Why do patients with urinary diversions have an increased risk of bone fracture? A systematic review on risk factors for osteoporosis and bone mineral density loss in this group of patients.

INTRODUCTION: Patients undergoing radical cystectomy with urinary diversions (UD) are at increased risk of bone fractures compared to the general population. Although a loss of bone mineral density (BMD) has been described in patients with UD, we still do not know with certainty why these patients follow this tendency. OBJECTIVE: We performed a systematic review of the available literature to analyze the prevalence of osteoporosis and bone alterations in patients with ileal UD and the possible associated risk factors. EVIDENCE ACQUISITION: We systematically searched PubMed® and Cochrane Library for original articles published before December 2022 according to PRISMA guidelines. EVIDENCE SYNTHESIS: A total of 394 publications were identified. We selected 12 studies that met the inclusion criteria with 496 patients included. Six of the twelve studies showed decreased BMD values. Prevalence of osteoporosis was specified in three articles, with values ranging ​​from 0% to 36%. Risk factors such as age, sex, body mass index, metabolic acidosis and renal function appear to have an impact on bone tissue reduction, while type of UD, follow-up, 25-hydroxyvitamin D and parathormone had less evidence or contradictory data. The heterogeneity of the studies analyzed could led to interpretation bias. CONCLUSIONS: UD are associated with multiple risk factors for osteoporosis and bone fractures. Identifying patients at highest risk and establishing diagnostic protocols in routine clinical practice are essential to reduce the risk of fractures and the resulting complications.

Prevalencia de acidosis metabólica en derivaciones ileales tras más de un año de la cistectomía radical y repercusiones metabólicas secundarias asociadas / Prevalence of metabolic acidosis in ileal diversions more than one year after radical cystectomy and associated secondary metabolic effects

Introducción y objetivo La acidosis metabólica (AM) es una alteración conocida en pacientes con derivaciones ileales. Es más frecuente en etapas tempranas postoperatorias y disminuye con el tiempo. Nuestro objetivo es determinar su prevalencia tras más de un año de seguimiento, analizar sus factores de riesgo y evaluar su impacto en diferentes perfiles metabólicos. Materiales y métodos Realizamos un estudio observacional entre enero de 2018 y septiembre de 2022 siguiendo las normas STROBE. La AM fue definida con valores de bicarbonato venoso <22mEq/l. Analizamos 133 pacientes con una media de seguimiento de 55,24±42,36 meses. Resultados Se identificaron 16 (12%) pacientes con AM. Los pacientes con y sin AM fueron comparables en edad, sexo y tiempo de seguimiento. El grupo con AM presentó una mayor tasa de anemia (68,75 vs. 19,65%; p<0,001) e insuficiencia renal (100 vs. 45,29%; p<0,001) y niveles venosos estadísticamente significativos mayores de creatinina, cloro, potasio, hormona paratiroidea y fósforo, pero menores valores de hemoglobina, filtrado glomerular, colesterol total, vitamina D, calcio y albúmina (todos p<0,05). El filtrado glomerular fue el único factor de riesgo independiente relacionado con la AM (OR: 0,914; IC 95%: 0,878-0,95; p<0,0001), demostrando una estrecha correlación con los valores de bicarbonato venoso (r=0,387; p<0,001). Conclusiones La AM es una alteración poco prevalente en derivaciones urinarias ileales transcurrido más de un año de la cistectomía, pero tiene implicaciones en el metabolismo hematológico, renal, proteico, lipídico y óseo. Aconsejamos su monitorización en pacientes con insuficiencia renal para poder realizar un diagnóstico y tratamientos precoces (AU)

Introduction and objective Metabolic acidosis (MA) is a well-known complication in patients with ileal urinary diversions. It is common in the early postoperative stages and decreases over time. Our objective is to investigate the prevalence of MA after more than one year of follow-up, identify the associated risk factors, and analyze its secondary metabolic consequences. Materials and methods We conducted an observational study between January 2018 and September 2022 following the STROBE guidelines. MA was defined as a serum bicarbonate level <22mEq/L. Finally, we analyzed 133 patients with a mean follow-up of 55.24±42.36 months. Results MA was observed in 16 (12%) patients. Patients with and without MA were comparable in age, sex, and follow-up time. The group with MA presented a higher rate of anemia (68,75% vs 19.65%, P<.001) and renal failure (100% vs 45.29%, P<.001), statistically significant higher levels of serum creatinine, chloride, potassium, parathyroid hormone, and phosphorus but lower serum values of hemoglobin, renal glomerular filtration rate, total cholesterol, vitamin D, calcium, and albumin (all P<.05). Renal glomerular filtration rate was the only independent risk factor related to the development of MA (OR: 0.914; 95% CI: 0.878-0.95; P<.0001), proving a close correlation with venous bicarbonate values (r=.387, P<.001). Conclusions MA is a little prevalent disorder in ileal urinary diversions more than one year after radical cystectomy is performed but it has secondary consequences on hematologic, renal, protein, lipid, and bone metabolism. We recommend to a close follow-up in patients with renal failure for early diagnosis and treatment (AU)

Acidosis metabólica tras cistectomía radical con derivación urinaria ileal. ¿Sabemos tanto como creemos? Revisión sistemática / Metabolic acidosis after ileal urinary diversion and radical cystectomy. Do we know as much as we believe? A systematic review

El contacto de la orina con la mucosa de la derivación urinaria (DU) tras la cistectomía radical (CR) produce diversos intercambios iónicos que promueven el desarrollo de la acidosis metabólica (AM). Esta alteración es una causa frecuente de reingresos y complicaciones a corto/largo plazo. Realizamos una revisión sistemática sobre la AM en CR con DU ileales, analizando su prevalencia, diagnóstico, factores de riesgo y tratamiento. Llevamos a cabo una revisión de la literatura de artículos publicados en Pubmed® y Cochrane Library antes de mayo de 2022 siguiendo las recomendaciones PRISMA. Se identificaron 421 artículos, de los cuales 25 cumplieron los criterios de inclusión sumando un total de 5.811 pacientes. Los estudios analizados demuestran mucha heterogeneidad en los criterios analíticos de diagnóstico y tratamiento utilizados, pudiendo sesgar los resultados de prevalencia. El desarrollo de la AM es multifactorial, siendo más frecuente su aparición durante el periodo postoperatorio temprano, especialmente en DU con segmentos ileales más largos, con mayor continencia urinaria y en pacientes con insuficiencia renal. La edad avanzada y la diabetes son factores de riesgo relacionados en periodos más tardíos. La AM es la causa más frecuente de segundos o más reingresos hospitalarios. La realización de profilaxis alcalinizante durante 3 meses en pacientes de riesgo podría mejorar estos resultados. Aunque la AM en DU ileales es una alteración conocida, esta revisión revela la necesidad de implementar criterios homogéneos de diagnóstico, monitorización y tratamiento, además de protocolizar estrategias de prevención/profilaxis en pacientes de riesgo (AU)

Urine contact with the mucosa of the urinary diversion (UD) after radical cystectomy (RC) produces different ion exchanges that favor the development of metabolic acidosis (MA). This phenomenon is a frequent cause of hospital readmission and short/long-term complications. We performed a systematic review of MA in RCs with ileal UD, analyzing its prevalence, diagnosis, risk factors and treatment. We systematically searched Pubmed® and Cochrane Library for original articles published before May 2022 according to PRISMA guidelines. A total of 421 articles were identified. We selected 25 studies that met the inclusion criteria involving 5811 patients. Obtaining precise data on the prevalence of MA is difficult, largely due to the heterogeneity of the diagnostic criteria used given the diversity of studies analyzed. Development of MA is multifactorial. In the early period, MA is more prevalent in patients with UD with longer ileal segments, better urinary continence, and impaired renal function. Age and diabetes are risk factors associated with MA in later periods. MA is the most common cause of second or more hospital readmissions. Prophylaxis with oral bicarbonate for three months in patients at risk could improve these results. Although MA after ileal UD is a well-known condition, this review highlights the need to implement homogeneous criteria for the diagnosis, follow-up, and treatment, in addition to protocolizing prevention/prophylaxis strategies in patients at risk (AU)

Prevalence of metabolic acidosis in ileal diversions more than one year after radical cystectomy and associated secondary metabolic effects.

INTRODUCTION AND OBJECTIVE: Metabolic acidosis (MA) is a well-known complication in patients with ileal urinary diversions. It is common in the early postoperative stages and decreases over time. Our objective is to investigate the prevalence of MA after more than one year of follow-up, identify the associated risk factors, and analyze its secondary metabolic consequences. MATERIALS AND METHODS: We conducted an observational study between January 2018 and September 2022 following the STROBE guidelines. MA was defined as a serum bicarbonate level ​​<22mEq/L. Finally, we analyzed 133 patients with a mean follow-up of 55.24 ± 42.36 months. RESULTS: MA was observed in 16 (12%) patients. Patients with and without MA were comparable in age, sex, and follow-up time. The group with MA presented a higher rate of anemia (68,75% vs 19,65%, p < 0.001) and renal failure (100% vs 45,29%, p < 0.001), statistically significant higher levels of serum creatinine, chloride, potassium, parathyroid hormone, and phosphorus but lower serum values ​​of hemoglobin, renal glomerular filtration rate, total cholesterol, vitamin D, calcium, and albumin (all p < 0.05). Renal glomerular filtration rate was the only independent risk factor related to the development of MA (OR 0.914; 95% CI 0.878-0.95; p < 0.0001), proving a close correlation with venous bicarbonate values ​​(r = 0.387, p < 0.001). CONCLUSIONS: MA is a little prevalent disorder in ileal urinary diversions more than one year after radical cystectomy is performed but it has secondary consequences on hematologic, renal, protein, lipid, and bone metabolism. We recommend to a close follow-up in patients with renal failure for early diagnosis and treatment.

Metabolic acidosis after ileal urinary diversion and radical cystectomy. Do we know as much as we think we do? A systematic review.

Urine contact with the mucosa of the urinary diversion (UD) after radical cystectomy (RC) produces different ion exchanges that favor the development of metabolic acidosis (MA). This phenomenon is a frequent cause of hospital readmission and short/long-term complications. We performed a systematic review of MA in RCs with ileal UD, analyzing its prevalence, diagnosis, risk factors and treatment. We systematically searched Pubmed® and Cochrane Library for original articles published before May 2022 according to PRISMA guidelines. A total of 421 articles were identified. We selected 25 studies that met the inclusion criteria involving 5811 patients. Obtaining precise data on the prevalence of MA is difficult, largely due to the heterogeneity of the diagnostic criteria used given the diversity of studies analyzed. Development of MA is multifactorial. In the early period, MA is more prevalent in patients with UD with longer ileal segments, better urinary continence, and impaired renal function. Age and diabetes are risk factors associated with MA in later periods. MA is the most common cause of second or more hospital readmissions. Prophylaxis with oral bicarbonate for three months in patients at risk could improve these results. Although MA after ileal UD is a well-known condition, this review highlights the need to implement homogeneous criteria for the diagnosis, follow-up, and treatment, in addition to protocolizing prevention/prophylaxis strategies in patients at risk.

Effects of sodium bicarbonate infusion on mortality in medical–surgical ICU patients with metabolic acidosis—A single-center propensity score matched analysis / Efectos de la infusión de bicarbonato de sodio sobre la mortalidad en pacientes de UCI médico-quirúrgica con acidosis metabólica: un análisis de puntuación de propensión en un solo Centro

Objective Metabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. Design Retrospective analysis. Setting Academic medical center. Patients or participants 971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. Interventions 441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). Main variables of interest Primary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. Results In the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99–1.17; p=.08; OR ATT 1.09; 95%-CI 0.99–1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86–1.56, p=.33) showed similar survival in the two study groups. Conclusions We did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis (AU)

Objetivo La acidosis metabólica se asocia con una alta mortalidad. A pesar de los beneficios teóricos del bicarbonato de sodio (BS), la evidencia actual sigue siendo controvertida. Investigamos los efectos relacionados con el BS sobre los resultados en pacientes de la UCI con acidosis metabólica. Diseño Análisis retrospectivo. Ÿmbito Centro médico académico. Pacientes o participante Se incluyeron 971 pacientes de la Unidad de Cuidados Intensivos (UCI) con acidosis metabólica (pH < 7,3, CO2 < 45 mmHg) tratados entre 2012 y 2016. Se calculó una puntuación de propensión (PS) mediante regresión logística. Los pacientes se emparejaron utilizando el PS. Variables de interés principales Intervenciones; 441 pacientes fueron tratados con BS 8,4% (grupo BS) y n = 530 pacientes no (grupo control). Resultados El resultado primario fue la mortalidad por todas las causas al alta de la UCI. Se calcularon el efecto promedio del tratamiento (ATE), el efecto promedio del tratamiento en los tratados (ATT) y los efectos de supervivencia relativa estimados a los 20 días. En la cohorte completa se observaron diferencias considerables en el pH, el exceso de bases y la mortalidad en la UCI (control 31% vs. grupo BS 56%, p < 0,001) al inicio del estudio entre los grupos. Después del emparejamiento de PS (n = 174 en cada grupo), no se observaron diferencias significativas en la mortalidad en la UCI (control 32% vs. grupo BS 41%; p = 0,07). Los odds ratios (OR) para ATE y ATT no mostraron asociación con la mortalidad en la UCI (OR ATE: 1,08, IC 95%; 0,99-1,17; p = 0,08; OR ATT 1,09; IC 95%; 0,99-1,2; p = 0,09). Los cocientes de riesgo a los 20 días (HR multivariable, muestra emparejada n = 348: 1,16, IC 95%; 0,86-1,56, p = 0,33) mostraron una supervivencia comparable. Conclusiones No observamos efectos de la infusión de BS sobre la mortalidad por todas las causas en pacientes con acidosis metabólica (AU)

Physiological variables of the "metabolic component" of acid-base balance and mortality in intensive care patients / Variables fisiológicas del "componente metabólico" del estado ácido base y mortalidad en pacientes de cuidados intensivos

Abstract Introduction: Metabolic acidosis is a frequent pathophysiological condition in critically ill patients. It can be assessed using different physiological variables, but their prognostic value has not yet been well established. Objective: To evaluate the association between the variables that allow assessing the metabolic component of acid-base balance (ABB) and 28-day mortality in patients admitted to an intensive care unit (ICU) in Bogotá, D.C., Colombia. Materials and methods: Prospective cohort study conducted in 122 patients admitted to an ICU between January and June 2013 and with a stay >24 hours. On admission to the ICU, blood samples were taken, and an arterial blood gas test was performed in order to calculate the following variables: anion gap (AG), corrected anion gap (AGc), standard base excess (BEst), metabolic H+, base excess-unmeasurable anions (BEua), arterial pH, arterial lactate, standard HCO3-st, and strong ion difference (SID). APACHE II and SOFA scores were also calculated. A bivariate analysis was performed in which ORs and their respective 95%CI were calculated, and then a multivariate analysis was conducted using a logistic regression model to identify the variables associated with 28-day mortality; a significance level of p<0.05 was considered. Results: Out of the 122 patients, 33 (27.05%) died at 28 days and 51 (48.80%) were women. Participants' mean age was 46.5 years (±15.7). The following variables were significantly associated with 28-day mortality in the bivariate analysis: SID (OR=1.150; p=0.008), BEua (OR=0.897; p=0.023), AG (OR=1.231; p=0.002), AGc (OR=1.232; p=0.003), blood pH (OR=0.001; p=0.023), APACHE II (OR=1.180; p=0.001), HCO3-st (OR=0.841; p=0.015). In the multivariate analysis, only the APACHE II score variable was significantly associated with 28-day mortality (OR=1.188; p=0.008). Conclusion: The physiological variables that allow assessing the metabolic component of ABB, both from the Henderson model and the Stewart model, were not significantly associated with 28-day mortality.

Resumen Introducción. La acidosis metabólica es una condición fisiopatológica frecuente en pacientes críticamente enfermos. Esta alteración es evaluada mediante diferentes variables fisiológicas; sin embargo, su valor pronóstico aún no está bien definido. Objetivo. Evaluar la asociación entre, por una parte, las variables del componente metabólico que permiten valorar el estado ácido base (EAB) y, por la otra, la mortalidad a 28 días en pacientes hospitalizados en una unidad de cuidados intensivos (UCI) en Bogotá D.C., Colombia. Materiales y métodos. Estudio de cohorte prospectivo realizado en 122 pacientes hospitalizados en una UCI entre enero y junio de 2013 y con una estancia mayor a 24 horas. Se tomaron muestras sanguíneas y gases arteriales de ingreso a UCI para el cálculo de las siguientes variables: anion gap (AG), anion gap corregido (AGc), base exceso estándar (BEst), H+ metabólicos, base exceso-aniones no medibles (BEua), pH arterial, lactato arterial, HCO3-st y brecha de iones fuertes (BIF). También se calcularon el puntaje APACHE II y el puntaje SOFA. Se realizó un análisis bivariado en el que se calcularon OR y sus respectivos IC95%, y luego uno multivariado, mediante un modelo de regresión logística, para identificar las variables asociadas con la mortalidad a 28 días; se consideró un nivel de significancia de p<0.05 Resultados. De los 122 pacientes, 33 (27.05%) fallecieron a 28 días y 51 (48.80%) eran mujeres. La edad promedio fue 46.5 años (±15.7). En el análisis bivariado, las siguientes variables se asociaron significativamente con la mortalidad a 28 días: BIF (OR=1.150; p=0.008), BEua (OR=0.897; p=0.023), AG (OR=1.231; p=0.002), AGc (OR=1.232; p=0.003), pH arterial (OR=0.001; p=0.023), APACHE II (OR=1.180;p=0.001), HCO3-st (OR=0.841;p=0.015). En el análisis multivariado, solo el puntaje APACHE II se asoció significativamente con la mortalidad a 28 días (OR=1.188; p=0.008). Conclusión. Las variables fisiológicas que permiten evaluar el componente metabólico del EAB, tanto las del modelo de Henderson, como las del modelo de Stewart, no se asociaron significativamente con la mortalidad a 28 días.

Transient early-childhood hyperkalaemia without salt wasting, pathophysiological approach of three cases.

Two types of early childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis (MA) due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present 3 patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia (TECHH) without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In 3 children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion (FE) of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic MA with FE of bicarbonate 0.58%-2.2%, positive urinary anion gap during MA and normal ability to acidify the urine. Based on these findings a diagnosis of TECHH without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that TECCH without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children.

A case of aluminum phosphide poisoning managed successfully in Nepal: a case report / Un caso de intoxicación por fosfuro de aluminio manejado con éxito en Nepal: informe de un caso

Aluminum phosphide (ALP) is a highly toxic compound most commonly available as Celphos in Nepal. Suicidal ingestion is common in developing countries like Nepal as it is easily available and has a high mortality rate. Farmers to protect crops from rodents and pests use it. Here we present a case of a 24-year-old female with suicidal ingestion of one and a half-tablet of ALP presented with abdominal pain and vomiting. The patient developed metabolic acidosis, hyperkalemia, acute respiratory distress, and hypotension during the Intensive Care Unit stay. Supportive treatment with gastric lavage (coconut oil), intravenous magnesium sulfate, sodium-bicarbonate infusion, adequate vasopressor and close monitoring of hemodynamic parameters helped in the survival of the patient (AU)

El fosfuro de aluminio (ALP) es un compuesto altamente tóxico más comúnmente disponible como Celphos en Nepal. La ingestión suicida es común en países en desarrollo como Nepal, ya que está fácilmente disponible, teniendo una alta tasa de mortalidad. Los agricultores lo utilizan para proteger los cultivos de roedores y plagas. Aquí presentamos el caso de una mujer de 24 años con ingesta suicida de una tableta y media de ALP que presentó dolor abdominal y vómitos. La paciente desarrolló acidosis metabólica, hiperpotasemia, dificultad respiratoria aguda e hipotensión durante su estancia en la Unidad de Cuidados Intensivos. El tratamiento de soporte con lavado gástrico (aceite de coco), sulfato de magnesio intravenoso, infusión de bicarbonato de sodio, vasopresor adecuado y monitoreo estrecho de los parámetros hemodinámicos ayudaron a la supervivencia del paciente (AU)

Hiperpotasemia transitoria del lactante sin pérdida salina, enfoque fisiopatológico de tres casos / Transient early-childhood hyperkalemia without salt wasting, physiopathological approach of three cases

Se reconocen 2 variedades de hiperpotasemia temprana de la infancia (del inglés Early childhood hyperkalemia) según la presencia o no de pérdida salina urinaria. Se trata de una entidad atribuida a un desorden madurativo en los receptores de aldosterona caracterizada por hiperpotasemia, acidosis metabólica hiperclorémica por diminución de la eliminación de amonio y bicarbonaturia, y creatinina normal con retraso de crecimiento. Presentamos 3 pacientes de la forma con ausencia de pérdida salina, a la que denominaremos hiperpotasemia transitoria del lactante sin pérdida salina, y discutimos su fisiopatología con relación a los nuevos conocimientos en el manejo tubular del sodio y el potasio por la aldosterona. En 3 pacientes de entre 30 y 120 días de edad con bronquiolitis y retraso de crecimiento se encontró hiperpotasemia en laboratorio de rutina. Presentaban creatinina normal, excreción fraccionada de potasio disminuida o inapropiadamente normal junto a niveles de aldosterona y renina plasmática inadecuadamente normales para el estado de hiperpotasemia, pero sin pérdida salina. También cursaban con acidosis metabólica hiperclorémica con bicarbonaturia (excreción fraccionada de bicarbonato 0,58-2,2%), anión restante urinario positivo durante acidosis metabólica y capacidad normal para acidificar la orina. En base a estos hallazgos se diagnosticó hiperpotasemia transitoria del lactante sin pérdida salina y se trataron con bicarbonato de sodio e hidroclorotiazida con buena respuesta. El cuadro fue transitorio permitiendo la suspensión del tratamiento. Dado que la hiperpotasemia transitoria del lactante sin pérdida salina es un desorden tubular transitorio con síntomas leves debe tenerse presente en el diagnóstico diferencial de hiperpotasemia en niños pequeños. (AU)

Two types of early-childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present three patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In three children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic metabolic acidosis with fractional excretion of bicarbonate 0.58–2.2%, positive urinary anion gap during metabolic acidosis and normal ability to acidify the urine. Based on these findings a diagnosis of transient early-childhood hyperkalemia without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that transient early-childhood hyperkalemia without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children. (AU)

Valores de la gasometría arterial en pacientes embarazadas con preeclampsia severa / Arterial blood gas parameters in pregnant patients with severe preeclampsia

Resumen OBJETIVO: Determinar e interpretar los valores de la gasometría arterial en pacientes embarazadas con preeclampsia severa. MATERIALES Y MÉTODOS: Estudio observacional, transversal, retrospectivo y descriptivo llevado a cabo en pacientes con más o menos 20 semanas de embarazo y diagnóstico establecido de preeclampsia severa atendidas en la unidad de cuidados intensivos entre el 1 de julio y el 31 de diciembre del 2019. Los datos generales, la condición obstétrica, los estudios de laboratorio clínico y los valores de la gasometría arterial se documentaron conforme a lo registrado en los expedientes clínicos. Se utilizó estadística descriptiva y los datos se procesaron en el programa SPSS versión 20. RESULTADOS: Se estudiaron 30 pacientes con media de edad de 31.6 ± 6.85 años, mediana de paridad 1, todas con feto único de 33.89 ± 3.43 semanas y residencia en la Ciudad de México. Los valores de la gasometría arterial fueron: pH 7.41 ± 0.08, presión parcial de dióxido de carbono 25.51 ± 6.12 mmHg, presión parcial de oxígeno 85.24 ± 41.81 mmHg, hematocrito 33.86 ± 7.51%, ión carbonato 16.95 ± 5.13 mmol/L, patrón de bicarbonato estandarizado 19.04 ± 2.50 mmol/L, gases de efecto invernadero 16.94 ± 2.51 mmHg, exceso de base del fluido extracelular -7.72 ± 5.60 mmol/L, BE (B) -7.36 ± 3.07 mmol/L, porcentaje de saturación de oxígeno 93 ± 8.29, hemoglobina total en la gasometría arterial 10.64 ± 2.36 g/dL, gradiente alvéolo-arterial de oxígeno 49.43 ± 10.98 mmHg, presión parcial de oxígeno 140.43 ± 106.93 mmHg, concentraciones de dióxido de carbono 0.79 ± 0.28 mmHg e Índice respiratorio 0.95 ± 2.57. CONCLUSIONES: Los resultados corresponden a un patrón gasométrico de acidosis metabólica compensada.

Abstract OBJECTIVE: To determine and interpret arterial blood gas values in pregnant patients with severe preeclampsia. MATERIALS AND METHODS: study carry out in a series of 30 patients with a pregnancy ≥ 20 weeks and an established diagnosis of SP admitted to the Intensive Care Unit from July 1 to December 31, 2019, in whom arterial blood gases are part of the routine studies upon admission to the ICU. Patients with recurrence of preeclampsia, eclampsia and HELLP syndrome or with metabolic, respiratory, cardiological and renal morbidities affecting arterial blood gas values were excluded. The general data, obstetric condition, clinical laboratory and arterial blood gas values were documented from the clinical records. Statistical analysis: descriptive statistics were used with the statistical package SPSS version 20. RESULTS: Thirty patients were studied, with a mean age of mean age 31.6 ± 6.85 years, median parity 1, all with a single product of 33.89±3.43 weeks and residence in Mexico City 31.37 ± 7 years. Arterial blood gas values were: pH 7.41 ± 0.08, PCO2 25.51 ± 6.12 mmHg, PO2 85.24 ± 41.81 mmHg, Hct 33.86 ± 7.51%, HCO3- 16.95 ± 5.13 mmol/L, HCO3- std 19.04 ± 2.50 mmol/L, TCO2 16.94 ± 2.51 mmHg, BE ecf -7.72 ± 5.60 mmol/L, BE (B) -7.36 ± 3.07 mmol/L, SO2c% 93 ± 8.29%, THbc 10.64 ± 2.36 g/dL, Aa DO2 49.43 ± 10.98 mmHg, pAO2 140.43 ± 106.93 mmHg, PaO2/PAO2 0.79 ± 0.28 mmHg and Respiratory Index 0.95 ± 2.57. CONCLUSIONS: The results correspond to a gasometric pattern of compensated metabolic acidosis.

Sistemática para el manejo del equilibrio ácido-base en pacientes graves / Systemization for the management of acid-base balance in seriously ill patients

Introducción: Las alteraciones del equilibrio ácido-base pueden ser de carácter primario. En la mayoría de los casos dependen de la complicación de una enfermedad preexistente. La frecuencia de estos trastornos es elevada, especialmente, en enfermos hospitalizados en las unidades de atención al paciente grave. Su aparición conlleva implicaciones pronósticas significativas. Objetivo: Sistematizar sobre el estado actual del manejo del equilibrio ácido-base. Método: Se realizó una revisión bibliográfica en la que se utilizaron las herramientas del método científico. Se examinó toda la bibliografía disponible publicada en los últimos cinco años y así, elaborar una síntesis crítica, acorde al criterio y las competencias de los autores sobre la temática. Resultados: Se expone la importancia de la evaluación clínica, que unida a los niveles de PCO2, y de exceso o déficit de bases en una gasometría arterial, permiten identificar el trastorno ácido base existente. Igualmente, se destaca que el CO2 tiene una función clave en el control de la ventilación, así como las modificaciones que produce al flujo sanguíneo cerebral, el pH y el tono adrenérgico. Otro aspecto importante fue la reciente práctica clínica de la "hipercapnia permisiva" para reducir el metabolismo tisular y de esta manera, mejorar la función del surfactante e impedir la nitración de las proteínas. Conclusiones: El manejo de los desequilibrios ácido-base debe ser del dominio de todos los profesionales vinculados a la asistencia médica, pues el retraso de su diagnóstico puede empeorar la evolución y el pronóstico de los pacientes graves(AU)

Introduction: Acid-base balance alterations can be of a primary nature. In most cases, they depend on the complication of a pre-existing disease. The frequency of these disorders is high, especially in patients hospitalized in critical care units. Its appearance carries significant prognostic implications. Objective: To systematize the current state of acid-base balance management. Method: A bibliographic review was carried out, for which the tools of the scientific method were used. All the available bibliography, published in the last five years, was examined; thus, a critical synthesis was prepared, according to the criteria and competences of the authors regarding the subject. Results: The importance of the clinical evaluation is exposed, which, together with PCO2 levels as well as excess or deficit of bases in an arterial blood gas, allow to identify the existing acid-base disorder. Likewise, it is highlighted that CO2 has a key function in ventilation control, together with the modifications it produces on cerebral blood flow, pH and adrenergic tone. Another important aspect was the recent clinical practice of "permissive hypercapnia" to reduce tissue metabolism and thus improve surfactant function and prevent protein nitration. Conclusions: The management of acid-base imbalances should be mastered by all professionals associated to medical care, since any delay in its diagnosis can worsen the evolution and prognosis of seriously ill patients(AU)

Effects of sodium bicarbonate infusion on mortality in medical-surgical ICU patients with metabolic acidosis-A single-center propensity score matched analysis.

OBJECTIVE: Metabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. DESIGN: Retrospective analysis. SETTING: Academic medical center. PATIENTS OR PARTICIPANTS: 971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. INTERVENTIONS: 441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). MAIN VARIABLES OF INTEREST: Primary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. RESULTS: In the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99-1.17; p=.08; OR ATT 1.09; 95%-CI 0.99-1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86-1.56, p=.33) showed similar survival in the two study groups. CONCLUSIONS: We did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis.

Transient early-childhood hyperkalemia without salt wasting, physiopathological approach of three cases. / Hiperpotasemia transitoria del lactante sin pérdida salina, enfoque fisiopatológico de tres casos.

Two types of early-childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present three patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In three children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic metabolic acidosis with fractional excretion of bicarbonate 0.58-2.2%, positive urinary anion gap during metabolic acidosis and normal ability to acidify the urine. Based on these findings a diagnosis of transient early-childhood hyperkalemia without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that transient early-childhood hyperkalemia without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children.

Renal tubular acidosis (RTA) and kidney stones: Diagnosis and management. / Acidosis tubular renal (ATR) y litiasis renal: Diagnóstico y manejo.

Renal tubular acidosis (RTA) is a set of raredis orders in which the renal tubule is unable to excreteacid normally and there by maintain normal acid-basebalance, resulting in a complete or incomplete metabolicacidosis. In distal RTA (dRTA, also known as classicalor type 1 RTA), there is a defect in excreting H+ ionsalong the distal nephron (distal tubule and collectingduct), leading to an alkaline urinary pH with calcium phosphate precipitation and stones. Causes of dRTAinclude genetic mutations, autoimmune disease, and some drugs.Clinical manifestations of the genetic forms of dRTA typically occur during childhood and may vary from mildclinical symptoms, such as a mild metabolic acidosis, hypokalaemia,and incidental detection of kidney stones, to more serious manifestations such as failure to thrive,severe metabolic acidosis, rickets and nephrocalcinosis.Progressive hearing loss may develop in patients withrecessive dRTA, which, depending the causative genemutation, can be present at birth or develop later in adolescence or early adulthood. Diagnosis of dRTA can be challenging, since it requires a high index of suspicion and/or measurement of urinary pH after an acid load, usually in the form of oral ammonium chloride; this should normally acidify the urine to pH below 5.3. In dRTA, urinary citrate levels a real so low and patients are at increased risk of for mingkidney stones from a combination of alkaline urine and low citrate. Ideally, affected patients need regular outpatient follow-up by a urologist and nephrologist. Thus, any patient found to have a calcium phosphate kidney stone, low urinary citrate, and raised urinary pH, especially with an early morning pH >5.5, should be evaluated for underlying dRTA. Patients with complete dRTA will have a low (<20 mmol/L) plasma or serum bicarbonate concentration, whereas in those with incomplete dRTA, bicarbonate levels are usually normal. Oral alkali as potassiumcitrate is still the mainstay of treatment in dRTA.

La acidosis tubular renal (ATR) es un conjunto de enfermedades raras en las que el túbulo renal es incapaz de excretar ácido de forma normal y por ello de mantener un balance ácido-base normal, resultando en una acidosis metabólica completa o incompleta. En la ATR distal (ATRd, también conocida como ATR tipo 1 o clásica), hay un defecto en la excreción de iones H+a lo largo de la parte distal de la nefrona (túbulo distal  y tubo colector) que conduce a un pH urinario alcalino con precipitación de fosfato cálcico y litiasis. Las causas de la ATRd incluyen mutaciones genéticas, enfermedad autoinmune y algunos fármacos. Las manifestaciones clínicas de la forma genética de la ATRd ocurren típicamente durante la infancia y pueden variar desde síntomas leves, como acidosis metabólica leve, hipokaliemia y detección accidental de litiasis renal, hasta manifestaciones más graves tales como falta de crecimiento, acidosis metabólica severa, raquitismo y nefrocalcinosis. En pacientes con ATRd recesiva puede desarrollarse una pérdida progresiva de audición que, dependiendo de la causa de la mutación genética, puede estar presente en el momento del nacimientoo desarrollarse más tarde en la adolescencia o edad adulta temprana.El diagnóstico de la ATRd puede ser un reto ya que requiere un alto grado de sospecha y/o la medición del pH urinario tras una carga ácida, normalmente en forma de cloruro amónico oral; esto debería normalmente acidificar la orina a un pH inferior a 5,3. En la ATRd, los niveles de citrato urinario también son bajos y los pacientes tienen un mayor riesgo de formar litiasis renal por una combinación de orina alcalina e hipocitraturia. Lo ideal es que los pacientes afectados sean seguidos de forma regular por un urólogo y un nefrólogo. Así,cualquier paciente con litiasis de fosfato cálcico, hipocitraturia y pH urinario elevado, especialmente con un pH urinario matutino >5,5, debería ser estudiado para descartar una ATRd oculta. Los pacientes con ATRd completa tendrán una concentración plasmática o sérica de bicarbonato baja (<20 mmol/L), mientras que en aquellos con una ATRd incompleta, los niveles de bicarbonato son generalmente normales. Los alcalinizantes orales como el citrato potásico son aún el principal pilar del tratamiento en la ATRd.

Successful correction of metabolic acidosis is difficult to achieve in chronic kidney disease. / Acidosis metabólica en la enfermedad renal crónica: dificultades para una corrección adecuada.

INTRODUCTION: Metabolic acidosis (MA) is a common complication of chronic kidney disease (CKD) and is associated with numerous adverse effects, which is why its correction is highly recommended. Oral sodium bicarbonate is the current treatment of choice. OBJECTIVES: To describe the prevalence of MA in advanced CKD patients and to determine the clinical and biochemical characteristics associated with its successful correction. MATERIAL AND METHODS: Retrospective, observational cohort study in adult patients with CKD stage 4-5. The inclusion criteria were: not being treated with alkali therapy at the time of inclusion, and to have at least three consecutive glomerular filtration rate (GFR) measurements and biochemical parameters during a minimum follow-up period of 3 months. Incident patients with serum bicarbonate<22 mEq/l were included in the follow-up study and treated with oral sodium bicarbonate. Correction was considered successful when more than half of the samples and the mean bicarbonate levels during individual follow-up were≥22 mEq/l. RESULTS: The study group consisted of 969 patients (age 65±14 years, 507 males) with a mean GFR of 14.8±4.5ml/min/1.73 m2. At baseline, 530 patients (55%) had serum bicarbonate<22mEq/l. They were treated with sodium bicarbonate and followed for 15 months. Satisfactory correction of MA was only achieved in 133 patients (25%). By multivariate logistic regression analysis, the main characteristics of patients with adequate control of MA were: age (OR=1.03; 95% CI 1.01 - 1.05), baseline GFR (OR=1.07; 1.02 - 1.12), and treatment with proton-pump inhibitors (OR=1.61; 95% CI 1.06 - 2.44). Patients who achieved successful correction of MA showed slower CKD progression (-1.67±3.71 vs -4.36±4.56ml/min/1.73 m2/year, P<.0001), and lower average serum potassium concentration (5.1±0.5 vs 5.3±0.5, P<.0001) than those who did not. However, there were no differences in the hospitalisation or mortality rate. CONCLUSION: MA is a common complication of advanced CKD but difficult to manage with current therapies. Due to the significant potential benefit of controlling MA, new, more effective therapies should be further researched.

Origen de la acidosis metabólica según los determinantes del déficit de base en pacientes con choque séptico como factor de riesgo para mortalidad / Origin of metabolic acidosis according to the determinants of the base deficit in patients with septic shock as a risk factor for mortality / Origem da acidose metabólica de acordo com os determinantes do déficit de base em pacientes com choque septico como fator de risco para a mortalidade

Resumen: Introducción: En los pacientes con choque séptico la acidosis metabólica es el trastorno ácido-base más frecuente, y el principal ion causante determinará el pronóstico en este grupo. Los estudios se han centrado en la estimación de lactato para determinar el pronóstico, aunque hoy en día sabemos que la acidosis metabólica en estos puede estar causada por el efecto, no sólo del lactato, sino también por el efecto del agua, del cloro, de la albúmina y de los aniones no medidos. Material y métodos: Se realizó un estudio de cohorte, ambispectivo, longitudinal, descriptivo y analítico. En aquéllos con diagnóstico de choque séptico y acidosis metabólica, ingresados a la Unidad de Cuidados Intensivos (UCI) en el periodo comprendido del 15 de junio del 2015 al 30 de julio del 2018. Se evaluó el riesgo para mortalidad de las variables: lactato, el efecto del agua, del cloro, de la albúmina y de los aniones no medidos. Todos los análisis estadísticos se realizaron con el programa SPSSTM 22.0. Resultados: En el periodo considerado, 87 cumplieron con los criterios de inclusión, de los cuales 46% fueron hombres y 54% mujeres. De éstos, 44.8% fallecieron durante su estancia. En el análisis multivariado, las variables con relevancia estadística, medidas al ingreso como factor de riesgo para mortalidad fueron: el efecto del agua con punto de corte > -0.75 mEq/L, presenta un OR 7.227 (IC95%: 1.831-28.5; p = 0.005), el efecto de la albúmina con punto de corte de > -4.75 mEq/L, presenta un OR 6.163 (IC95%: 1.786-21.2; p = 0.004). Conclusión: La acidosis metabólica va más allá de la adición o remoción de solutos, teniendo gran importancia la disociación del agua.

Abstract: Introduction: In patients with septic shock, metabolic acidosis is the most frequent acid-base disorder and the main causative ion will determine the prognosis in this group of patients. Studies have focused on the estimation of lactate to determine the prognosis, although today we know that metabolic acidosis in these patients may be caused by the effect not only of lactate but also by the effect of water, effect of chlorine, effect of albumin and effect of unmeasured anions. Material and methods: A cohort study was performed, ambispective, longitudinal, descriptive and analytical. In patients diagnosed with septic shock and metabolic acidosis, admitted to the Intensive Care Unit (ICU) in the period from June 15, 2015 to July 30, 2018. The risk for mortality of the variables was evaluated: lactate, the effect of water, the effect of chlorine, the effect of albumin and the effect of unmeasured anions. All statistical analyzes were performed with the SPSSTM 22.0 program. Results: In the period considered, 87 patients met the inclusion criteria, of which 46% were male and 54% were female. 44.8% of patients died during their stay. In the multivariate analysis, the variables with statistical significance, measures at admission as a risk factor for mortality were: the effect of water with cut-off point > -0.75 mEq/L, presents an OR 7.227 (CI95%: 1.831-28.5; p = 0.005), the effect of albumin with cut-off point of > -4.75 mEq/L, presents an OR 6.163 (CI95%: 1.786-21.2, p = 0.004). Conclusion: Metabolic acidosis goes beyond the addition or removal of solutes, the dissociation of water having great importance.

Resumo: Introdução: Em pacientes com choque séptico a acidose metabólica é o distúrbio ácido-base mais frequente e o principal íon causador determinará o prognóstico nesse grupo de pacientes. Os estudos têm focado na estimativa do lactato para determinar o prognóstico, embora hoje sabemos que a acidose metabólica nesses pacientes pode ser causada pelo efeito não só do lactato, mas também pelo efeito da água, do cloro, da albumina e efeito dos ânions não medidos. Material e métodos: Foi realizado um estudo de coorte, ambispectivo, longitudinal, descritivo e analítico em pacientes com diagnóstico de choque séptico e acidose metabólica, internados na Unidade de Terapia Intensiva (UTI) no período de 15 de junho de 2015 a 30 de julho de 2018. Avaliou-se o risco de mortalidade das variáveis: lactato, efeito da água, do cloro, da albumina e efeito de ânions não medidos. Todas as análises estatísticas foram realizadas com o programa SPSS v22.0. Resultados: No período considerado, 87 pacientes preencheram os critérios de inclusão, dos quais 46% eram do sexo masculino e 54% do sexo feminino. 44.8% dos pacientes morreram durante a internação. Na análise multivariada, as variáveis com relevância estatística medidas no momento da internação como fator de risco para mortalidade foram: o efeito da água com ponto de corte > -0.75 mEq/L, apresentou um OR 7.227 (IC95%: 1.831-28.5; p = 0.005), o efeito da albumina com um ponto de corte > -4.75 mEq/L, apresentou um OR 6.163 (CI95%: 1.786-21.2; p = 0.004). Conclusão: A acidose metabólica vai além da adição ou remoção de solutos, sendo a dissociação da água de grande importância.

Dietary Acid Load: mechanisms and evidence of its health repercussions. / Carga ácida de la dieta; mecanismos y evidencia de sus repercusiones en la salud.

Diet composition has long been known to influence acid-base balance by providing acid or base precursors. In general, foods rich in protein, such as meat, cheese, eggs, and others, increase the production of acid in the body, whereas fruit and vegetables increase alkalis. The capacity of acid or base production of any food is called potential renal acid load (PRAL). Diets high in PRAL induce a low-grade metabolic acidosis state, which is associated with the development of metabolic alterations such as insulin resistance, diabetes, hypertension, chronic kidney disease, bone disorders, low muscle mass and other complications. The aim of this paper is to review the available evidence which evaluates the association of the PRAL of the diet with the incidence of chronic diseases and metabolic disorders, as well as related mechanisms involved in their development.

Acidosis láctica por intoxicación alcohólica / Lactic acidosis by alcohol intoxication

La acidosis metabólica láctica es un trastorno severo del metabolismo intermediario, que conlleva una elevada tasa de mortalidad. Pueden presentarse en el contexto de isquemia tisular extensa, fallo cardiocirculatorio, shock séptico, o desencadenarse por determinados tóxicos (metanol, etanol, etc) y fármacos (metformina y otros). El etanol es un depresor del sistema nervioso central que provoca un cuadro clínico caracterizado por euforia, alteraciones de la conducta, pérdida de la inhibición, ataxia, verborrea y, finalmente, estupor y coma, dependiendo del grado de intoxicación además pueden presentar cuadros convulsivos. En este reporte se presenta el caso de una paciente joven con intoxicación alcohólica

Lactic acidosis is a severe disorder of intermediary metabolism, which leads to a high mortality rate. It can occur in the context of extensive tissue ischemia, cardiocirculatory failure, septic shock or triggered by certain toxins (methanol, ethanol, etc.) and drugs (metformin and others). Ethanol is a central nervous system depressant that causes a clinical picture characterized by euphoria, behavioral changes, loss of inhibition, ataxia, verbiage and, finally, stupor and coma, depending on the degree of intoxication can also present seizures. In this report we present, the case of a young patient with alcohol intoxication

Síndrome por Infusión de propofol en un caso de estatus epiléptico refractario / Propofol infusion syndrome in a refractory epileptic status case

INTRODUCCIÓN: El síndrome por infusión de propofol (SIP) es una reacción adversa poco frecuente, pero potencialmente letal descrita por la utilización de dicho fármaco en infusión intravenosa (IV) continua. El diagnóstico se basa en la combinación de acidosis metabólica, rabdomiolisis, hiperkalemia, hepatomegalia, insuficiencia renal, hiperlipidemia, arritmias e insuficiencia cardiaca rápida mente progresiva. OBJETIVO: Presentación de un caso clínico de SIP y revisión de literatura. CASO CLÍNICO: Paciente femenino de 6 años de edad con antecedentes de epilepsia secundaria a extensa alteración del desarrollo cortical hemisférico derecho. Presentó estatus epiléptico refractario que requirió ingreso a Unidad de Cuidados Intensivos para soporte vital y tratamiento, el que incluyó como terapia de tercera línea infusión intravenosa continua de propofol en dosis progresivas hasta alcanzar una tasa 10 mg/kg/h. Cursó con compromiso hemodinámico y a las 24 h de iniciado el tratamiento se observó alza de la creatinifosfokinasa (CK), acidosis metabólica y lactacidemia elevada, y luego de descartar otras causas se planteó el diagnóstico de SIP por lo que se suspendió la droga, logrando estabilización hemodinámica a las 24 h. DISCUSIÓN: El diagnóstico de SIP es complejo, se debe considerar en pacientes que estén recibiendo el fármaco y presenten acidosis metabólica o insuficiencia cardiaca. Los factores que más influyen en la mortalidad son la dosis acumulativa de la droga, la presencia de fiebre y lesión encéfalo craneana. En el caso descrito la paciente recibió una dosis mayor a 4 mg/ kg/h que es la dosis máxima recomendada y respondió favorablemente luego de 12 h después de la suspensión del fármaco.

INTRODUCTION: Propofol Infusion Syndrome (PRIS) is a rare but potentially lethal adverse reaction secondary to the continuous intravenous infusion of this drug. The diagnosis is based on the com bination of metabolic acidosis, rhabdomyolysis, hyperkalemia, hepatomegaly, renal failure, hyperli pidemia, arrhythmias, and rapidly progressive heart failure. OBJECTIVE: To report a case of PRIS and literature review. CLINICAL CASE: A 6-year-old female patient with history of epilepsy secondary to large malformation of cortical development of the right hemisphere. The patient presented a refractory status epilepticus that required admission to the Intensive Care Unit for life support and treatment, which included continuous intravenous infusion of propofol at 10 mg/kg/h. She developed hemo dynamic instability, and after 24 h of treatment an increase of creatine phosphokinase (CPK) levels, metabolic acidosis and elevated lactacidemia were observed. After ruling out other causes, PRIS was diagnosed; therefore, the drug was suspended, achieving hemodynamic stabilization after 24 hours. DISCUSSION: The diagnosis of PRIS is complex and should be considered in patients who are receiving this drug and present metabolic acidosis or heart failure. The factors that most influence mortality are the cumulative dose of the drug, the presence of fever, and cranial brain injury. In the case described, the patient received a dose higher than 4 mg/kg/h, which is the maximum recommended dose, and responded favorably 12 hours after stopping the drug.