Pelvic fracture in the patient with multiple injuries: factors and lesions associated with mortality. / Paciente politraumático con fractura de pelvis: factores y lesiones asociados a la mortalidad.

OBJECTIVES: The main objective of this study was to identify demographic, clinical, analytical factors or injuries associated with 30-day mortality in patients with pelvic fractures. MATERIAL AND METHODS: Prospective observational study of patients with multiple injuries including pelvic fractures between January 2009 and January 2017. We recorded demographic, clinical, and laboratory data on arrival at the emergency department; type of pelvic fracture; treatments; associated lesions; and 30-day mortality. Univariable and multivariable models were used to analyze the data. RESULTS: A total of 2061 multiple-injury patients were attended; 118 had pelvic fractures. Fifteen of the patients with pelvic fractures (12.7%) died within 30 days. Arterial blood pressure on admission was less than 90 mm Hg in 23.7%, heart rate was over 100 beats per minute in 41.52%, lactic acid level was 20 mg/dL or higher in 67.6%, and base excess of -6 or less was recorded for 26.3%. The mean Injury Severity Score was 20 points. Angiographic embolization was required in 80.6% and preperitoneal packing in 3.4%. The main associated lesions were rib fractures (35.6%), hemo-pneumothorax (31.3%), spinal injuries (35.6%), and head injuries (30%). CONCLUSION: The 6 independent variables associated with risk of death in multiple-injury patients with pelvic fractures are age, female sex, complex fractures (Tile type C), lactic acid level of 20 mg/dL or more, base excess of -6 or less, and bowel perforation.

OBJETIVO: El principal objetivo de este estudio es identificar aquellos factores demográficos, clínicos, analíticos o lesiones asociadas relacionados con la mortalidad a 30 días. METODO: Estudio observacional con recogida prospectiva de datos de pacientes politraumáticos (PPT) con fractura de pelvis (FP) asociada entre enero de 2009 y enero de 2017. Se recogieron variables demográficas, clínicas y analíticas a la llegada al servicio de urgencias, tipo de fractura pélvica, procedimientos terapéuticos, lesiones asociadas y mortalidad a los 30 días. Se realizó un análisis de asociación uni y multivariable. RESULTADOS: Se atendieron 2.061 PPT, de ellos 118 presentaban FP. La mortalidad a los 30 días fue del 12,7% (15 PPT). El 23,7% ingresaron con una presión arterial sistólica < 90 mmHg, el 41,52% con frecuencia cardiaca > 100 lpm, 67,6% con lactacidemia >= 20 mg/dl y el 26,3% con un exceso de base (EB) <= ­6. El Injury Severity Score medio fue de 20 puntos. Requirieron angiembolización el 80,6% y packing preperitoneal el 3,4%. Las principales lesiones asociadas fueron: fracturas costales (35,6%), hemo-neumotórax (31,3%), lesiones de raquis (35,6%) y traumatismo craneoencefálico (30%). Los factores independientes asociados a la mortalidad fueron: la edad, el sexo femenino, las fracturas complejas (Tile C), un lactato >= 20 mg/dL, un EB <= ­6 y la asociación a perforación intestinal. CONCLUSIONES: Se identifican 6 factores independientes relacionados con la mortalidad a 30 días de los PPT con FP.

The Basic Metabolic Profile in Heart Failure-Marker and Modifier.

PURPOSE OF REVIEW: The physiologic determinants of each of the components of the basic metabolic profile in patients with heart failure will be explored. Additionally, the review will discuss the prognostic value of alterations in the basic metabolic profile as well as their effects on management. RECENT FINDINGS: Abnormalities in the basic metabolic profile have significant correlation with clinical outcomes and can modify treatment in heart failure. Hypochloremia has recently received increased attention for these reasons. Elevated creatinine, increased blood urea nitrogen, hyponatremia, and hypochloremia correlate with worse mortality and diuretic resistance in heart failure. Hypokalemia, even when mild, has proven to be a worse clinical indicator than modest elevations in serum potassium. Hypochloremia is mechanistically linked to hyponatremia and metabolic alkalosis, but recent compelling data suggests that it can provide more discriminating prognostic information. Knowledge of the physiologic basis for each of these alterations informs their management.

Bicarbonate Concentration, Acid-Base Status, and Mortality in the Health, Aging, and Body Composition Study.

BACKGROUND AND OBJECTIVES: Low serum bicarbonate associates with mortality in CKD. This study investigated the associations of bicarbonate and acid-base status with mortality in healthy older individuals. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We analyzed data from the Health, Aging, and Body Composition Study, a prospective study of well functioning black and white adults ages 70-79 years old from 1997. Participants with arterialized venous blood gas measurements (n=2287) were grouped into <23.0 mEq/L (low), 23.0-27.9 mEq/L (reference group), and ≥28.0 mEq/L (high) bicarbonate categories and according to acid-base status. Survival data were collected through February of 2014. Mortality hazard ratios (HRs; 95% confidence intervals [95% CIs]) in the low and high bicarbonate groups compared with the reference group were determined using Cox models adjusted for demographics, eGFR, albuminuria, chronic obstructive pulmonary disease, smoking, and systemic pH. Similarly adjusted Cox models were performed according to acid-base status. RESULTS: The mean age was 76 years, 51% were women, and 38% were black. Mean pH was 7.41, mean bicarbonate was 25.1 mEq/L, 11% had low bicarbonate, and 10% had high bicarbonate. Mean eGFR was 82.1 ml/min per 1.73 m(2), and 12% had CKD. Over a mean follow-up of 10.3 years, 1326 (58%) participants died. Compared with the reference group, the mortality HRs were 1.24 (95% CI, 1.02 to 1.49) in the low bicarbonate and 1.03 (95% CI, 0.84 to 1.26) in the high bicarbonate categories. Compared with the normal acid-base group, the mortality HRs were 1.17 (95% CI, 0.94 to 1.47) for metabolic acidosis, 1.21 (95% CI, 1.01 to 1.46) for respiratory alkalosis, and 1.35 (95% CI, 1.08 to 1.69) for metabolic alkalosis categories. Respiratory acidosis did not associate with mortality. CONCLUSIONS: In generally healthy older individuals, low serum bicarbonate associated with higher mortality independent of systemic pH and potential confounders. This association seemed to be present regardless of whether the cause of low bicarbonate was metabolic acidosis or respiratory alkalosis. Metabolic alkalosis also associated with higher mortality.

Monitoring of acid-base and regulating variables during abdominal lavage.

This prospective clinical study was performed to determine acid-base regulating variables during abdominal lavage treatment for patients with severe peritonitis or after abdominal surgery. Arterial blood was sampled from twelve patients with secondary peritonitis and nine patients after abdominal surgery without peritonitis at three time points: immediately before, immediately after and 15 minutes after abdominal lavage with normal saline solution. The total amount of irrigant fluid, the strong ion difference [(Na+ + K+)-(Cl- + lactate-)], and total protein concentrations were determined and standard bicarbonate, standard base excess were calculated from pH and PaCO2. Peritonitis patients developed a moderate alkalaemia (pH 7.440-7.485). The alkalaemia was unmasked after optimization of mild hypoventilation, but was supported by a decrease in protein concentration of about 3.4 mEql/l in the first 15 minutes after the lavage. There was no marked increase in chloride concentration in either the peritonitis or the control group. The data indirectly exclude major fluid absorption during abdominal lavage with 3000 to 6000 ml normal saline, given that we found no clinically relevant electrolyte and acid-base changes that might be expected after rapid fluid absorption. The factors of major influence in acid-base regulation were ventilation and protein loss in the course of abdominal lavage. Monitoring of the Stewart variables is an easily applicable method of monitoring acid-base regulating variables in the perioperative course of patients undergoing abdominal lavage therapy.

Predictors of alkalosis after liver transplantation.

BACKGROUND: Metabolic alkalosis (MA) is common after orthotopic liver transplantation (OLT). METHODS: The study was conducted to identify factors associated with MA after 285 OLTs. MA, defined as total carbon dioxide content of 30 mEq/L or greater, developed in 115 patients (40%) within the first 3 postoperative days. RESULTS: By univariate analysis, patients with MA had a greater preoperative carbon dioxide content (24.4 +/- 3 versus 22.9 +/- 2.9 mEq/L; P < 0.0001) and hematocrit (35% +/- 5% versus 33% +/- 6%; P < 0.02), but lower creatinine (0.9 +/- 0.5 versus 1.2 +/- 1.2 mg/dL; P < 0.001) and blood urea nitrogen levels (15 +/- 12 versus 19 +/- 17 mg/dL; P < 0.001) compared with controls. Patients with MA were administered more citrate intraoperatively compared with controls (6.2 +/- 5.2 versus 4.5 +/- 3.6 mEq/kg of body weight; P < 0.02). Patients with MA had a lower postoperative potassium level (3.7 +/- 0.4 versus 4 +/- 0.5 mEq/L; P < 0.0001) and cumulative fluid balance (-0.66 +/- 1.87 versus +0.003 +/- 3.9 L; P < 0.007) compared with controls. By multivariate analysis, preoperative carbon dioxide content (odds ratio, 1.19; 95% confidence interval [CI], 1.08 to 1.31 per mEq/L), creatinine level (odds ratio, 0.61; 95% CI, 0.39 to 0.96 per mg/dL), intraoperative administered citrate (odds ratio, 3.35; 95% CI, 1.71 to 6.53 per 10 mEq/kg body weight), and postoperative potassium level (odds ratio, 0.32; 95% CI, 0.18 to 0.57 per mEq/L) were independently associated with MA. MA was not associated with increased hospital mortality (7.8% versus 8.2%, MA versus controls). However, patients with MA spent more time on mechanical ventilation than controls (5 +/- 0.8 versus 3 +/- 0.6 days; P < or = 0.03). CONCLUSION: Preoperative total carbon dioxide content, renal function, intraoperative administered citrate, and postoperative potassium level are independently associated with MA after primary OLT.

Alkalemia-associated morbidity and mortality in medical and surgical patients.

The difference in death rate among medical and surgical inpatients having alkalemia is incompletely defined. This prospective study was done to identify the incidence, mortality, and clinical factors that resulted in a poor outcome in both groups of patients. We screened a total of 10,811 consecutive arterial blood gas values; in 4,427 (40.9%) the pH was greater than 7.44, and in 2,577 (23.8%) the pH was greater than 7.48. The study group consisted of 409 patients (213 medical, 196 surgical) whose pH value was greater than 7.48; 253 of these patients (61.9%) had pure respiratory alkalosis, 120 (29.3%) had mixed respiratory and metabolic alkalosis, 27 (6.6%) had a mixed acid base disorder, and nine (2.2%) had pure metabolic alkalosis. Overall group mortality was 27.9% and increased as pH values rose, reaching 48.5% when the pH was greater than 7.60. The overall mortality among medical patients (36.6%) exceeded that among the surgical patients (12.4%) (P less than .05), an observation that applied over a wide range of pH values. Patients having mixed respiratory and metabolic alkalosis had a significantly poorer outcome (44.2% mortality) than the alkalemic group as a whole (27.9% mortality) (P less than .05). Alkalemia-associated illnesses are common in hospitalized patients and are associated with high mortality in both medical and surgical patients, though the death rate is higher among medical patients. Mixed respiratory and metabolic alkalosis appears to be associated with a particularly poor prognosis.

Clinical significance of the elevated anion gap.

To determine the clinical significance of a high anion gap (more than 16 meq/liter), consecutive patients in whom electrolyte determinations were made in an emergency room and who had either a normal (8 to 16 meq/liter) (n = 571) or a high (n = 100) anion gap were contrasted. No differences were noted between the groups with regard to age or length of stay in the hospital, but in the group with a high anion gap, there was an increased severity and frequency of multiple electrolyte disorders, and higher general admission rates (66 percent with high anion gap versus 51 percent with normal anion gap, p less than 0.02), rates of admission to an intensive care unit (25 percent with high anion gap versus 14 percent with normal anion gap, p less than 0.03), and mortality within one week of admission (12 percent with high anion gap versus 0.5 percent with normal anion gap, p less than 0.001) as compared with the group with a normal anion gap. Notably, patients without severe electrolyte abnormalities and a high anion gap had higher admission rates and a 50-fold increased mortality rate as compared with the group without severe electrolyte disturbances and a normal anion gap. Thus, an elevated anion gap is associated with an increased severity of illness that is independent of concomitant severe electrolyte abnormalities. Patients with a normal or high anion gap that survived the first week of hospitalization were shown to have an extremely low risk for mortality.