Association of alactic base excess with in-hospital mortality in patients with acute myocardial infarction: a retrospective cohort study.

BACKGROUND: Alactic base excess (ABE) is a novel biomarker to evaluate the renal capability of handling acid-base disturbances, which has been found to be associated with adverse prognosis of sepsis and shock patients. This study aimed to evaluate the association between ABE and the risk of in-hospital mortality in patients with acute myocardial infarction (AMI). METHODS: This retrospective cohort study collected AMI patients' clinical data from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The outcome was in-hospital mortality after intensive care unit (ICU) admission. Univariate and multivariate Cox proportional hazards models were performed to assess the association of ABE with in-hospital mortality in AMI patients, with hazard ratios (HRs) and 95% confidence intervals (CI). To further explore the association, subgroup analyses were performed based on age, AKI, eGFR, sepsis, and AMI subtypes. RESULTS: Of the total 2779 AMI patients, 502 died in hospital. Negative ABE (HR = 1.26, 95%CI: 1.02-1.56) (neutral ABE as reference) was associated with a higher risk of in-hospital mortality in AMI patients, but not in positive ABE (P = 0.378). Subgroup analyses showed that negative ABE was significantly associated with a higher risk of in-hospital mortality in AMI patients aged>65 years (HR = 1.46, 95%CI: 1.13-1.89), with eGFR<60 (HR = 1.35, 95%CI: 1.05-1.74), with AKI (HR = 1.32, 95%CI: 1.06-1.64), with ST-segment elevation acute myocardial infarction (STEMI) subtype (HR = 1.79, 95%CI: 1.18-2.72), and without sepsis (HR = 1.29, 95%CI: 1.01-1.64). CONCLUSION: Negative ABE was significantly associated with in-hospital mortality in patients with AMI.

Course of lactate, pH and base excess for prediction of mortality in medical intensive care patients.

INTRODUCTION: As base excess had shown superiority over lactate as a prognostic parameter in intensive care unit (ICU) surgical patients we aimed to evaluate course of lactate, base excess and pH for prediction of mortality of medical ICU patients. MATERIALS AND METHODS: For lactate, pH and base excess, values at the admission to ICU, at 24 ± 4 hours, maximum or minimum in the first 24 hours and in 24-48 hours after admission were collected from all patients admitted to the Medical ICU of the University Hospital Tübingen between January 2016 until December 2018 (N = 4067 at admission, N = 1715 with ICU treatment > 48 h) and investigated for prediction of in-hospital-mortality. RESULTS: Mortality was 22% and significantly correlated with all evaluated parameters. Strongest predictors of mortality determined by ROC were maximum lactate in 24 h (AUROC 0.74, cut off 2.7 mmol/L, hazard ratio of risk group with value > cut off 3.20) and minimum pH in 24 h (AUROC 0.71, cut off 7.31, hazard ratio for risk group 2.94). Kaplan Meier Curves stratified across these cut offs showed early and clear separation. Hazard ratios per standard deviation increase were highest for maximum lactate in 24 h (HR 1.65), minimum base excess in 24 h (HR 1.56) and minimum pH in 24 h (HR 0.75). CONCLUSION: Lactate, pH and base excess were all suitable predictors of mortality in internal ICU patients, with maximum / minimum values in 24 and 24-48 h after admission altogether stronger predictors than values at admission. Base excess and pH were not superior to lactate for prediction of mortality.

Association between anion gap and mortality of aortic aneurysm in intensive care unit after open surgery.

BACKGROUND: There has not been a well-accepted prognostic model to predict the mortality of aortic aneurysm patients in intensive care unit after open surgery repair. Otherwise, our previous study found that anion gap was a prognosis factor for aortic aneurysm patients. Therefore, we wanted to investigate the relationship between anion gap and mortality of aortic aneurysm patients in intensive care unit after open surgery repair. METHODS: From Medical Information Mart for Intensive Care III, data of aortic aneurysm patients in intensive care unit after open surgery were enrolled. The primary clinical outcome was defined as death in intensive care unit. Univariate analysis was conducted to compare the baseline data in different groups stratified by clinical outcome or by anion gap level. Restricted cubic spline was drawn to find out the association between anion gap level and mortality. Subgroup analysis was then conducted to show the association in different level and was presented as frost plot. Multivariate regression models were built based on anion gap and were adjusted by admission information, severity score, complication, operation and laboratory indicators. Receiver operating characteristic curves were drawn to compare the prognosis ability of anion gap and simplified acute physiology score II. Decision curve analysis was finally conducted to indicate the net benefit of the models. RESULTS: A total of 405 aortic aneurysm patients were enrolled in this study and the in-intensive-care-unit (in-ICU) mortality was 6.9%. Univariate analysis showed that elevated anion gap was associated with high mortality (P value < 0.001), and restricted cubic spline analysis showed the positive correlation between anion gap and mortality. Receiver operating characteristic curve showed that the mortality predictive ability of anion gap approached that of simplified acute physiology score II and even performed better in predicting in-hospital mortality (P value < 0.05). Moreover, models based on anion gap showed that 1 mEq/L increase of anion gap improved up to 42.3% (95% confidence interval 28.5-59.8%) risk of death. CONCLUSIONS: The level of serum anion gap was an important prognosis factor for aortic aneurysm mortality in intensive care unit after open surgery.

Association of serum chloride level alterations with in-hospital mortality.

BACKGROUND: We aimed to assess the association between alterations in serum chloride levels during hospitalisation and mortality. METHODS: We reviewed all adult patients admitted to our hospital from the year 2009 to 2013, who had at least two serum chloride measurements during hospitalisation. The serum chloride change during hospitalisation, defined as the absolute difference between the highest and lowest serum chloride levels, was categorised into seven groups; 0-2, 3-4, 5-6, 7-8, 9-10, 11-12 and ≥13 mEq/L. Multivariable logistic regression was performed to assess the independent association between serum chloride change and in-hospital mortality, using the serum chloride change of 0-2 mEq/L as the reference group. RESULTS: A total of 57 880 patients, with median serum chloride change of 5 (IQR 3-9) mEq/L, were studied. The in-hospital mortality was progressively increased with larger chloride change, from 0.6% in group of 0-2 mEq/L to 5.9% in group of ≥13 mEq/L (p<0.001). In adjusted analysis, serum chloride change of ≥7 mEq/L was significantly associated with increased in-hospital mortality. For upward trend, serum chloride change of ≥3 mEq/L was significantly associated with increased in-hospital mortality, whereas, for downward trend, serum chloride change was not consistently associated with in-hospital mortality. CONCLUSION: Alterations in serum chloride during hospitalisation were associated with increased hospital mortality. The association was more prominent with upward than downward trend of serum chloride.

A novel scoring system for assessing the severity of electrolyte and acid-base disorders and predicting outcomes in hospitalized patients.

Electrolyte and acid-base disorders are commonly seen in critically ill and other hospitalized patients. A scoring system is needed to assess the severity of electrolyte and acid-base disorders and to predict outcome in hospital patients. Herein, we prospectively enrolled a total of 322,046 patients, including 84,700 patients in the derivation cohort and 237,346 in the validation cohort, in a large, tertiary hospital in East China from 2014 to 2017. A points-scoring system of general electrolyte and acid-base disorders with a sum of 20.8 points was generated by multiple logistic regression analysis of the derivation cohort. Receiver operating characteristic curve analysis showed that the optimal cut-off value of 2.0 was associated with 65.4% sensitivity and 88.4% specificity (area under the curve: 0.818 (95% CI 0.809 to 0.827)) to predict hospital mortality in the validation cohort. On Kaplan-Meier survival analysis, the five intervals of risk score (Q1: 0 to 2.0; Q2: 2.1 to 2.5; Q3: 2.6 to 3.3; Q4: 3.4 to 4.5; and Q5: >4.5 points) showed differences in hospital survival (p<0.001). Elevated (delta) risk score >2 during hospitalization increased the risk of hospital death, while those with a delta risk score <0 and <-2 points had higher survival rates. This novel scoring system could be used to evaluate and to dynamically monitor the severity of electrolyte and acid-base disorders in hospitalized patients.

Serum anion gap at admission as a predictor of mortality in the pediatric intensive care unit.

An accurate method to predict the mortality in the intensive care unit (ICU) patients has been required, especially in children. The aim of this study is to evaluate the value of serum anion gap (AG) for predicting mortality in pediatric ICU (PICU). We reviewed a data of 461 pediatric patients were collected on PICU admission. Corrected anion gap (cAG), the AG compensated for abnormal albumin levels, was significantly lower in survivors compared with nonsurvivors (p < 0.001). Multivariable logistic regression analysis identified the following variables as independent predictors of mortality; cAG (OR 1.110, 95% CI 1.06-1.17; p < 0.001), PIM3 [OR 7.583, 95% CI 1.81-31.78; p = 0.006], and PRISM III [OR 1.076, 95% CI 1.02-1.14; p = 0.008]. Comparing AUCs for mortality prediction, there were no statistically significant differences between cAG and other mortality prediction models; cAG 0.728, PIM2 0.779, PIM3 0.822, and PRISM III 0.808. The corporation of cAG to pre-existing mortality prediction models was significantly more accurate at predicting mortality than using any of these models alone. We concluded that cAG at ICU admission may be used to predict mortality in children, regardless of underlying etiology. And the incorporation of cAG to pre-existing mortality prediction models might improve predictability.

Acid base imbalances in ill neonatal foals and their association with survival.

REASONS FOR PERFORMING STUDY: Acid-base imbalances observed in human paediatric patients are associated with outcome. Likewise, neonatal foals may have different acid-base imbalances associated with diagnosis or prognosis. OBJECTIVES: To determine acid-base imbalances by the quantitative method in ill neonatal foals and assess their association with diagnosis and prognosis. STUDY DESIGN: Observational prospective clinical study. METHODS: This study included 65 ill neonatal foals (32 septic, 33 nonseptic) admitted to an equine referral hospital from 2005 to 2011with acid-base parameters determined on admission and a control group of 33 healthy neonatal foals. Blood pH, pCO2 , sodium, potassium, chloride, L-lactate, albumin and phosphate concentrations were determined. Bicarbonate, globulin, measured strong ion difference (SIDm ), nonvolatile weak buffer concentrations (Atot ), base excess and its components were calculated. Analysis of covariance (ANCOVA) and multiple linear regression statistical analyses were performed. Results are summarised as mean ± s.d. for normally distributed variables and median [25-75th percentiles] for non-normally distributed ones. RESULTS: A total of 63% of ill foals had respiratory alkalosis and 58.5% had SIDm acidosis. The combination of both alterations was detected in 21 of 65 ill foals and abnormal pH was found in 24 of 65. Compared with healthy foals, ill foals had significantly lower SIDm (nonseptic 31.6 ± 6.3 [P<0.01] and septic 32.0 ± 6.4 [P<0.01] vs. control 40.3 ± 3.1 mmol/l), potassium (nonseptic 3.5 [3.3-3.8; P<0.01] and septic 3.6 [3.2-4.3; P = 0.01] vs. control 4.2 [3.8-4.5] mEq/l) and higher L-lactate (nonseptic 5.1 ± 4.2 [P = 0.01] and septic 5.0 ± 3.7 [P = 0.03] vs. control 2.5 ± 1.3 mmol/l). Significantly higher L-lactate and venous pCO2 were found in nonsurviving (6.4 ± 3.5 mmol/l [P = 0.04] and 51 ± 13 mmHg [P<0.01]) compared with surviving foals. CONCLUSIONS: The most common acid-base imbalances observed in ill foals were respiratory alkalosis, SIDm acidosis or mixed respiratory alkalosis with strong ion acidosis. Increased venous pCO2 and blood L-lactate concentration were associated with poor outcome.

Hyperchloremia is associated with 30-day mortality in major trauma patients: a retrospective observational study.

BACKGROUND: Chloride is important for maintaining acid-base balance, muscular activity, osmosis and immunomodulation. In patients with major trauma, chloride levels increase after fluid therapy; this is associated with poor clinical outcomes. The purpose of this study was to determine whether hyperchloremia was associated with increased mortality in patients who had sustained major trauma. METHODS: This study enrolled 266 major trauma patients by retrospective chart review, from January 2011 to December 2015. Patients were older than 16 years; were admitted to an intensive care unit; survived more than 48 h; and had sustained major trauma, defined as an injury severity score ≥ 16. Hyperchloremia was defined as a chloride level > 110mEq/L. Delta chloride (Δchloride) was defined as the difference between the serum chloride level measured 48-h post-admission and the initial level. Clinical and laboratory variables were compared between survivors (n = 235) and non-survivors (n = 31). A multivariate logistic regression analysis was performed to assess the association between hyperchloremia 48-h post-admission (hyperchloremia-48) and 30-day mortality. RESULTS: The overall 30-day mortality was 11.7 % (n = 31). Hyperchloremia-48 occurred in 65 patients (24.4 %) and the incidence was significantly different between survivors and non-survivors (19.6 vs. 61.3 %, respectively, p < 0.001). Multivariate logistic analysis identified hyperchloremia-48 and Δchloride as independent predictive factors for 30-day mortality in major trauma patients. DISCUSSION: Infusion of chloride-rich solutions, such as normal saline, is itself associated with hyperchloremia, which has been associated with poor patient outcomes. Patients receiving normal saline were more likely to suffer major postoperative complications, acute kidney injury, and infections. Moreover, large changes in serum chloride levels correlated with greater in-hospital mortality. CONCLUSION: Hyperchloremia 48-h post-admission and Δchloride was associated with 30-day mortality in major trauma patients. These indices may be useful prognostic markers.

Non-lactate strong ion difference: a clearer picture.

PURPOSE: The recommended method for elucidating the effects of strong ions other than lactate on acid-base balance is to calculate the non-lactate strong ion difference (SIDnl). A relationship between HCO3 (-) and SIDnl in hyperchloremic patients has already been demonstrated; in the present study, the relationships between SIDnl, the apparent strong ion difference (SIDa), and mortality at intensive care unit (ICU) admission were investigated. METHODS: In our two-center study, 2691 patients admitted to the ICU were retrospectively evaluated, including 1069 critically ill patients. These patients were divided into three subgroups according to their SIDnl levels at admission to the ICU: low (<38 mmol L(-1)), normal (38-40 mmol L(-1)), and high (>40 mmol L(-1)). Patient age, gender, diagnosis, blood gas values, length of ICU stay, and mortality were recorded. RESULTS: The low-SIDnl group included 768 patients (71.8 %), the normal-SIDnl group consisted of 127 patients (11.9 %), and the high-SIDnl group contained 174 patients (16.3 %). There was no significant difference in lactate levels among the SIDnl groups (p = 0.635). In a multivariate logistic regression model, likelihood of mortality was increased 1.24-fold (1.20-1.28), 2.56-fold (1.61-4.08) and 2.55-fold (1.003-6.47) by APACHE II, lactate level ≥2mmol L(-) and low SIDnl (p < 0.001, p < 0.001, and p = 0.049, respectively). CONCLUSIONS: SIDnl can be used to determine the effects of strong ions other than lactate on SIDa values and acid-base balance. Furthermore, a low SIDnl at ICU admission can be a prognostic indicator of mortality.

Can venous base excess replace arterial base excess as a marker of early shock and a predictor of survival in trauma?

INTRODUCTION: Arterial base excess is an established marker of shock and predictor of survival in trauma patients. However, venous blood is more quickly and easily obtained. This study aimed to determine if venous base excess could replace arterial base excess as a marker in trauma patients at presentation and if venous base excess is predictive of survival at 24 hours and one week. METHODS: This was a prospective study of 394 trauma patients presenting to the emergency department of a tertiary hospital over a 17-month period. Data on base excess at presentation, vital signs, shock index (SI), injury severity score (ISS), and mortality at 24 hours and one week was collected and analysed. RESULTS: Arterial and venous blood gas tests were performed on 260 and 134 patients, respectively. Patients were stratified into groups based on their SI and ISS for analysis. There was no statistical difference between mean venous blood gas and arterial blood gas levels at presentation when SI > 0.7, regardless of ISS (p > 0.05). The mortality rate was 4.57%. Both venous and arterial base excess was lower in nonsurvivors compared to survivors (p < 0.05). However, at 24 hours and one week, the difference in base excess values at presentation between survivors and nonsurvivors was greater when using venous base excess compared to arterial base excess (11.53 vs. 4.28 and 11.41 vs. 2.66, respectively). CONCLUSION: In conclusion, venous base excess can replace arterial base excess in trauma patients as a means of identifying and prognosticating early shock.

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

BACKGROUND/AIM: Acid-base disorders are common within critically ill patients. Physicochemical approach described by Stewart and modified by Figge gives precise quantification method of metabolic acidosis and insight into its main mechanisms, as well as influence of unmeasured anion on metabolic acidosis. The aims of this study were to determine whether the conventional acid-base variables are connected with survival rate of critically ill patients at Intensive care unit; whether strong ion difference/strong ion gap (SID/SIG) is a better predictor of mortality rate comparing to conventional acid-base variables; to determine all significant predictable parameters for the 28-day mortality rate at intensive care units. METHODS: This retrospective observational analytic study included 142 adult patients requiring mechanical ventilation, survivors (n = 68) and nonsurvivors (n = 74). Apparent strong ion difference (SIDapp), effective strong ion difference (SIDeff) and SIG values were calculated with the Stewart-Figge's quantitative biophysical method. Descriptive and analytical statistical methods were used in the study [t-test, Mann-Whitney U test, χ2-test, binary logistic regression, Reciever operating characteristic (ROC) curves, calibration]. RESULTS: Age, Na+, acute physiology and chronic health evaluation (APACHE II), Cl-, albumin, SIG, SID app, SIDeff, and aninon gap (AG) were statistically significant predictors. AG represented a model with imprecise calibration, i.e. a model with little predictive power. APACHE II had p-value more than 0.05 if it was near it, and therefore it could be considered potentially unreliable for outcome prediction. SIDeff and SIG represented models with well-defined calibration. ROC analysis results showed that APACHE II, Cll-, albumin, SIDeff, SIG i AG had the largest area bellow the curve. By creation of logistic models with calibration methods, we found that outcome depends on SIG and APACHE II score. CONCLUSION: Based on our data, unmeasured anions provide prediction of mortality of critically ill patients on mechanical ventilation, unlike the traditional acid-base variables which are not accurate predictors of the 28-day mortality rate.

Strong ion gap is associated with mortality in pediatric burn injuries.

Severe burn injury produces significant tissue damage, resulting in metabolic acidosis. Current methods of acid-base evaluation are based on dependent variables that may not be accurate after burn injury. The strong ion method of acid-base evaluation is based on independent variables and may accurately predict outcomes in severely burn-injured patients. The authors hypothesize that an increased strong ion gap present on admission will be associated with mortality in severely burn-injured pediatric patients. A retrospective chart review was performed of burn-injured pediatric patients with a TBSA 20% or greater. Data collected included age, TBSA burn injury, mechanism of injury, survival, ventilator days, hospital length of stay, intensive care unit length of stay, and admission laboratory values. Apparent and effective strong ion difference (SIDa, SIDe) were calculated. The strong ion gap (SIG) was determined as the difference between SIDa and SIDe. A total of 48 patients were included in the study. Mean age (years) and TBSA were 7.9 ± 0.8 years and 56.8 ± 2.6%. Eleven patients (23%) died. Mean TBSA for survivors (54.2 ± 2.9%) did not significantly differ from that of nonsurvivors (65.7 ± 5.34%). Ten patients suffered inhalation injury, which was associated with an odds ratio of 10.1* for mortality. Mean SIDa was 44.2 ± 3.2 for the entire study population. Survivors had a significantly lower SIDa (36.6 ± 0.5) than nonsurvivors (59.7 ± 13*). Mean SIDe for all patients was (25 ± 0.7) and did not differ significantly between survivors (24.7 ± 0.7) and nonsurvivors (25.8 ± 2). SIG for nonsurvivors (33.91 ± 14*) was significantly higher than for survivors (14.9 ± 0.3). Controlling for both TBSA and inhalation injury, death was associated with both an increased SIDa (B = 19.3*) and SIG (B = 17.3*). SIG is increased in severely burn-injured pediatric patients, indicating the presence of metabolic acidosis. Furthermore, an increased SIG is significantly associated with mortality. (*P <.05.).

External validation of the Emergency Trauma Score for early prediction of mortality in trauma patients.

OBJECTIVES: The Emergency Trauma Score has been developed for early estimation of mortality risk in adult trauma patients with an Injury Severity Score of 16 or higher. Emergency Trauma Score combines four early predictors available at the trauma resuscitation room: age, Glasgow Coma Scale, base excess, and prothrombin time. Our goal was to validate the Emergency Trauma Score in two large external cohorts. As the Injury Severity Score is not accurately known at the time patients present at the resuscitation room, we evaluated the performance of Emergency Trauma Score in all trauma patients. DESIGN: External validation study using data from two prospectively collected trauma registries. SETTING: Two academic level 1 trauma centers. PATIENTS: Adult patients admitted to the hospital after treatment at the trauma resuscitation room. INTERVENTION: Calibration and discrimination of the original Emergency Trauma Score were assessed within each cohort separately. MEASUREMENT AND MAIN RESULTS: A total of 4,418 consecutive patients were evaluated. Discrimination was good in both validation cohorts, with areas under the receiver-operating curve curves that were even higher (0.94 and 0.92, respectively) than that in the original cohort (0.83). Predicted mortality was systematically too high compared with actual mortality in patients with low-to-medium expected risk (< 25%). Calibration improved in the lower expected risk range after exclusion of patients with Injury Severity Score less than 16. CONCLUSIONS: The Emergency Trauma Score model performs well in discriminating between trauma patients who will survive and who will not. If applied to all trauma patients, predicted mortality risks are too high in the low-risk category.

Strong ion difference and gap predict outcomes after adult burn injury.

BACKGROUND: The strong ion difference (SID) (apparent [SIDa] and effective [SIDe]) and strong ion gap (SIG) provide a comprehensive method of evaluating acid-base status in critically ill patients. The SID is the difference between strong cations and strong anions in plasma, while the SIG demonstrates the presence of unmeasured ions. This approach accounts for changes in a patient's protein status, which is particularly important in those with burn injuries. We hypothesized that the SIDa, SIDe, and SIG during the first 72 hours after admission would be predictive of mortality in burn patients. METHODS: This study is a retrospective review of adults with 20% or greater total body surface area burns admitted during a 7-year period to a regional burn center. SIDa, SIDe, and SIG were calculated at admission and for the first 3 days. These results were then compared with Acute Physiology and Chronic Health Evaluation II (APACHE II) and sepsis-related organ failure assessment (SOFA) scores. RESULTS: A total of 113 patients met the criteria and had full data sets, with mean ± SEM age of 45.4 ± 1.4 years and total body surface area burn of 41.4% ± 1.6%. Mortality was 27.4%. At admission, APACHE II remained most predictive of mortality (p = 0.006). However, admission SIG (SIDa - SIDe) was also predictive of mortality on multivariate analysis (odds ratio, 1.11). Day 1 SIDa (Na+ + K+ + Ca2+ + Mg2+ - Cl-) and SIDe ([1,000 × 2.46 × 10(-11) × PaCO2/10(-pH)] + [[albumin] × (0.123 × pH - 0.631)] + [[PO4] × (0.309) × pH - 0.469)]) were also associated with mortality (odds ratio, 1.16 and 1.13 respectively), and SIDe with length of stay and ventilator days (p < 0.05). CONCLUSION: The SID and SIG are predictive of mortality, hospital length of stay, and ventilator days in adult burn patients. They also elucidate complex acid-base disorders. LEVEL OF EVIDENCE: Prognostic study, level II.

Use of different approaches of acid-base derangement to predict mortality in critically ill patients.

BACKGROUND: There have been controversial data regarding the application of acid-base analysis based on Stewart methodology to predict clinical outcome in different populations. OBJECTIVE: To compare predictive ability of the physicochemical approach and the traditional bicarbonate approach of acid-base analysis in critically ill patients in relation to 28-days mortality and to evaluate the use of the physico chemical approach determined by the strong ion gap (SIG) in 1) medical compared to surgical critically ill patients; and 2) sepsis compared to non-sepsis patients. MATERIAL AND METHOD: This retrospective cohort study included 410 critically ill patients in the adult medical and surgical intensive care units (ICU) at a tertiary care hospital over a 2-year period. For each patient, values derived from the bicarbonate approaches including anion gap (AG), corrected anion gap (cAG) and lactate and those obtained from the physicochemical approach like SIG were simultaneously computed at ICU admission. The comparison of predictive ability between different approaches was assessed by forward stepwise logistic regression and the area under the receiver operating characteristic (aROC) curves. RESULTS: Of the 410 patents enrolled, 205 (50%) were admitted in the medical ICU and 226 patients (55%) were male. Overall 28-day mortality was 44.6% (183/410). The comparison between medical and surgical patients showed no difference in age (59 vs. 64 yr), APACHE II score (21 vs. 20), presence of sepsis (71% vs. 70%) and 28-day mortality (45% vs. 44%). Acid-base disturbance in non-survivors (n = 183) and survivors (n = 227) determined by pH (7.39 +/- 0.04 vs. 7.41 +/- 0.01), serum bicarbonate (16.0 +/- 6.1 vs. 17.9 +/- 7.4) and PaCO2 (32.4 +/- 13.4 vs. 29.4 +/- 8.2) were comparable. However non-survivors had higher levels of SIG (9.7 +/- 6.2 vs. 6.4 +/- 5.2) and cAG (27.5 +/- 8.8 vs. 20.3 +/- 8.6) than survivors did. According to a ROC curves, the predictive ability to discriminate between survivors and non-survivors of lactate, cAG AG and SIG are 0.77, 0.72, 0.68 and 0.67, respectively. Correlations between the SIG and values derived from bicarbonate approach are fair. There was no difference in SIG values between surgical and medical patients with the same severity scores. Sepsis patients (n = 291) had significantly higher SIG than non-sepsis patients (n = 129) did (8.81 +/- 6.38 vs. 5.74 +/- 4.14; p = 0.01). CONCLUSION: Compared to the traditional approach, an alternative Stewart approach does not provide any greater advantage to predict mortality in the studied population. Because of complex calculation, the usefulness of such approach on the routine clinical practice may be limited.

Thoracic trauma in Iraq and Afghanistan.

BACKGROUND: Thoracic injuries are common among civilian trauma and have a high associated mortality. The use of body armor and exposure to different mechanisms of injury in combat setting could lead to different injury patterns and incidences from those found in peacetime. METHODS: Thoracic trauma incidence rates and mortality risks were calculated from data extracted from the Joint Theatre Trauma Registry. RESULTS: Among patients injured in military operations in Iraq and Afghanistan, 10.0% sustained thoracic injuries and had a mortality rate of 10.5%. Penetrating injuries were the most common mechanism of injury. The most common thoracic injury was pulmonary contusion. The highest mortality rate was in the subset of patients with thoracic vascular injuries or flail chest. The variables most strongly associated with mortality were number of units of blood transfused, admission base deficit, international normalization ratio, pH, Abbreviated Injury Scale scores for head and neck regions, and Injury Severity Score. Blunt injuries had the same mortality risk as penetrating injuries. CONCLUSION: Combat-related thoracic trauma is common and associated with significant mortality in Iraq and Afghanistan.

[Hyperglycemic crisis in patients with diabetes mellitus]. / Hyperglykämische Krise bei Patienten mit Diabetes mellitus.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most acute life-threatening complications of diabetes mellitus and in most cases treatment should be administered in an intensive care unit. Clinically, DKA and HHS differ according to the presence of metabolic acidosis; however, the treatment of DKA and HHS is similar. The main principles are intravenous administration of insulin and correction of fluid and electrolyte abnormalities which are typically present. By the application of a standardized treatment algorithm a low mortality rate can be achieved.

Admission base deficit and lactate levels in Canadian patients with blunt trauma: are they useful markers of mortality?

BACKGROUND: Elevated base deficit (BD) and lactate levels at admission in patients with injury have been shown to be associated with increased mortality. This relationship is undefined in the Canadian experience. The goal of this study was to define the association between arterial blood gas (ABG) values at admission and mortality for Canadians with severe blunt injury. METHODS: A retrospective review of 3,000 consecutive adult major trauma admissions (Injury Severity Score, ≥ 12) to a Canadian academic tertiary care referral center was performed. ABG values at the time of arrival were analyzed with respect to associated mortality and length of stay. RESULTS: A total of 2,269 patients (76%) had complete data available for analysis. After exclusion of patients who sustained a penetrating injury or were admitted for minor falls (ground levels or low height), 445 had an ABG drawn within 2 hours of arrival. Patients who died displayed a higher median lactate (3.6 vs. 2.2, p < 0.0001), a worse median BD (-10 vs. -5, p < 0.0001), and a lower pH (7.23 vs. 7.31, p < 0.0001) at arrival compared with those of survivors. A statistically significant association was also observed between lactate and BD values at arrival and both mortality and length of stay (p < 0.0001). CONCLUSION: Despite population differences, ABGs at admission in Canadian patients with blunt trauma accurately reflect mortality in a similar manner to the previously published literature. Survival curves with lactate and BD values at arrival should be available to all clinicians within their individual trauma centers for both acute care and quality assurance. LEVEL OF EVIDENCE: Prognostic study, level III.

Established markers of renal and hepatic failure are not appropriate to predict mortality in the acute stage before extracorporeal life support implantation.

OBJECTIVES: End-organ function, especially of the kidney and liver, actual inflammation and acid-base balance affect the outcome in extracorporeal life support (ECLS) patients. However, the often unexpected necessity of ECLS implies that information on patients is scarce. Even established global scores are not always useful in the rapid decision process for ECLS. Therefore, we evaluated laboratory parameters for kidney or liver function and for inflammation and acid-base balance with regard to outcome. METHODS: The retrospective analysis includes 69 consecutive adult patients with veno-arterial ECLS. Laboratory markers for function of kidney (creatinine, urea) and liver (total bilirubin in plasma, glutamate oxaloacetate transaminase and glutamate pyruvate transaminase) as well as for inflammation (C-reactive protein, leucocyte counts) and acid-base balance (pH, lactate) were acquired within 24 h before ECLS implantation. RESULTS: A total of 38 patients (55%) could be weaned or bridged. Bridged patients were switched to ventricular assist devices, n=10, or total artificial hearts, n=2, and one patient underwent heart transplantation. Overall, 26 ECLS patients (38%) survived for >4 weeks. Thirty-one patients (45%) died on ECLS. About three out of four patients presented with impaired renal or hepatic performance, approximately two-thirds with signs of increased inflammatory state, and more than a half with deranged acid-base balance. Neither signs of hepatic or renal failure nor of inflammation or impaired acid-base balance allowed a prediction of survival in these patients. The outcome did also not depend on indication for ECLS implantation. However, there was a significant correlation between the patients' age and mortality (P=0.006). CONCLUSIONS: Our data indicate that renal and hepatic insufficiency, increased inflammatory state and deranged acid-base balance as determined by pre-operative laboratory data are not associated with poor outcome of ECLS. Further, survival is not related to indications for ECLS. In a number of patients, ECLS allows for successful bridging to other treatment options.

The impact of hyperlactatemia on postoperative outcome after adult cardiac surgery.

PURPOSE: To evaluate the value of blood lactate value in predicting postoperative mortality (primary outcome), duration of ventilation, and length of stay in an intensive care unit (ICU) and hospital (secondary outcomes). METHODS: We performed a prospective observation study on 1,820 consecutive patients undergoing open heart surgery in a tertiary university medical center. Blood lactate levels were obtained from patients on admission to the cardiac surgical ICU and measured serially. RESULTS: All patients were divided into three groups according to their maximum blood lactate levels: group I (normolactatemia, lactate ≤2.2 mmol/l), 332 patients; group II (mild hyperlactatemia, lactate 2.2-4.1 mmol/l), 1,054 patients; and group III (severe hyperlactatemia, lactate ≥4.4 mmol/l), 434 patients. Maximum blood lactate levels ≥4.4 mmol/l during the first 10 h post admission were associated with prolonged ventilation time, longer ICU stay, and increased mortality (P < 0.001). CONCLUSIONS: Hyperlactatemia is common after cardiac surgery. Maximal lactate threshold ≥4.4 mmol/l in the first 10 h after operation accurately predicts postoperative mortality.