DOCSLIB.ORG

Guidelines for Potential Multiple Organ Donors (Adult). Part II

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Guidelines for Potential Multiple Organ Donors (Adult). Part II ARTIGO ESPECIAL Glauco Adrieno Westphal, Milton Diretrizes para manutenção de múltiplos órgãos Caldeira Filho, Kalinca Daberkow Vieira, Viviane Renata Zaclikevis, no potencial doador adulto falecido. Parte II. Miriam Cristine Machado Bartz, Ventilação mecânica, controle endócrino metabólico Raquel Wanzuita, Álvaro Réa-Neto, Cassiano Teixeira, Cristiano Franke, e aspectos hematológicos e infecciosos Fernando Osni Machado, Joel de Andrade, Jorge Dias de Matos, Guidelines for potential multiple organ donors (adult). Part II. Alfredo Fiorelli, Delson Morilo Lamgaro, Fabiano Nagel, Felipe Mechanical ventilation, endocrine metabolic management, Dal-Pizzol, Gerson Costa, José hematological and infectious aspects Mário Teles, Luiz Henrique Melo, Maria Emília Coelho, Nazah Cherif RESUMO das alterações hematológicas é igualmente Mohamed Youssef, Péricles Duarte, importante considerando as implicações Rafael Lisboa de Souza A atuação do intensivista durante a da prática transfusional inapropriada. manutenção do potencial doador falecido Ressalta-se ainda o papel da ventilação na busca da redução de perdas de doadores protetora na modulação inflamatória e e do aumento da efetivação de transplantes conseqüente aumento do aproveitamen- não se restringe aos aspectos hemodinâmi- to de pulmões para transplante. Por fim, cos. O adequado controle endócrino-me- assinala-se a relevância da avaliação crite- tabólico é essencial para a manutenção do riosa das evidências de atividade infecciosa aporte energético aos tecidos e do controle e da antibioticoterapia na busca do maior hidro-eletrolítico, favorecendo inclusive a utilização de órgãos de potenciais doadores estabilidade hemodinâmica. A abordagem falecidos. A presente diretriz é uma iniciativa conjunta da Associação de Medicina INTRODUÇAO Intensiva Brasileira (AMIB) e da Associação Brasileira de Transplantes de Órgãos (ABTO) e teve apoio de SC Durante a evolução para a morte encefálica (ME) ocorrem diversas alterações Transplantes - Central de Notificação fisiológicas como resposta à perda das funções do tronco cerebral. A fase inicial está Captação e Distribuição de Órgãos e relacionada à “tempestade simpática” resultado da liberação maciça de adrenalina, Tecidos do Estado de Santa Catarina- corticosteróide e glucagon. CNCDO/SC. A hiperatividade adrenérgica com eventual sobrecarga do ventrículo esquerdo leva ao edema pulmonar hidrostático e lesões de isquemia-reperfusão, além de in- tenso processo inflamatório que pode afetar o tecido pulmonar. Metabolicamente há aumento do gasto energético e da gliconeogênese. Esta é conseqüência, da maior resistência à insulina nos tecidos periféricos e da diminuição da liberação de insulina pelo pâncreas resultando em hiperglicemia. Na progressão do quadro, há a disfunção do eixo hipotálamo-hipofisário levan- do ao diabetes insipidus, com ausência do hormônio antidiurético, resultando em Final da elaboração: Junho de 2011 distúrbios hidro-eletrolíticos severos. Conflitos de interesse:Nenhum. O manejo destes distúrbios endócrino-metabólicos é importante para garantir a boa contratilidade cardíaca e estabilidade hemodinâmica. Estudos demonstram Autor correspondente: que o uso da terapia hormonal combinada (insulina, corticóide, hormônio tireoi- Glauco Adrieno Westphal diano, vasopressina) baseado na melhora da estabilidade hemodinâmica resulta em Rua Oscar Schneider, 237 - Bairro aumento do número de órgãos captados além da melhor qualidade dos transplantes Atiradores realizados com esses órgãos. CEP: 89203-040 – Joinville (SC), Associado a lesão do tecido cerebral temos a liberação de tromboplastina tecidu- Brasil. al, presente em grande quantidade no cérebro, que em última instância pode levar a Fone: (47) 3423-0303 depleção dos fatores de coagulação e plaquetas causando sangramento. E-mail: [email protected] Além dos insultos que o organismo sofre com a “tempestade simpática”, com a Rev Bras Ter Intensiva. 2011; 23(3):269-282 270 Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R et al. disfunção do eixo hipotálamo-hipofisário e com a lesão do D: Opinião desprovida de avaliação crítica, baseada em tecido cerebral, tem os efeitos do próprio tratamento, como consensos, estudos fisiológicos ou modelos animais. a hiperidratação, ou as consequências deletérias da ventilação mecânica, como barotrauma e volutrauma para contribuir Considerando a escassez de evidências em estudos com para a manutenção ou mesmo piora da função respiratória. doadores falecidos, parte das recomendações foi baseada em É fundamental estabelecer uma estratégia de ventilação que analogias com outras realidades clínicas. Por esta razão, consi- não acrescente dano ao tecido pulmonar. Por isso, a estratégia derações fisiológicas, epidemiológicas, e experimentais foram protetora de ventilação com baixo volume corrente é reco- utilizadas. mendado. Os temas foram divididos em sete sub-grupos de discus- Muitos potenciais doadores são excluídos pela presença de são: 1) Aspectos gerais, 2) Suporte hemodinâmico, 3) Manejo infecção, suspeita ou comprovada, no momento do diagnós- endócrino-metabólico, 4) Ventilação mecânica e manutenção tico de morte cerebral. Há, no entanto, uma forte tendência pulmonar, 5) Manutenção hepática, 6) Manutenção renal para o uso de critérios expandidos de doação, ou mais popu- e 7) Manutenção do coração. Cada subgrupo dispôs de um larmente, doadores limítrofes. Por tanto, não há contraindi- coordenador responsável por estimular e nortear a discussão cação absoluta a doação de órgãos e nem se deve interromper entre os membros via correio eletrônico. Os textos gerados em a manutenção do doador falecido com base em culturas posi- cada subgrupo foram organizados pela Comissão de Redação tivas ou diagnóstico clínico de infecção. e Planejamento, submetidos à revisão da Comissão Executiva e devolvidos aos subgrupos para revisão. O texto integral foi OBJETIVO finalizado e distribuído a todos os membros da Diretriz e discu- tido em reunião plenária realizada no XIV Congresso Sulbra- Contribuir com as coordenações institucionais de trans- sileiro de Medicina Intensiva realizado em Joinville em maio plantes, de forma a nortear e uniformizar os cuidados presta- de 2011. Os coordenadores apresentaram as recomendações dos ao doador falecido, buscando incrementar quantitativa e que foram submetidas à discussão. Considerando a baixa for- qualitativamente o transplante de órgãos com medidas apli- ça de evidência de boa parte das recomendações, agregou-se a cáveis à realidade brasileira. definição do grau de recomendação de acordo com o sistema GRADE (Grading of Recommendation, Assessment, Develop- METODOLOGIA ment and Evaluation). Este sistema classifica a qualidade das recomendações como FORTE (deve ser feito), FRACA (talvez A partir de ampla pesquisa da literatura realizada pela deva ser feito) e NÃO ESPECÍFICA (não há vantagens nem Comissão de Redação e Planejamento constituída por inten- desvantagens). Uma recomendação forte em favor de uma in- sivistas e residentes de terapia intensiva, formularam-se ques- tervenção reflete os efeitos desejáveis e compensam claramente tões preliminares enviadas a todos os autores como ponto de os efeitos indesejáveis. A recomendação fraca em favor de uma partida para sugestões, substituições, e elaboração de novas intervenção indica que os efeitos desejáveis da adesão provavel- perguntas. mente serão superiores aos indesejáveis, mas o grupo não está As questões formuladas foram revisadas pela Comissão confiante sobre isso, quer porque algumas das provas são de Executiva e posteriormente encaminhadas aos autores para o baixa qualidade ou porque necessitam de mais estudos sobre o desenvolvimento do texto. tema. A recomendação não específica considera que os bene- As questões elaboradas motivaram a revisão da literatura fícios e desvantagens estão equilibrados, devendo ser avaliada utilizando-se o conceito PICO, onde: P refere-se à população caso a caso. Uma recomendação forte deve ser interpretada alvo, I à intervenção, C ao controle ou grupo de comparação como “recomendamos” e uma fraca como “sugerimos”. e O ao desfecho clínico. Os artigos encontrados foram analisados criticamente e Descrição do método de coleta de evidência categorizados conforme grau de recomendação e a força de A fonte primária de consulta foi a base de dados MEDLI- evidência: NE por meio acesso ao serviço PubMed de Pesquisa Biblio- gráfica em Publicações Médicas. As buscas foram direcionadas A: Estudos experimentais ou observacionais de maior para atender perguntas estruturadas na metodologia PICO. consistência. Pela interface MeSH (Medical Subject Heading), inseriu-se B: Estudos experimentais ou observacionais de menor os descritores da seguinte forma: (organ donor OR donor consistência. management OR brain death AND recommendation OR C: Relatos de casos (estudos não controlados). consensus), (organ donor OR donor management OR lung Rev Bras Ter Intensiva. 2011; 23(3):269-282 Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido 271 transplantation AND mechanical ventilation OR strategies convencional tiveram critérios de elegibilidade de doação de of ventilation), (organ donor OR donor management OR seus pulmões versus 56 (95%) no grupo da estratégia proteto- lung transplantation AND fluid challenge OR fluid resusci- ra (diferença de 41% [95% IC, 26,5% a 54,8%]; p< 0,001). tation OR positive balance), (organ donor OR donor mana- O número de pacientes que tiveram os pulmões aproveitados gement OR lung transplantation
Load more

Recommended publications
  • Pathophysiology of Acid Base Balance: the Theory Practice Relationship
    Intensive and Critical Care Nursing (2008) 24, 28—40 ORIGINAL ARTICLE Pathophysiology of acid base balance: The theory practice relationship Sharon L. Edwards ∗ Buckinghamshire Chilterns University College, Chalfont Campus, Newland Park, Gorelands Lane, Chalfont St. Giles, Buckinghamshire HP8 4AD, United Kingdom Accepted 13 May 2007 KEYWORDS Summary There are many disorders/diseases that lead to changes in acid base Acid base balance; balance. These conditions are not rare or uncommon in clinical practice, but every- Arterial blood gases; day occurrences on the ward or in critical care. Conditions such as asthma, chronic Acidosis; obstructive pulmonary disease (bronchitis or emphasaemia), diabetic ketoacidosis, Alkalosis renal disease or failure, any type of shock (sepsis, anaphylaxsis, neurogenic, cardio- genic, hypovolaemia), stress or anxiety which can lead to hyperventilation, and some drugs (sedatives, opoids) leading to reduced ventilation. In addition, some symptoms of disease can cause vomiting and diarrhoea, which effects acid base balance. It is imperative that critical care nurses are aware of changes that occur in relation to altered physiology, leading to an understanding of the changes in patients’ condition that are observed, and why the administration of some immediate therapies such as oxygen is imperative. © 2007 Elsevier Ltd. All rights reserved. Introduction the essential concepts of acid base physiology is necessary so that quick and correct diagnosis can The implications for practice with regards to be determined and appropriate treatment imple- acid base physiology are separated into respi- mented. ratory acidosis and alkalosis, metabolic acidosis The homeostatic imbalances of acid base are and alkalosis, observed in patients with differing examined as the body attempts to maintain pH bal- aetiologies.
    [Show full text]
  • Acid-Base Physiology & Anesthesia
    ACID-BASE PHYSIOLOGY & ANESTHESIA Lyon Lee DVM PhD DACVA Introductions • Abnormal acid-base changes are a result of a disease process. They are not the disease. • Abnormal acid base disorder predicts the outcome of the case but often is not a direct cause of the mortality, but rather is an epiphenomenon. • Disorders of acid base balance result from disorders of primary regulating organs (lungs or kidneys etc), exogenous drugs or fluids that change the ability to maintain normal acid base balance. • An acid is a hydrogen ion or proton donor, and a substance which causes a rise in H+ concentration on being added to water. • A base is a hydrogen ion or proton acceptor, and a substance which causes a rise in OH- concentration when added to water. • Strength of acids or bases refers to their ability to donate and accept H+ ions respectively. • When hydrochloric acid is dissolved in water all or almost all of the H in the acid is released as H+. • When lactic acid is dissolved in water a considerable quantity remains as lactic acid molecules. • Lactic acid is, therefore, said to be a weaker acid than hydrochloric acid, but the lactate ion possess a stronger conjugate base than hydrochlorate. • The stronger the acid, the weaker its conjugate base, that is, the less ability of the base to accept H+, therefore termed, ‘strong acid’ • Carbonic acid ionizes less than lactic acid and so is weaker than lactic acid, therefore termed, ‘weak acid’. • Thus lactic acid might be referred to as weak when considered in relation to hydrochloric acid but strong when compared to carbonic acid.
    [Show full text]
  • Metabolic Alkalosis Is the Most Common Acid-Base Disorder in ICU
    Mæhle et al. Critical Care 2014, 18:420 http://ccforum.com/content/18/2/420 LETTER Metabolic alkalosis is the most common acid–base disorder in ICU patients Kjersti Mæhle1*, Bjørn Haug2, Hans Flaatten3,4 and Erik Waage Nielsen1,5,6 Publications give diverging information as to which alkalosis is a complication of mechanical ventilation metabolic acid–base disorder is the most common in in patients with chronic obstructive pulmonary dis- the ICU [1,2]. We explored the distribution of base ease [4]. excess (BE) values in a large number of ICU patients If the count of repetitive sampling influenced our re- and evaluated if this distribution was related to rising sults, we assume they are skewed towards acidosis, as sodium values after admission. BE values were ob- unstable and acidotic patients tend to have acid–base tained during ICU admission in selected periods samples drawn more frequently. from a first level small community hospital, a second Data from the Norwegian National Intensive Care level central hospital with university affiliations, and Registry [5] suggest that the difference in BE values be- a third level large Norwegian university/regional tween the three hospitals in our study may partly stem hospital. Sodium values were from ICU patients in from difference in patients’ lengths of stay. In our study, the second level hospital. Laboratory values were an- the second level hospital had the longest median length onymously retrieved from databases in each hospital, of stay (2.7 days). aggregated and analyzed in Qlikview or Excel and A coupling of metabolic alkalosis to rising sodium exported to GraphPad Prism for column statistics and values proposed by Lindner and colleagues [6] did not analysis of variance and for preparing graphs and seem to apply to patients in our study, as the day- frequency histograms.
    [Show full text]
  • Parenteral Nutrition Primer: Balance Acid-Base, Fluid and Electrolytes
    Parenteral Nutrition Primer: Balancing Acid-Base, Fluids and Electrolytes Phil Ayers, PharmD, BCNSP, FASHP Todd W. Canada, PharmD, BCNSP, FASHP, FTSHP Michael Kraft, PharmD, BCNSP Gordon S. Sacks, Pharm.D., BCNSP, FCCP Disclosure . The program chair and presenters for this continuing education activity have reported no relevant financial relationships, except: . Phil Ayers - ASPEN: Board Member/Advisory Panel; B Braun: Consultant; Baxter: Consultant; Fresenius Kabi: Consultant; Janssen: Consultant; Mallinckrodt: Consultant . Todd Canada - Fresenius Kabi: Board Member/Advisory Panel, Consultant, Speaker's Bureau • Michael Kraft - Rockwell Medical: Consultant; Fresenius Kabi: Advisory Board; B. Braun: Advisory Board; Takeda Pharmaceuticals: Speaker’s Bureau (spouse) . Gordon Sacks - Grant Support: Fresenius Kabi Sodium Disorders and Fluid Balance Gordon S. Sacks, Pharm.D., BCNSP Professor and Department Head Department of Pharmacy Practice Harrison School of Pharmacy Auburn University Learning Objectives Upon completion of this session, the learner will be able to: 1. Differentiate between hypovolemic, euvolemic, and hypervolemic hyponatremia 2. Recommend appropriate changes in nutrition support formulations when hyponatremia occurs 3. Identify drug-induced causes of hypo- and hypernatremia No sodium for you! Presentation Outline . Overview of sodium and water . Dehydration vs. Volume Depletion . Water requirements & Equations . Hyponatremia • Hypotonic o Hypovolemic o Euvolemic o Hypervolemic . Hypernatremia • Hypovolemic • Euvolemic • Hypervolemic Sodium and Fluid Balance . Helpful hint: total body sodium determines volume status, not sodium status . Examples of this concept • Hypervolemic – too much volume • Hypovolemic – too little volume • Euvolemic – normal volume Water Distribution . Total body water content varies from 50-70% of body weight • Dependent on lean body mass: fat ratio o Fat water content is ~10% compared to ~75% for muscle mass .
    [Show full text]
  • Residency Essentials Full Curriculum Syllabus
    RESIDENCY ESSENTIALS FULL CURRICULUM SYLLABUS Please review your topic area to ensure all required sections are included in your module. You can also use this document to review the surrounding topics/sections to ensure fluidity. Click on the topic below to jump to that page. Clinical Topics • Gastrointestinal • Genitourinary • Men’s Health • Neurological • Oncology • Pain Management • Pediatrics • Vascular Arterial • Vascular Venous • Women’s Health Requisite Knowledge • Systems • Business and Law • Physician Wellness and Development • Research and Statistics Fundamental • Clinical Medicine • Intensive Care Medicine • Image-guided Interventions • Imaging and Anatomy Last revised: November 4, 2019 Gastrointestinal 1. Portal hypertension a) Pathophysiology (1) definition and normal pressures and gradients, MELD score (2) Prehepatic (a) Portal, SMV or Splenic (i) thrombosis (ii) stenosis (b) Isolated mesenteric venous hypertension (c) Arterioportal fistula (3) Sinusoidal (intrahepatic) (a) Cirrhosis (i) ETOH (ii) Non-alcoholic fatty liver disease (iii) Autoimmune (iv) Viral Hepatitis (v) Hemochromatosis (vi) Wilson's disease (b) Primary sclerosing cholangitis (c) Primary biliary cirrhosis (d) Schistosomiasis (e) Infiltrative liver disease (f) Drug/Toxin/Chemotherapy induced chronic liver disease (4) Post hepatic (a) Budd Chiari (Primary secondary) (b) IVC or cardiac etiology (5) Ectopic perianastomotic and stomal varices (6) Splenorenal shunt (7) Congenital portosystemic shunt (Abernethy malformation) b) Measuring portal pressure (1) Direct
    [Show full text]
  • N Dullet , S Mathevosian , R Ahuja , a Anavim , D Nguyen , K Kansagra
    The Utility of an Interventional Radiology Trainee as a Member of the Intensive Care Unit Team N Dullet1, S Mathevosian2, R Ahuja3, A Anavim3, D Nguyen3, K Kansagra4, M Ferra3 1The University of Arizona, Tucson, AZ, 2UCLA David Geffen School of Medicine, Los Angeles, CA, 3Albert Einstein Medical Center, Philadelphia, PA, 4Kaiser Permanente Medical Center, Los Angeles, CA Background Mechanical Ventilation and Non-Invasive Ventilation Rounding in the ICU POCUS Definitions The role of the IR resident varies by institution and type of ICU, with some The IR resident is uniquely positioned Knowledge of critical care principles is essential as the IR Vt (Tidal Volume) The volume delivered per respiratory cycle. 6-8mL/kg for ARDS, while 8-10mL/kg may be used for other patients to provide assistance with timely service has become involved in increasingly complex residents rotating in SICU and others rotating in a MICU. In some instances, the resident acts as a senior, while the resident may act as an intern in other diagnosis and procedures with patient care. An ICU rotation is now a requirement of the PEEP (Peak End Expiratory Pressure) The pressure applied at the end of the expiratory phase, which keeps the alveoli open cases. POCUS. POCUS applications will be integrated IR residency and ESIR pathway. The ICU RR (Respiratory Rate) Number of respirations, reported per minute more thoroughly discussed in an F O Percent oxygenation of inspired air, room air is 21% rotation is an opportunity for the IR trainee to learn I 2 During pre-charting and pre-rounding, it is essential to review the accompanying poster.
    [Show full text]
  • Original Research Article Acid Based Disorders in Intensive Care Unit: a Hospital-Based Study
    International Journal of Advances in Medicine Rajendran B et al. Int J Adv Med. 2019 Feb;6(1):62-65 http://www.ijmedicine.com pISSN 2349-3925 | eISSN 2349-3933 DOI: http://dx.doi.org/10.18203/2349-3933.ijam20190086 Original Research Article Acid based disorders in intensive care unit: a hospital-based study Babu Rajendran*, Seetha Rami Reddy Mallampati, Sheju Jonathan Jha J. Department of General Medicine, Vinayaka Missions Medical College, Vinayaka Missions Research Foundation-DU, Karaikal, Puducherry, India Received: 08 January 2019 Accepted: 16 January 2019 *Correspondence: Dr. Babu Rajendran, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Acid base disorders are common in the ICU patients and pose a great burden in the management of the underlying condition. Methods: Identifying the type of acid-base disorders in ICU patients using arterial blood gas analysis This was a retrospective case-controlled comparative study. 46 patients in intensive care unit of a reputed institution and comparing the type of acid-base disorder amongst infectious (10) and non-infectious (36) diseases. Results: Of the study population, 70% had mixed acid base disorders and 30% had simple type of acid base disorders. It was found that sepsis is associated with mixed type of acid-base disorders with most common being metabolic acidosis with respiratory alkalosis. Non-infectious diseases were mostly associated with metabolic alkalosis with respiratory acidosis.
    [Show full text]
  • A Case-Based Approach to Acid-Base Disorders
    A Case-Based Approach to Acid-Base Disorders Justin Muir, PharmD Clinical Pharmacy Manager, Medical ICU NewYork-Presbyterian Hospital Columbia University Irving Medical Center [email protected] Disclosures None Objectives At the completion of this activity, pharmacists will be able to: 1. Describe acid-base physiology and disease states that lead to acid-base disorders. 2. Demonstrate a step-wise approach to interpretation of acid-base disorders and compensatory states. 3. Analyze contemporary literature regarding the use of sodium bicarbonate in metabolic acidosis. At the completion of this activity, pharmacy technicians will be able to: 1. Explain the importance of acid-base balance. 2. List the acid-base disorders seen in clinical practice. 3. Identify potential therapies used to treat acid-base disorders. Case A 51 year old man with history of erosive esophagitis, diabetes mellitus, chronic pancreatitis, and bipolar disorder is admitted with several days of severe nausea, vomiting, and abdominal pain. 135 87 31 pH 7.46 / pCO 29 / pO 81 861 2 2 BE -3.8 / HCO - 18 / SaO 96 5.6 20 0.9 3 2 • What additional data should be obtained? • What acid base disturbance(s) is/are present? Introduction • Acid base status is tightly regulated to maintain normal biochemical reactions and organ function • Body uses multiple mechanisms to maintain homeostasis • Abnormalities are extremely common in hospitalized patients with a higher incidence in critically ill with more complex pictures • A standard approach to analysis can help guide diagnosis and treatment Important acid-base determinants Blood gas generally includes at least: Normal range Measurement Description (arterial blood) pH -log [H+] 7.35-7.45 pCO2 partial pressure of dissolved CO2 35-45 mmHg pO2 partial pressure of dissolved O2 80-100 mmHg Base excess calculated measure of metabolic acid/base deviation from normal -3 to +3 SO2 calculated measure of Hgb O2 saturation based on pO2 95-100% - HCO3 calculated measure based on relationship of pH and pCO2 22-26 mEq/L Haber RJ.
    [Show full text]
  • Neurologic Complications of Electrolyte Disturbances and Acid–Base Balance
    Handbook of Clinical Neurology, Vol. 119 (3rd series) Neurologic Aspects of Systemic Disease Part I Jose Biller and Jose M. Ferro, Editors © 2014 Elsevier B.V. All rights reserved Chapter 23 Neurologic complications of electrolyte disturbances and acid–base balance ALBERTO J. ESPAY* James J. and Joan A. Gardner Center for Parkinson’s Disease and Movement Disorders, Department of Neurology, UC Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA INTRODUCTION hyperglycemia or mannitol intake, when plasma osmolal- ity is high (hypertonic) due to the presence of either of The complex interplay between respiratory and renal these osmotically active substances (Weisberg, 1989; function is at the center of the electrolytic and acid-based Lippi and Aloe, 2010). True or hypotonic hyponatremia environment in which the central and peripheral nervous is always due to a relative excess of water compared to systems function. Neurological manifestations are sodium, and can occur in the setting of hypovolemia, accompaniments of all electrolytic and acid–base distur- euvolemia, and hypervolemia (Table 23.2), invariably bances once certain thresholds are reached (Riggs, reflecting an abnormal relationship between water and 2002). This chapter reviews the major changes resulting sodium, whereby the former is retained at a rate faster alterations in the plasma concentration of sodium, from than the latter (Milionis et al., 2002). Homeostatic mech- potassium, calcium, magnesium, and phosphorus as well anisms protecting against changes in volume and sodium as from acidemia and alkalemia (Table 23.1). concentration include sympathetic activity, the renin– angiotensin–aldosterone system, which cause resorption HYPONATREMIA of sodium by the kidneys, and the hypothalamic arginine vasopressin, also known as antidiuretic hormone (ADH), History and terminology which prompts resorption of water (Eiskjaer et al., 1991).
    [Show full text]
  • ACS/ASE Medical Student Core Curriculum Acid-Base Balance
    ACS/ASE Medical Student Core Curriculum Acid-Base Balance ACID-BASE BALANCE Epidemiology/Pathophysiology Understanding the physiology of acid-base homeostasis is important to the surgeon. The two acid-base buffer systems in the human body are the metabolic system (kidneys) and the respiratory system (lungs). The simultaneous equilibrium reactions that take place to maintain normal acid-base balance are: H" HCO* ↔ H CO ↔ H O l CO g To classify the type of disturbance, a blood gas (preferably arterial) and basic metabolic panel must be obtained. A basic understanding of normal acid-base buffer physiology is required to understand alterations in these labs. The normal pH of human blood is 7.40 (7.35-7.45). This number is tightly regulated by the two buffer systems mentioned above. The lungs contain carbonic anhydrase which is capable of converting carbonic acid to water and CO2. The respiratory response results in an alteration to ventilation which allows acid to be retained or expelled as CO2. Therefore, bradypnea will result in respiratory acidosis while tachypnea will result in respiratory alkalosis. The respiratory buffer system is fast acting, resulting in respiratory compensation within 30 minutes and taking approximately 12 to 24 hours to reach equilibrium. The renal metabolic response results in alterations in bicarbonate excretion. This system is more time consuming and can typically takes at least three to five days to reach equilibrium. Five primary classifications of acid-base imbalance: • Metabolic acidosis • Metabolic alkalosis • Respiratory acidosis • Respiratory alkalosis • Mixed acid-base disturbance It is important to remember that more than one of the above processes can be present in a patient at any given time.
    [Show full text]
  • The ABC's of Acid-Base Balance
    JPPT REVIEW ARTICLE The ABC’s of Acid-Base Balance Gordon S. Sacks, PharmD The University of Wisconsin—Madison, Madison, Wisconsin A step-wise systematic approach can be used to determine the etiology and proper management of acid-base disorders. The objectives of this article are to: (1) discuss the physiologic processes in- volved in acid-base disturbances, (2) identify primary and secondary acid-base disturbances based upon arterial blood gas and laboratory measurements, (3) utilize the anion gap for diagnostic pur- poses, and (4) outline a stepwise approach for interpretation and treatment of acid-base disorders. Case studies are used to illustrate the application of the discussed systematic approach. KEYWORDS: acid-base J Pediatr Pharmacol Ther 2004;9:235-42 Although acid-base disorders are frequently terms of H+, but due to confusing terminology it encountered in hospital and ambulatory care set- was proposed to convert H+ terminology to pH.1 tings, they are often considered the most difficult When taking the negative logarithm of the H+ areas to understand in medicine. Misdiagnosis due to common misconceptions of acid-base ho- ABBREVIATIONS: AG, Anion gap; HCO3, Bicarbonate; CNS, meostasis often delays identification of the pri- Central nervous system; ECF, Extracellular fluid; Hgb, Hemoglobin; ICU, Intensive care unit; THAM, Tromethamine mary disorder, causing a disruption in the deliv- ery of appropriate therapy. By understanding the concentration, pH represents a measure of H+ basic principles of acid-base physiology, the inter- activity. Optimal function for tissues and organs pretation of acid-base data, and the mechanisms within the human body depends on maintaining responsible for acid-base perturbations, the clini- blood pH between 7.10 and 7.60.
    [Show full text]
  • Severe Metabolic Alkalosis from Acute Baking Soda Ingestion Presenting
    edicine: O M p y e Hailemariam et al., Emerg Med (Los Angel) 2018, c n n A e 8:1 c g c r e e s DOI: 10.4172/2165-7548-8-1000362 s m E Emergency Medicine: Open Access ISSN: 2165-7548 Case Report Open Access Severe Metabolic Alkalosis from Acute Baking Soda Ingestion Presenting with Acute Respiratory Failure and Ischemic Stroke Hailemariam F*, Finn V, Betancourt B, Yimer A and Bavli S Department of Medicine, St. John’s Episcopal Hospital, Far Rockaway, New York, USA *Corresponding author: Hailemariam F, Department of Medicine, St. John's Episcopal Hospital, Internal Medicine, 327 Beach 19th St, FarRockaway, NY 11691, USA, Tel: 4043848130; E-mail: [email protected] Received Date: December 29, 2017; Accepted Date: January 23, 2018; Published Date: February 1, 2018 Copyright: © 2018 Hailemariam F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Baking Soda is a universally available household product. It is used to treat heartburn, indigestion as a home remedy. It's generally well tolerated but abuse and overdose can cause toxicities with serious metabolic and neurological complications. We discuss here a case of a patient with acute baking soda toxicity that developed acute respiratory failure and large bilateral cerebral infarctions leading to death. To our research this is the first reported case of cerebral infarctions following baking soda toxicity. Our report underlines the need for healthcare professionals to be aware on the complications of baking soda overdose and its urgent treatment.
    [Show full text]