (norepinefrina) para melhora do débito cardíaco e perfusão renal, a associação de diuréticos e uso da aminofilina para indução de diurese, e a utilização de protocolos de sedação e mobilização precoce são algumas estratégias que podem reduzir morbimortalidade na unidade de terapia intensiva.

ABSTRACT Patients admitted to an intensive care unit are prone to cumulated fluid overload and receive intravenous volumes through the aggressive resuscitation recommended for septic shock treatment, as well as other fluid sources related to medications and nutritional support. The liberal liquid supply strategy has been associated with higher morbidity and mortality. Although there are few prospective pediatric studies, new strategies are being proposed. This non-systematic review discusses the pathophysiology of fluid overload, its consequences, and the available therapeutic strategies. During systemic inflammatory response syndrome, the endothelial glycocalyx is damaged, favoring fluid extravasation and resulting in interstitial edema. Extravasation to the third space results in longer mechanical ventilation, a greater need for renal replacement therapy, and longer intensive care unit and hospital stays, among other changes. Proper hemodynamic monitoring, as well as cautious infusion of fluids, can minimize these damages. Once cumulative fluid overload is established, treatment with long-term use of loop diuretics may lead to resistance to these medications. Strategies that can reduce intensive care unit morbidity and mortality include the early use of vasopressors (norepinephrine) to improve cardiac output and renal perfusion, the use of a combination of diuretics and aminophylline to induce diuresis, and the use of sedation and early mobilization protocols.

The clinical comparative study on the therapeutic effects of NICU patients implemented by NICU professional doctors and non-NICU professional doctors / 天津医药

Objective To explore the implementation styles on the therapeutic effects on the neurosurgical intensive care unit (NICU) patients. Methods Patients were enrolled during February 3, 2015 to February 3, 2016. The key point time was August 3, 2015 when the treatment in our NICU was fully implemented by NICU professional doctors. Based on this time point, all the enrolled patients were divided into non-NICU professional doctor implementing (NNPDI) group and NICU professional doctor implementing (NPDI) group. Thus non-NICU professional doctors and professional doctors were the leaders of diagnosis and treatment in tow groups. The length of hospital stay, complications, prognosis and other therapeutic outcomes were compared between two groups. Results The length of hospital stay was longer in NPDI group than that in NNPDI group (P0.05). The proportion of referral to other wards and fatality rate were both lower in NPDI group than those in NNPDI group (P0.05). Conclusion The NICU professional doctor implementing may be contribute to, at least in part, the improving of prognosis of NICU patients without obvious advantages in most complications. The level of professional management remains to be improved.

Electrocardiogram analysis of 339 patients with abnormal blood potassium / 中国医师进修杂志

Objective To research the electrocardiogram (ECG) manifestations of common electrolyte disturbance and to discuss the accuracy of ECG diagnosis. Methods One hundred and sixty-nine hospitalized patients with hyperkalemia and 170 patients with hypokalemia were selected and the results of ECG were analyzed. Results In mild hyperkalemia patients (serum potassium concentration 5.5- 6.5 mmol/L), the ECG abnormal rate was 91.4% (64/70). In mild hypokalemia patients (serum potassium concentration 3.0-3.5 mmol/L), the ECG abnormal rate was 56.9% (41/72). There was significant difference (P < 0.05). The greater the deviation of serum potassium concentration, the more obvious the characteristic changes of ECG. Conclusions In addition to the blood biochemical test, ECG is also a kind of check tool that can help to diagnose abnormal blood potassium.

Ajustes Cardiovasculares Induzidos pela Desidratação Crônica nas Fases Iniciais do Período Pós-Natal em Ratos Acordados / Cardiovascular Adjustments Induced by Chronic Dehydration in the Early Stages of PostNatal in Awake Rats

Alterações da osmolaridade do compartimento extracelular podem alterar o volume, o metabolismo e a função celular. Em virtude disso,varias complicações podem ser observadas, dentre elas a hipertensão arterial. Assim, a regulação precisa do volume e da osmolaridade docompartimento extracelular é fundamental para a manutenção das funções normais do organismo e da sobrevivência. O objetivo desse estudofoi avaliar os parâmetros hemodinâmicos através de desidratação induzida por furosemide em ratos jovens não anestesiados. Foram utilizados,ratos Wistar com cinco dias de idade, divididos em dois grupos experimentais, um controle (n=10) e um submetido ao tratamento comFurosemide (10mg/kg de massa corpórea, n=12), administrado três vezes por semana, durante dois meses. Após o tratamento, os animaisforam anestesiados para cateterização com cânulas inseridas na artéria e veia femorais, através de um corte inguinal de um dos lados. Ascânulas foram transpassadas subcutaneamente através do dorso do animal e foram exteriorizadas. Os experimentos foram realizados apósuma recuperação de 48h do procedimento cirúrgico, utilizando um amplificador e um software. Os resultados obtidos demonstraram que nãohouve diferenças nos testes induzidos de ingestão de água durante os 120 minutos analisados, quando comparados o grupo controle e o grupofurosemide, respectivamente. Na análise da pressão arterial méia e frequência cardíaca, não foi observada modificação dos níveis basais. Essepadrão de resposta também foi obtido quando analisado a PAS e PAD. Com esses resultados, concluímos que a depleção do compartimentoextracelular induzido pela administração de furosemide em ratos jovens não é fator determinante para alteração dos parâmetros hemodinâmicosna fase adulta.

Changes in osmolarity of the extracellular compartment may change the volume, metabolism and cellular function. As a result, manycomplications can be observed, among them hypertension. Thus, precise regulation of the volume and osmolality of the extracellularcompartment is critical to maintaining normal body functions and survival. Previous results demonstrated that despite anesthetized ratssubmitted to chronic diuretic treatment showed no change in sensitivity to sodium and water, an increased arterial pressure was observed. Thepresent study aims to assess hemodynamic parameters through furosemide-induced dehydration in anaesthetized young rats. Five days oldWistar rats divided into two groups, a control (n = 10) and a group subjected to subcutaneous treatment with the diuretic Furosemide (10mg/kg of body weight, n = 12) were used. After treatment, the animals were anesthetized for the implantation of the polyethylene tubes, which wereinserted into the artery (for records cardiovascular variables) and femoral vein through a cut inguinal one side (left / right). The cannulaswere transfixed subcutaneously through the back of the animal and were exteriorized. Data were recorded after a 48h recovery of the surgicalprocedure, using an amplifier and software. No differences in induced intake test of water within 120 minutes were observed. With respect tomean arterial pressure and heart rate, no modification on baseline levels were observed (PAM: 99.4 ± 1.9 mmHg, control vs 102.7 ± 1 mmHg,furosemide; FC: 362.5 ± 5.2 bpm, control vs 364.9 ± 7 bpm, furosemide). This response pattern was also obtained for SBP (124.3 ± 6 mmHg,control vs 130 ± 1.6 mmHg, furosemide) and DBP (82.2 ± 1.9 mmHg, control vs 82.1 ± 1 mmHg, furosemide). We concluded that depletionof the extracellular compartment induced by furosemide administration in young rats is not a determining factor to change the hemodynamicparameters in adulthood.

Influence factors of body mass index before pregnancy and the relationship with gestational weight gain,maternal and infants complications / 中华围产医学杂志

Objective To explore the prevalence and the relative factors of the overweight and the obese in a population of Gansu Province pre-pregnancy women.and the effects of pre-pregnancy maternal body mass index (BMI) on gestational weight gain and pregnant outcome.Methods We conducted a populationbased birth cohort study in Gansu Province Maternity and Child Health Care Hospital from February,2010 to December,2011.Single live term birth women who have complete anthropometry were enrolled this study.They were categorized into four BMI groups according to World Health Organization's BMI recommendations for Asian populations.We explored the prevalence and the relative factors of the overweight and the obese,and the effects of pre-pregnancy maternal body mass index on gestational weight gain and birth outcomes by Chi-square test,analysis of variance.Results A total of 6 400 cases included in this study.The BMI range is from 13.3 to 38.1,the average BMI is (20.6 ±2.7).Among 6 400 cases,636 cases(9.9％) and 416 cases (6.5％) were overweight and obese.The average age (unit:years) is increase gradually in low weight group (27.8±3.8),normal group (29.1 ±4.3),overweight group (30.3 ±4.7) and obese group (30.6±4.6),the difference was statistically significant (F=77.490,P＜0.01).The result prompt that the median BMI increased with the increasing of maternal age (r=0.18,P＜0.01).The BMI of multiparous women (21.22 ±2.63) is higher than nulliparous women (20.43 ± 2.64),the difference was statistically significant (t=-9.630,P＜0.01).The BMI has negatively correlated with education level and economic income level (r=-0.06,P＜0.01; r=-0.04,P=0.036).With the increase of BMI,the weight gain of early (13 weeks) pregnancy (F=8.892,P＜ 0.01) and the total weight gain during whole pregnancy (F=21.700,P＜ 0.01) gradually reduced in four groups.The neonatal birth weight in overweight group is largest,in turn higher than obesity group,normal group and low weight group,the difference was statistically significant (F=11.261,P＜0.01).With increasing BMI,the incidence of pre eclampsia (x2=85.758,P＜0.05),gestational diabetes mellitus (x2=58.913,P＜0.05),postpartum hemorrhage (x2=13.501,P＜0.05),neonatal hypoglycemia (x2=6.563,P＜0.05) and neonatal pulmonary hyaline membrane (x2=9.579,P＜0.05) was increased.The incidence of caesarean section (x2=125.442,P＜0.05),macrosomia (x2=62.963,P＜0.05) and birth defects (x2=9.087,P＜0.05) also increased.The incidence of abnormal umbilical cord in overweight group is highest,in turn higher than normal group,low weight group,and the obesity group (x2=15.82g,P=0.001).The incidence of neonatal electrolyte disorder in obesity group was higher than low weight group,normal group,and the overweight group (x2=12.092,P=0.007).The incidence of preterm birth in overweight group is highest,in turn higher than obesity group,normal group and the low weight group (x2=7.865,P=0.049).Compared with the normal group,the risk of caesarean section (OR=l.700,95％ CI:1.325-2.181),pre-eclampsia (OR=2.436,95％ CI:1.578-3.761),gestational diabetes (OR=3.182,95％ CI:1.049-9.653) and abnormal umbilical cord (OR=2.252,95％ CI:1.267-4.004) in overweight group was increased.the risk of pre eclampsia (OR=2.585,95％ CI:1.020-6.914),macrosomia (OR=2.484,95％ CI:1.017 6.070),neonatal electrolyte disorder (OR=4.430,95％ CI:1.290-t5.217) in obesity group was increased.Conclusions The median BMI before pregnancy increased with increasing maternal age,parity,but decreased with education level and income level.The weight gain of early (13 weeks) pregnancy and the total weight gain during whole pregnancy decreased with increasing BMI.Overweight and obesity before pregnancy increased the risk the caesarean section,preeclampsia,gestational diabetes,macrosomia and neonatal electrolyte disorder.

Five cases report of Ebola virus disease / 中华传染病杂志

Objective To analyze the clinical characteristics ,treatment and outcome of Ebola virus disease so as to provide early clinical recognition and treatment for this disease .Methods The clinical manifestations and treatment of 5 cases of Ebola virus disease in Ebola Holding Center of Sierra‐Leone China Friendship Hospital from 15 March 2015 to 15 May 2015 were retrospectively analyzed .And the clinical characteristics and possible effective treatment were discussed combined with related literature . Results Five patients were diagnosed with Ebola virus disease by polymerase chain reaction and 4 cases of 5 patients had confirmed contact history ,while 1 case had no clear contact history .All the 5 cases presented with low fever ,headache and joint pain .Three cases then progressed into severe gastrointestinal symptoms such as nausea ,vomiting ,diarrhea and hypovolemic shock .The patients presented with fast heart rate and shortness of breath and other inflammatory response syndrome in acute phase .One patient rapidly progressed to liver pain ,jaundice and anuria ,then died .Three severe cases recovered after treated with fluid resuscitation ,circulation maintenance and electrolyte balance in acute phase .Conclusions The early symptoms of Ebola virus disease are low fever ,joint pain and nausea .Frequent vomiting ,diarrhea , low blood pressure and electrolyte disorder indicate severe conditions .Shock and electrolyte disorder are deadly complications .Early recognition ,diagnosis and treatment are the key to improve the prognosis .

Diuretics-induced hyponatremia——A systematic review of the published articles / 中华内分泌代谢杂志

MEDLINE,Ovid,CNKI,and Vip Database were retrieved for articles of diuretics induced hyponatremia.6 retrospective studies,2 prospective studies,and 31 case reports were included.Pearson correlation coefficient of the cumulative dose and serum sodium level was-0.121 (P =0.757).It is suggested that serum sodium level should be closely monitored while administrating diuretics,especially in patients with high-risk of hyponatremia.

Desequilíbrios hidroeletrolíticos na sala de emergência / Water-electrolyte imbalances in the emergency room

JUSTIFICATIVA E OBJETIVOS: Desequilíbrios hidroeletrolíticos são frequentemente observados em pacientes críticos, sendo comuns em pacientes de emergência. A apresentação clinica pode ser assintomática ou com graves sintomas como alteração do estado neurológico ou arritmias cardíacas. Fazer o diagnóstico através de exames laboratoriais parece ser fácil, porém é necessário conhecer os mecanismos patofisiológicos envolvidos, uma vez que uma correção inadequada pode causar sequelas importantes ou mesmo a morte do paciente. CONTEÚDO: Foram selecionados artigos da base de dados Pubmed, dando prioridade aqueles publicados entre 2007 e 2012. Foram usadas como palavras-chave: hiponatremia, hipernatremia, hipocalemia, hipercalemia, hipocalcemia, hipercalcemia,distúrbios eletrolíticos, magnésio e fósforo. CONCLUSÃO: Os principais desequilíbrios hidroeletrolíticos encontrados na sala de emergência e a associação clínica com as principais doenças associadas, bem como a importância de uma correção adequada devem pertencer ao conhecimento do médico emergencista.

BACKGROUND AND OBJECTIVES: Water-electrolyte imbalances are frequently observed in critical ill patients and are common in the emergency care. Clinical presentation can be asymptomatic or severe with neurological alterations or cardiac arrhythmias. Make the diagnosis using laboratory tests may be easy, but the pathophysiological understanding of these disorders is more important: an innapropriated correction may cause severe damage or can be fatal to the patient. CONTENTS: We selected articles in Pubmed baseline and we gave priority to those published from 2007 to 2012. The keywords were: hyponatremia, hypernatremia, hypocalemia, hypercalemia, hypocalcemia, hypercalcemia, electrolyte disturbance, magnesium, chloro and phosphorus. CONCLUSION: The main electrolyte imbalances found in the emergency room, showing the clinical association with major diseases, and the importance of a proper correction must belong tothe knowledge of the emergency physician.

Monitorização de eletrólitos urinários em pacientes críticos: estudo preliminar observacional / Urinary electrolyte monitoring in critically ill patients: a preliminary observational study

OBJETIVO: Sobreviventes e não sobreviventes da unidade de terapia intensiva apresentam perfis ácido-básicos distintos. A regulação renal de eletrólitos urinários e a diferença de íons fortes urinários têm papéis principais na homeostase ácido- básica. O objetivo deste estudo foi avaliar a potencial utilidade da mensuração diária dos eletrólitos urinários na monitorização ácido-básica e da função renal. MÉTODOS: Foram registrados, prospectivamente e diariamente, parâmetros ácido-básicos plasmáticos e marcadores tradicionais da função renal, em paralelo à medição dos eletrólitos urinários em pacientes com sonda vesical internados na unidade de terapia intensiva. Os pacientes que permaneceram na unidade de terapia intensiva com sonda vesical por pelo menos 4 dias foram incluídos neste estudo. RESULTADOS: Dos 50 pacientes incluídos neste estudo, 22% vieram a óbito durante a internação na unidade de terapia intensiva. A incidência de lesão renal aguda foi significativamente maior nos não sobreviventes, durante os 4 dias de observação (64% versus 18% em sobreviventes). O cloreto e o sódio urinário foram mais baixos, e a diferença de íons fortes urinários mais alta, no 1º dia, em pacientes que desenvolveram lesão renal aguda tanto nos sobreviventes como nos não sobreviventes. Ambos os grupos tiveram débito urinário semelhante, embora os não sobreviventes tenham apresentado diferença de íons fortes urinários persistentemente mais alta durante o período de observação. Os sobreviventes apresentaram melhoria progressiva no perfil metabólico ácido-básico devido ao aumento, no plasma, da diferença de íons fortes e à diminuição dos ácidos fracos. Essas mudanças foram concomitantes à diminuição da diferença de íons fortes urinários. Com relação aos não sobreviventes, os parâmetros ácido-básicos não tiveram alteração significativa durante o seguimento. CONCLUSÃO: A avaliação diária dos eletrólitos urinários e da diferença de íons fortes urinários é útil para a monitorização ácido-básica e da função renal em pacientes críticos, tendo perfis distintos entre sobreviventes e não sobreviventes na unidade de terapia intensiva.

OBJECTIVE: Intensive care unit survivors and non-survivors have distinct acid-base profiles. The kidney's regulation of urinary electrolytes and the urinary strong ion difference plays a major role in acid-base homeostasis. The aim of this study was to evaluate the potential utility of daily spot urinary electrolyte measurement in acid-base and renal function monitoring. METHODS: We prospectively recorded daily plasma acid-base parameters and traditional markers of renal function in parallel with spot urinary electrolyte measurements in patients with urinary catheters admitted to our intensive care unit. Patients who remained in the intensive care unit for at least 4 days with a urinary catheter were included in the study. RESULTS: Of the 50 patients included in the study, 22% died during their intensive care unit stay. The incidence of acute kidney injury was significantly higher in non-survivors during the 4-day observation period (64% vs. 18% in survivors). Urinary chloride and sodium were lower and urinary strong ion difference was higher on day 1 in patients who developed acute kidney injury among both survivors and non-survivors. Both groups had similar urine output, although non-survivors had persistently higher urinary strong ion difference on all days. Survivors had a progressive improvement in metabolic acid-base profile due to increases in the plasma strong ion difference and decreases in weak acids. These changes were concomitant with decreases in urinary strong ion difference. In non-survivors, acid-base parameters did not significantly change during follow-up. CONCLUSIONS: Daily assessment of spot urinary electrolytes and strong ion difference are useful components of acid-base and renal function evaluations in critically ill patients, having distinct profiles between intensive care unit survivors and non-survivors.

A Case of Adenocarcinoma of the Transverse Colon with Humoral Hypercalcemia of Malignancy

Hypercalcemia is a common electrolyte imbalance in patients with malignancy. Approximately 80% of hypercalcemia is associated with humoral hypercalcemia of malignancy (HHM), but occurs rarely in colorectal carcinomas. A 72-year-old man was admitted with abdominal pain and bowel habit change. Colonoscopy showed a malignant tumor in the transverse colon. Laboratory data showed an elevated serum calcium level (11.6 mg/dL) and elevated parathyroid hormone-related peptide level (12.2 pmol/L). Histology showed poorly differentiated adenocarcinoma. We infused intravenous normal saline, furosemide and pamidronate. The serum calcium level was subsequently normalized. However, the patient died from cancer progression 10 days later. With a review of the relevant literature, we report a case of adenocarcinoma of the transverse colon with HHM.

Equilíbrio Hidroeletrolítico e relaxamento cerebral com salina isoncótica hipertônica versus manitol (20 por cento) durante neuroanestesia eletiva / Hydroelectrolytic balance and cerebral relaxation with hypertonic isoncotic saline versus mannitol (20 percent) during elective neuroanesthesia / Equilibrio hidroelectrolítico y relajación cerebral con salino isoncótico-hipertónico versus manitol (20 por ciento) durante neuroanestesia electiva

JUSTIFICATIVA E OBJETIVOS: É necessário proceder a relaxamento cerebral durante cirurgia intracraniana e a terapia hiperosmolar é uma das medidas para sua produção. Com frequência, pacientes neurocirúrgicos apresentam distúrbios de sódio. O objetivo deste trabalho foi quantificar e determinar o relaxamento cerebral e a duração das alterações hidroeletrólíticas decorrentes do uso do manitol versus solução isoncótica hipertônica (SIH) durante neurocirurgia. MÉTODO: Foram avaliados relaxamento cerebral e alterações hidroeletrolíticas de 29 pacientes adultos antes, 30 e 120 minutos após o término da infusão de carga aproximadamente equiosmolar de manitol 20 por cento (250 mL) ou SIH (120 mL). Registraram-se volume de líquidos intravenosos infundidos e diurese. Considerou-se p < 0,05 como significativo. RESULTADOS: Não houve diferença estatística significativa entre os dois grupos quanto ao relaxamento cerebral. Embora várias diferenças nos eletrólitos e no equilíbrio ácido-básico com o uso de manitol ou SIH tenham alcançado significância estatística, apenas a redução do sódio plasmático, 30 minutos após o uso do manitol, em média de 6,42 ± 0,40 mEq.L-1 e a elevação do cloro em média 5,41 ± 0,96 mEq.L-1 e 5,45 ± 1,45 mEq.L-1, 30 e 120 minutos, respectivamente, após a SIH deslocaram transitoriamente os níveis séricos desses íons da faixa de normalidade laboratorial. O grupo do manitol (20 por cento) apresentou diurese significativamente maior nos dois tempos estudados em comparação com o grupo da SIH. CONCLUSÕES: Solução salina isoncótica hipertônica [NaCl 7,2 por cento/HES (200/0,5) 6 por cento] e manitol (20 por cento), em dose única com cargas osmolares equivalentes, foram efetivos e seguros em produzir relaxamento cerebral durante os procedimentos neurocirúrgicos eletivos sob anestesia geral.

BACKGROUND AND OBJECTIVE: Cerebral relaxation during intracranial surgery is necessary, and hiperosmolar therapy is one of the measures used to this end. Frequently, neurosurgical patients have sodium imbalances. The objective of the present study was to quantify and determine cerebral relaxation and duration of hydroelectrolytic changes secondary to the use of mannitol versus hypertonic isoncotic solution (HIS) during neurosurgery. METHODS: Cerebral relaxation and hydroelectrolytic changes were evaluated in 29 adult patients before de beginning of infusion, and 30 and 120 minutes after the infusion of equiosmolar loads of approximately 20 percent mannitol (250 mL) or HIS (120 mL). The volume of intravenous fluids infused and diuresis were recorded. A p < 0.05 was considered significant. RESULTS: A statistically significant difference in cerebral relaxation between both groups was not observed. Although several changes in electrolyte levels and acid-base balance with mannitol or HIS reached statistical significance only the reduction in plasma sodium 30 minutes after infusion of mannitol, mean of 6.42 ± 0.40 mEq.L-1, and the increase in chloride, mean of 5.41 ± 0.96 mEq.L-1 and 5.45 ± 1.45 mEq.L-1 30 and 120 minutes after infusion of HIS, caused a transitory dislocation of serum ion levels from normal range. The mannitol (20 percent) group had a significantly greater diuresis at both times studied compared with HIS group. CONCLUSIONS: A single dose of hypertonic isoncotic saline solution [7.2 percent NaCl/6 percent HES (200/0.5)] and mannitol (20 percent) with equivalent osmolar loads were effective and safe in producing cerebral relaxation during elective neurosurgical procedures under general anesthesia.

JUSTIFICATIVA Y OBJETIVOS: La relajación cerebral es necesaria durante la cirugía intracraneana, y la terapia hiperosmolar es una de las medidas para su producción. Los pacientes neuroquirúrgicos a menudo presentan disturbios del sodio. El objetivo del trabajo fue cuantificar y determinar la relajación cerebral y la duración de las alteraciones hidroelectrolíticas provenientes del uso del manitol versus solución isoncótica hipertónica (SIH), durante la neurocirugía. MÉTODO: Se evaluaron la relajación cerebral y las alteraciones hidroelectrolíticas de 29 pacientes adultos antes, 30 y 120 min después del término de la infusión de carga aproximadamente equiosmolar de manitol 20 por ciento (250 mL) o SIH (120 mL). Se registró el volumen de los líquidos intravenosos infundidos y la diuresis. El P < 0,05 fue considerado significativo. RESULTADOS: No hubo ninguna diferencia estadística significativa entre los dos grupos en cuanto a la relajación cerebral. Aunque varias diferencias en los electrólitos y el equilibrio ácido-básico con el uso de manitol o SIH, hayan alcanzado una significancia estadística, solamente la reducción del sodio plasmático 30 min después del uso del manitol, como promedio de 6,42 ± 0,40 mEq.L-1, y la elevación del cloro como promedio 5,41 ± 0,96 mEq.L-1 y 5,45 ± 1,45 mEq.L-1, 30 y 120 min respectivamente después de la SIH, alteraron transitoriamente los niveles séricos de esos iones del rango de la normalidad laboratorial. El grupo del manitol (20 por ciento) tuvo una diuresis significativamente mayor en los dos tiempos estudiados en comparación con el grupo de la SIH. CONCLUSIONES: La solución salina isoncótica-hipertónica [NaCl 7,2 por ciento/HES (200/0,5) 6 por ciento] y manitol (20 por ciento), en dosis única con carga osmolar equivalente, fueron efectivos y seguros para generar la relajación cerebral durante los procedimientos neuroquirúrgicos electivos bajo la anestesia general.

Protective effect of sirolimus on water-electrolyte imbalance following bilateral ureteral obstruction in rats / 中华泌尿外科杂志

Objective To explore the molecular mechanism of renal function defects after urinary obstruction and investigate the effect of sirolimus on the expression of γ-ENaC,Na + K + ATPase and AQP2,and its mechanism of renal Water-Electrolyte imbalance following bilateral ureteral obstruction (BUO) in rat kidneys.Methods Forty-eight rats were randomly divided into a sham operation group ( sham group),a BUO group,and a sirolimus treatment after BUO group.Bilateral ureters were exposed and occluded with ligature in the BUO and sirolimus treatment groups.Twenty-four hours later,the obstructed ureters were decompressed by removal of the ligature.The sham animal group underwent identical surgical procedures,but the ureter was simply dissected without removal of the ligature.The sirolimus treatment groups was given sirolimus intragastricly 0.4 ml per day (2 mg/kg · d) from the day before surgery until the rats were scari fled.The sham and BUO groups were given the same volume of intragastric saline.The urine and blood were collected at 4 d,7 d after surgery,and the functional data were observed.The expression of γ-ENaC,Na+K + ATPase and AQP2 were examined by immnohistochemistry and immunoblotting.Results On day four and seven post ureteral obstruction release,urine volume in the BUO group were (85.31 ± 13.15,66.39 ±10.56 ml),significantly higher than that of sham operation (35.36 ± 7.74,33.90 ± 8.03 ml) and sirolimus treatment groups (69.81 ± 10.70 ml,48.57 ± 9.01 ml) (P ＜ 0.05 ).Urine sodium concentrations in the BUO group were (42.17 ± 7.35 mmol/L,43.63 ± 18.39 mmoL/L),significantly lower than that of sham operation ( 170.56 ± 18.39 mmoL/L,172.52 ± 7.35 mmol/L) and sirolimus treatment groups (76.18 ± 13.20 mmol/L,134.28 ± 13.20 mmol/L),P ＜ 0.05.Immunoblotting assay showed that,on day four and seven post rats ureteral obstructions were released,integral optical density of γ-ENaC (2.09 ±0.32,2.27 ±0.35),Na+ K+ATP enzyme (2.41 ±0.48,2.67 ±0.43) and AQP2 (2.17 ±0.45,2.63 ±0.28) in the sirolimus treatment group were significantly higher than those of BUO group ( 1.28 ± 0.21,1.45 ±0.17) (1.99 ±0.28,2.18±0.24) (0.93 ±0.22,1.31 ±0.16),but still lower than the sham group (2.58±0.51,2.60±0.56) (2.89±0.53,2.97 ±0.66) (3.05 ±0.63,3.10±0.67).There were significant differences among all the three groups ( P ＜ 0.05 ).Conclusions The downregulation of γ-ENaC,Na + K + ATPase and AQP2 expression after BUO may contribute to the impaired renal tubular sodium reabsorption,decreased urinary concentration,and postobstructive polyuria.Sirolimus treatment significantly prevents impairment in renal function and also prevents downregulation of y-ENaC,Na + K+ ATPase and AQP2during BUO,demonstrating a marked renoprotective effect of sirolimus treatment in conditions with urinary tract obstruction.

Evaluation and Management of Volume Status: A Practical View / 대한내과학회지

Objective, rapid, and accurate assessment of volume status is important in the early management of acute, critical illnesses, as inappropriate therapy may lead to interventions with fatal outcomes. Traditionally, the history and physical examinations have been used for this assessment, but have limitations. Radioisotopic measurement or invasive hemodynamic monitoring is impractical, complicated, and expensive. Recently developed technologies offer rapid, accurate estimation of volume status with the potential to improve clinical outcome. This review discusses the methods available for volume assessment, including ultrasound, bioimpedance, and the historical tools.

Hypomagnesemia is a risk factor for nonrecovery of renal function and mortality in AIDS patients with acute kidney injury

The objective of the present study was to determine the prevalence of electrolyte disturbances in AIDS patients developing acute kidney injury in the hospital setting, as well as to determine whether such disturbances constitute a risk factor for nephrotoxic and ischemic injury. A prospective, observational cohort study was carried out. Hospitalized AIDS patients were evaluated for age; gender; coinfection with hepatitis; diabetes mellitus; hypertension; time since HIV seroconversion; CD4 count; HIV viral load; proteinuria; serum levels of creatinine, urea, sodium, potassium and magnesium; antiretroviral use; nephrotoxic drug use; sepsis; intensive care unit (ICU) admission, and the need for dialysis. Each of these characteristics was correlated with the development of acute kidney injury, with recovery of renal function and with survival. Fifty-four patients developed acute kidney injury: 72 percent were males, 59 percent had been HIV-infected for >5 years, 72 percent had CD4 counts <200 cells/mm³, 87 percent developed electrolyte disturbances, 33 percent recovered renal function, and 56 percent survived. ICU admission, dialysis, sepsis and hypomagnesemia were all significantly associated with nonrecovery of renal function and with mortality. Nonrecovery of renal function was significantly associated with hypomagnesemia, as was mortality in the multivariate analysis. The risks for nonrecovery of renal function and for death were 6.94 and 6.92 times greater, respectively, for patients with hypomagnesemia. In hospitalized AIDS patients, hypomagnesemia is a risk factor for nonrecovery of renal function and for in-hospital mortality. To determine whether hypomagnesemia is a determinant or simply a marker of critical illness, further studies involving magnesium supplementation in AIDS patients are warranted.

Síndrome inapropriada do hormônio antidiurético (SIADH) pós-abdominoplastia / Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) post abdominoplasty

Este é um caso de síndrome inapropriada do hormônio antidiurético (SIADH) em umamulher, 39 anos, hígida, sem comorbidades importantes, submetida a abdominoplastia semlipoaspiração associada, que desenvolveu, 30 horas após a cirurgia, hiponatremia aguda(sódio 114,9 mEq/L-1), com importantes manifestações neurológicas. O difícil diagnósticoprecoce desta situação clínica grave, em pacientes saudáveis, pode causar importantes sequelasneurológicas e até mesmo o óbito. O diagnóstico precoce e a instituição de tratamentode reposição corretos são a chave para evitar lesões cerebrais irreversíveis.

This is a case of syndrome of inappropriate anti-diuretic hormone (SIADH) in a healthy woman,39 years old without comorbites, with developed postoperative acute hyponatremia (sodium 114mEq/L-1) after abdominoplasty without liposuction with important neurologic manifestations.The initial diagnosis of this syndrome in normal patients could avoid permanent neurologicdamage. The early recognition and correct treatment are vital to avoid a poor cerebral outcome.

Study of calcium-phosphorous metabolism and intact parathyroid hormone levels in end stage renal disease patients / 北京大学学报(医学版)

Objective: To investigate the state of calcium-phosphorus metabolism and serum intact parathyroid hormone (iPTH) levels in end stage renal disease (ESRD) patients, to analyze clinical characters, and to provide scientific basis for clinical treatment. Methods: The data of 100 ESRD patients who received hemodialysis in Peking University First Hospital from January 2000 to July 2003 were analyzed retrospectively. Results: (1) The levels of serum total calcium were adjusted by serum albumin. There were 15 patients with hypocalcemia and 85 patients with normocalcemia or hypercalcemia. 31.8% of the latter took calcium-containing phosphate binders or/and vitamin D. In the 14 patients with hypocalcemia and 58 patients without low serum calcium who did not take calcium-containing phosphate binders or/and vitamin D, we found the levels of carbon dioxide combining power (CO 2CP) were lower in the group of hypocalcemia (P