RESUMO
OBJECTIVE: To evaluate the outcomes of patients with sepsis-associated organ dysfunction and septic shock who receive fluid resuscitation with balanced and unbalanced solutions in a middle-income country. DESIGN: An observational, analytical cohort study with propensity score matching (PSM) in children admitted to a pediatric intensive care unit (PICU). Patients from one month to 17 years old who required fluid boluses due to hemodynamic instability were included. The primary outcome was the presence of acute kidney injury and the secondary outcomes were the need to begin continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay and mortality. MEASUREMENTS AND MAIN RESULTS: Out of the 1,074 admissions to the PICU during the study period, 99 patients had sepsis-associated organ dysfunction and septic shock. Propensity score matching was performed including each patient´s baseline characteristics. The median age was 9.9 months (IQR 4.9-22.2) with 55.5% of the patients being male. Acute kidney injury was seen less frequently in children who received a balanced solution than in those who received an unbalanced solution (20.3% vs 25.7% P = 0.006 ORa, 0.75; 95% CI, 0.65-0.87), adjusted for disease severity. In addition, the group that received balanced solutions had less need for CRRT (3.3 % vs 6.5%; P = 0.02 ORa 0.48; 95% CI, 0.36-0.64) and a shorter PICU stay (6 days IQR 4.4-20.2 vs 10.2 days IQR 4.7-26; P < 0.001) than the group with unbalanced solutions. We found no difference in the frequency of metabolic acidosis (P = 0.37), hyperchloremia (P = 0.11) and mortality (P = 0.25) between the 2 groups. CONCLUSION: In children with sepsis-associated organ dysfunction and septic shock, the use of unbalanced solutions for fluid resuscitation is associated with a higher frequency of acute kidney injury, a greater need for continuous renal support and a longer PICU stay compared to the use of balanced solutions, in a middle-income country.
Assuntos
Acidose , Injúria Renal Aguda , Sepse , Choque Séptico , Acidose/etiologia , Acidose/terapia , Injúria Renal Aguda/complicações , Injúria Renal Aguda/terapia , Criança , Estudos de Coortes , Hidratação , Humanos , Lactente , Masculino , Insuficiência de Múltiplos Órgãos/complicações , Ressuscitação , Estudos Retrospectivos , Sepse/complicações , Sepse/terapiaAssuntos
Encéfalo , Transtornos da Consciência , Erros de Diagnóstico , Dissulfiram , Doença de Lyme , Convulsões , Inibidores de Acetaldeído Desidrogenases/administração & dosagem , Inibidores de Acetaldeído Desidrogenases/toxicidade , Acidose/induzido quimicamente , Acidose/diagnóstico , Acidose/terapia , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Encéfalo/fisiopatologia , Doença Crônica , Deterioração Clínica , Transtornos da Consciência/induzido quimicamente , Transtornos da Consciência/diagnóstico , Erros de Diagnóstico/efeitos adversos , Erros de Diagnóstico/prevenção & controle , Dissulfiram/administração & dosagem , Dissulfiram/toxicidade , Eletroencefalografia/métodos , Evolução Fatal , Humanos , Prescrição Inadequada/efeitos adversos , Prescrição Inadequada/prevenção & controle , Doença de Lyme/diagnóstico , Doença de Lyme/tratamento farmacológico , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Minociclina/administração & dosagem , Minociclina/efeitos adversos , Assistência ao Paciente/métodos , Respiração Artificial/métodos , Convulsões/induzido quimicamente , Convulsões/diagnóstico , Tinidazol/administração & dosagem , Tinidazol/efeitos adversosRESUMO
Introducción. La cetoacidosis diabética (CAD) se caracteriza por acidosis metabólica (AM) con anión restante (AR) elevado, aunque, ocasionalmente, puede presentar hipercloremia. Se postuló que la presencia de hipercloremia inicial podría reflejar un mejor estado de hidratación; sin embargo, su prevalencia y su impacto en el tratamiento de la CAD se desconoce. Objetivos. Determinar la prevalencia de AM con componente hiperclorémico previo al inicio del tratamiento y evaluar si su presencia se asocia con mejor estado de hidratación y con menor tiempo de salida de la CAD, en comparación con los pacientes con AR elevado exclusivo. Pacientes y métodos. Se agruparon los pacientes internados con CAD (período entre enero de 2014 y junio de 2016) según presentaran, al ingresar, AM con AR elevado exclusivo o con hipercloremia y se compararon sus variables clínicas, de laboratorio y la respuesta al tratamiento. Resultados. Se incluyeron 40 pacientes -amp;#91;17 varones, mediana de edad: 14,5 años (2,4-18)-amp;#93;, 22 con AM con componente hiperclorémico (prevalencia de 55%) y 18 con AR elevado exclusivo. La presencia de hipercloremia no se asoció con mejor estado de hidratación (porcentaje de déficit de peso en ambos grupos: 4,9%; p= 0,81) ni con una respuesta terapéutica más rápida (con componente hiperclorémico: 9,5 horas; con AR elevado exclusivo: 11 horas; p= 0,64). Conclusiones. En niños con CAD, la prevalencia de AM con componente hiperclorémico fue del 55% y no se asoció con un mejor estado de hidratación ni con una salida más temprana de la descompensación metabólica.
Introduction. Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis (MA) with a high anion gap (AG), although, occasionally, it can present with hyperchloremia. It has been postulated that the early presence of hyperchloremia could reflect a better hydration status; however, its prevalence and impact on DKA treatment remain unknown. Objectives. To determine the prevalence of the hyperchloremic component in MA prior to treatment and to assess whether it is associated with a better hydration status and a shorter recovery time from DKA compared to patients with high AG only. Patients and Methods. Patients hospitalized with DKA (between January 2014 and June 2016) were grouped according to whether they were admitted with MA with high AG only. or with hyperchloremia, and clinical and laboratory outcome measures and response to treatment were compared. Results. Forty patients (17 males, median age: 14.5 years -amp;#91;2.4-18-amp;#93;) were included; 22 with hyperchloremic metabolic acidosis (prevalence of 55%) and 18 with metabolic acidosis with high AG only. The presence of hyperchloremia was not associated with a better hydration status (weight loss percentage in both groups: 4.9%; p= 0.81) nor with a faster treatment response (MA with a hyperchloremic component: 9.5 hours; MA with high AG only: 11 hours; p= 0.64). Conclusions. The prevalence of MA with a hyperchloremic component among children with DKA was 55% and was not associated with a better hydration status nor with a faster recovery from the metabolic decompensation.
Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Equilíbrio Ácido-Base/fisiologia , Acidose/terapia , Cloretos/sangue , Cetoacidose Diabética/terapia , Acidose/fisiopatologia , Desequilíbrio Hidroeletrolítico , Prevalência , Estudos Transversais , Cetoacidose Diabética/fisiopatologia , Estado de Hidratação do Organismo/fisiologiaRESUMO
INTRODUCTION: Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis (MA) with a high anion gap (AG), although, occasionally, it can present with hyperchloremia. It has been postulated that the early presence of hyperchloremia could reflect a better hydration status; however, its prevalence and impact on DKA treatment remain unknown. determine the prevalence of the hyperchloremic component in MA prior to treatment and to assess whether it is associated with a better hydration status and a shorter recovery time from DKA compared to patients with high AG only. Patients and Methods. Patients hospitalized with DKA (between January 2014 and June 2016) were grouped according to whether they were admitted with MA with high AG only. or with hyperchloremia, and clinical and laboratory outcome measures and response to treatment were compared. RESULTS: Forty patients (17 males, median age: 14.5 years [2.4-18]) were included; 22 with hyperchloremic metabolic acidosis (prevalence of 55%) and 18 with metabolic acidosis with high AG only. The presence of hyperchloremia was not associated with a better hydration status (weight loss percentage in both groups: 4.9%; p= 0.81) nor with a faster treatment response (MA with a hyperchloremic component: 9.5 hours; MA with high AG only: 11 hours; p= 0.64). CONCLUSIONS: The prevalence of MA with a hyperchloremic component among children with DKA was 55% and was not associated with a better hydration status nor with a faster recovery from the metabolic decompensation.
Introducción. La cetoacidosis diabética (CAD) se caracteriza por acidosis metabólica (AM) con anión restante (AR) elevado, aunque, ocasionalmente, puede presentar hipercloremia. Se postuló que la presencia de hipercloremia inicial podría reflejar un mejor estado de hidratación; sin embargo, su prevalencia y su impacto en el tratamiento de la CAD se desconoce. Objetivos. Determinar la prevalencia de AM con componente hiperclorémico previo al inicio del tratamiento y evaluar si su presencia se asocia con mejor estado de hidratación y con menor tiempo de salida de la CAD, en comparación con los pacientes con AR elevado exclusivo. Pacientes y métodos. Se agruparon los pacientes internados con CAD (período entre enero de 2014 y junio de 2016) según presentaran, al ingresar, AM con AR elevado exclusivo o con hipercloremia y se compararon sus variables clínicas, de laboratorio y la respuesta al tratamiento. Resultados. Se incluyeron 40 pacientes [17 varones, mediana de edad: 14,5 años (2,4-18)], 22 con AM con componente hiperclorémico (prevalencia de 55%) y 18 con AR elevado exclusivo. La presencia de hipercloremia no se asoció con mejor estado de hidratación (porcentaje de déficit de peso en ambos grupos: 4,9%; p= 0,81) ni con una respuesta terapéutica más rápida (con componente hiperclorémico: 9,5 horas; con AR elevado exclusivo: 11 horas; p= 0,64). Conclusiones. En niños con CAD, la prevalencia de AM con componente hiperclorémico fue del 55% y no se asoció con un mejor estado de hidratación ni con una salida más temprana de la descompensación metabólica.
Assuntos
Equilíbrio Ácido-Base/fisiologia , Acidose/terapia , Cloretos/sangue , Cetoacidose Diabética/terapia , Acidose/fisiopatologia , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Cetoacidose Diabética/fisiopatologia , Feminino , Humanos , Masculino , Estado de Hidratação do Organismo/fisiologia , Prevalência , Desequilíbrio HidroeletrolíticoRESUMO
Metabolic acidosis is highly prevalent in hemodialysis patients. The disorder is associated with increased mortality and its deleterious effects are already present in the predialysis phase of chronic kidney disease. Metabolic acidosis has been linked to progression of chronic kidney disease, changes in protein and glucose metabolism, bone and muscle disorders and cardiovascular disease. At present, the control of metabolic acidosis in hemodialysis is mainly focused on the supply of bicarbonate during dialysis session, but further studies are needed to set the optimum target serum bicarbonate and the best concentration of the bicarbonate dialysate. The present study reviews pathophysiological and epidemiological aspects of metabolic acidosis in hemodialysis patients and also addresses its adverse effects and treatment.
Assuntos
Acidose , Falência Renal Crônica/terapia , Diálise Renal , Acidose/etiologia , Acidose/terapia , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/metabolismoRESUMO
Abstract Metabolic acidosis is highly prevalent in hemodialysis patients. The disorder is associated with increased mortality and its deleterious effects are already present in the predialysis phase of chronic kidney disease. Metabolic acidosis has been linked to progression of chronic kidney disease, changes in protein and glucose metabolism, bone and muscle disorders and cardiovascular disease. At present, the control of metabolic acidosis in hemodialysis is mainly focused on the supply of bicarbonate during dialysis session, but further studies are needed to set the optimum target serum bicarbonate and the best concentration of the bicarbonate dialysate. The present study reviews pathophysiological and epidemiological aspects of metabolic acidosis in hemodialysis patients and also addresses its adverse effects and treatment.
Resumo A acidose metabólica é altamente prevalente em pacientes em hemodiálise. A doença está associada com mortalidade aumentada e os seus efeitos deletérios já estão presentes na fase pré-diálise da doença renal crônica. A acidose metabólica tem sido associada a progressão da doença renal crônica, alterações no metabolismo das proteínas e da glicose, doenças ósseas e musculares e enfermidades cardiovasculares. Atualmente, o controle da acidose metabólica em hemodiálise está voltado principalmente para o suprimento de bicarbonato durante a sessão de diálise, porém, mais estudos são necessários para definir o bicarbonato sérico alvo ideal e a melhor concentração de bicarbonato do banho. O artigo revisa os aspectos fisiopatológicos e epidemiológicos da acidose metabólica em pacientes em hemodiálise e também aborda seus efeitos adversos e tratamento.
Assuntos
Humanos , Acidose/etiologia , Acidose/terapia , Diálise Renal , Falência Renal Crônica/terapia , Falência Renal Crônica/complicações , Falência Renal Crônica/metabolismoRESUMO
PURPOSE: Hyperleptinemia and metabolic acidosis (MA) are frequently observed in patients on hemodialysis (HD). While the role of leptin in patients on HD is not completely understood, HD only partially corrects MA. Both leptin and acidosis have effect on bone disease. The goal of the present study was to evaluate the effects of MA correction on chronic kidney disease-mineral and bone disorder laboratory parameters and leptin levels. METHODS: Forty-eight patients on HD, aged 43±19 years, were prospectively studied. Individual adjustments in the bicarbonate dialysate concentration were made to maintain pre-dialysis concentration≥22 mEq/l. Blood gas analysis was done monthly for 4 months (M1-M4). RESULTS: From M0 to M4, serum albumin increased (from 3.5 ±0.3 to 4.0±0.3 g/l, p<0.0001) while ß2 microglobulin decreased (from 27.6±8.3 to 25.8±6.8 µg/ml, p=0.025). Serum leptin decreased in all but three patients, as well as leptin/adiponectin ratio (p<0.0001). There was a decrease in ionized serum calcium (from 5.0±0.5 to 4.7±0.5 mg/dl, p =0.002) and an increase in parathyroid hormone (PTH) [from 191 (85, 459) to 446 pg/ml (212, 983), p<0.0001] and in serum phosphate (from 5.4±1.4 to 5.8±1.1 mg/dl, p=0.048). CONCLUSION: MA correction in HD patients can decrease leptin, an atherogenic marker. The impact of such treatment extends to uremic bone disease, as decrease in serum calcium and increase in PTH. However, this could be an undesirable effect because it may aggravate a secondary hyperparathyroidism. Whether the reduction in leptin levels has impact on outcomes in patients on hemodialysis deserves further investigation.
Assuntos
Acidose/terapia , Bicarbonatos/sangue , Soluções para Diálise/química , Falência Renal Crônica/terapia , Leptina/sangue , Diálise Renal , Acidose/sangue , Adiponectina/sangue , Adulto , Bicarbonatos/administração & dosagem , Gasometria , Cálcio/sangue , Feminino , Humanos , Concentração de Íons de Hidrogênio , Falência Renal Crônica/sangue , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Fosfatos/sangue , Estudos Prospectivos , Albumina Sérica/metabolismo , Fatores Sexuais , Adulto Jovem , Microglobulina beta-2/sangueRESUMO
A 60-year old female patient was found comatosed at home and taken to the hospital's Emergency Department by her relatives. It was learnt that she wrapped her knees with spirit-impregnated cotton pad for pain for one week. On physical examination, only a colour change of purple violet on her knees was noted. Metabolic acidosis with increased anion gap was detected by arterial blood analysis. The patient underwent haemodialysis. She was discharged from the hospital with no complaints, alert and rational following five days of follow-up treatment, with the diagnosis of methyl alcohol poisoning.