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American Journal of Kidney Diseases :... Sep 2023The respiratory system plays an integral part in maintaining acid-base homeostasis. Normal ventilation participates in the maintenance of an open buffer system, allowing... (Review)
Review
The respiratory system plays an integral part in maintaining acid-base homeostasis. Normal ventilation participates in the maintenance of an open buffer system, allowing for excretion of CO produced from the interaction of nonvolatile acids and bicarbonate. Quantitatively of much greater importance is the excretion of CO derived from volatile acids produced from the complete oxidation of fat and carbohydrate. A primary increase in CO tension of body fluids is the cause of respiratory acidosis and develops most commonly from one or more of the following: (1) disorders affecting gas exchange across the pulmonary capillary, (2) disorders of the chest wall and the respiratory muscles, and/or (3) inhibition of the medullary respiratory center. Respiratory alkalosis or primary hypocapnia is most commonly caused by disorders that increase alveolar ventilation and is defined by an arterial partial pressure of CO <35 mm Hg with subsequent alkalization of body fluids. Both disorders can lead to life-threatening complications, making it of paramount importance for the clinician to have a thorough understanding of the cause and treatment of these acid-base disturbances.
Topics: Humans; Acidosis, Respiratory; Alkalosis, Respiratory; Carbon Dioxide; Hypocapnia; Bicarbonates; Alkalosis; Hydrogen-Ion Concentration; Acid-Base Equilibrium
PubMed: 37341662
DOI: 10.1053/j.ajkd.2023.02.004 -
European Journal of Internal Medicine Nov 2023Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA... (Review)
Review
Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.
Topics: Pregnancy; Female; Humans; Diabetic Ketoacidosis; Insulin; Fluid Therapy; Potassium; Diabetes Mellitus
PubMed: 37419787
DOI: 10.1016/j.ejim.2023.07.005 -
The Journal of Emergency Medicine Aug 2023The use of sodium bicarbonate to treat metabolic acidosis is intuitive, yet data suggest that not all patients benefit from this therapy. (Review)
Review
BACKGROUND
The use of sodium bicarbonate to treat metabolic acidosis is intuitive, yet data suggest that not all patients benefit from this therapy.
OBJECTIVE
In this narrative review, we describe the physiology behind commonly encountered nontoxicologic causes of metabolic acidosis, highlight potential harm from the indiscriminate administration of sodium bicarbonate in certain scenarios, and provide evidence-based recommendations to assist emergency physicians in the rational use of sodium bicarbonate.
DISCUSSION
Sodium bicarbonate can be administered as a hypertonic push, as a resuscitation fluid, or as an infusion. Lactic acidosis and cardiac arrest are two common scenarios where there is limited benefit to routine use of sodium bicarbonate, although certain circumstances, such as patients with concomitant acute kidney injury and lactic acidosis may benefit from sodium bicarbonate. Patients with cardiac arrest secondary to sodium channel blockade or hyperkalemia also benefit from sodium bicarbonate therapy. Recent data suggest that the use of sodium bicarbonate in diabetic ketoacidosis does not confer improved patient outcomes and may cause harm in pediatric patients. Available evidence suggests that alkalinization of urine in rhabdomyolysis does not improve patient-centered outcomes. Finally, patients with a nongap acidosis benefit from sodium bicarbonate supplementation.
CONCLUSIONS
Empiric use of sodium bicarbonate in patients with nontoxicologic causes of metabolic acidosis is not warranted and likely does not improve patient-centered outcomes, except in select scenarios. Emergency physicians should reserve use of this medication to conditions with clear benefit to patients.
Topics: Humans; Child; Bicarbonates; Sodium Bicarbonate; Acidosis, Lactic; Acidosis; Heart Arrest
PubMed: 37442665
DOI: 10.1016/j.jemermed.2023.04.012 -
BMJ Open Diabetes Research & Care Oct 2023Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor... (Review)
Review
Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.
Topics: Humans; Diabetic Ketoacidosis; Sodium-Glucose Transporter 2 Inhibitors; Diabetes Mellitus, Type 2; Insulin; Ketones
PubMed: 37797963
DOI: 10.1136/bmjdrc-2023-003666 -
Journal of Osteopathic Medicine Sep 2023Diabetic ketoacidosis (DKA) is an endocrine emergency that can occur in people with diabetes. Its incidence is estimated to be 220,340 hospital admissions each year.... (Review)
Review
CONTEXT
Diabetic ketoacidosis (DKA) is an endocrine emergency that can occur in people with diabetes. Its incidence is estimated to be 220,340 hospital admissions each year. Treatment algorithms include fluid resuscitation, intravenous (IV) insulin infusion, and scheduled electrolyte and glucose monitoring. The misdiagnosis of DKA in the setting of hyperglycemic emergencies results in overtreatment and unnecessary increases in healthcare utilization and costs.
OBJECTIVES
The aims of this study were to determine how often DKA is overdiagnosed in the context of other acute hyperglycemic emergencies, to describe the baseline characteristics of patients, to determine the hospital treatments for DKA, and to identify the frequency of endocrinology or diabetology consultation in the hospital setting.
METHODS
A retrospective chart review was conducted utilizing charts from three different hospitals within a hospital system. Charts were identified utilizing ICD-10 codes for admissions to the hospital for DKA. If the patient was over 18 and had one of the diagnostic codes of interest, the chart was reviewed for further details regarding the criteria for DKA diagnosis as well as admission and treatment details.
RESULTS
A total of 520 hospital admissions were included for review. DKA was incorrectly diagnosed in 28.4 % of the hospital admissions reviewed, based on a review of the labs and DKA diagnostic criteria. Most patients were admitted to the intensive care unit (ICU) and treated with IV insulin infusion (n=288). Consultation of endocrinology or diabetology occurred in 40.2 % (n=209) of all hospital admissions, and 128 of those consults occurred in ICU admissions. The diagnosis of DKA was incorrect in 92 of the patients admitted to the medical surgical unit (MSU) and in 49 of patients admitted to the ICU.
CONCLUSIONS
Almost one third of hospital admissions for hyperglycemic emergencies were misdiagnosed and managed as DKA. DKA diagnostic criteria are specific; however, other diagnoses like hyperosmolar hyperglycemic syndrome (HHS), hyperglycemia, and euglycemic DKA can make an accurate diagnosis more complicated. Education directed at improving the diagnostic accuracy of DKA among healthcare providers is needed to improve diagnostic accuracy, ensure the appropriate use of hospital resources, and potentially reduce costs to the healthcare system.
Topics: Humans; Diabetic Ketoacidosis; Retrospective Studies; Emergencies; Blood Glucose Self-Monitoring; Blood Glucose; Hospitals; Insulins; Diabetes Mellitus
PubMed: 37406169
DOI: 10.1515/jom-2023-0019 -
Nutrients Oct 2023In glucose-deprived conditions, ketone bodies are produced by the liver mitochondria, through the catabolism of fatty acids, and are used peripherally, as an alternative... (Review)
Review
In glucose-deprived conditions, ketone bodies are produced by the liver mitochondria, through the catabolism of fatty acids, and are used peripherally, as an alternative energy source. Ketones are produced in the body under normal conditions, including during pregnancy and the neonatal period, when following a ketogenic diet (KD), fasting, or exercising. Additionally, ketone synthesis is also augmented under pathological conditions, including cases of diabetic ketoacidosis (DKA), alcoholism, and several metabolic disorders. Nonetheless, diet is the main regulator of total body ketone concentrations. The KDs are mimicking the fasting state, altering the default metabolism towards the use of ketones as the primary fuel source. Recently, KD has gained recognition as a medical nutrition therapy for a plethora of metabolic conditions, including obesity and diabetes mellitus (DM). The present review aims to discuss the role of ketones, KDs, ketonemia, and ketonuria in DM, presenting all the available new evidence in a comprehensive manner.
Topics: Female; Pregnancy; Infant, Newborn; Humans; Ketone Bodies; Ketones; Diabetic Ketoacidosis; Ketosis; Glucose; Diet, Ketogenic; Metabolic Diseases; Diabetes Mellitus
PubMed: 37892458
DOI: 10.3390/nu15204383 -
Critical Care Medicine Nov 2023To identify the best population, design of the intervention, and to assess between-group biochemical separation, in preparation for a future phase III trial. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
To identify the best population, design of the intervention, and to assess between-group biochemical separation, in preparation for a future phase III trial.
DESIGN
Investigator-initiated, parallel-group, pilot randomized double-blind trial.
SETTING
Eight ICUs in Australia, New Zealand, and Japan, with participants recruited from April 2021 to August 2022.
PATIENTS
Thirty patients greater than or equal to 18 years, within 48 hours of admission to the ICU, receiving a vasopressor, and with metabolic acidosis (pH < 7.30, base excess [BE] < -4 mEq/L, and Pa co2 < 45 mm Hg).
INTERVENTIONS
Sodium bicarbonate or placebo (5% dextrose).
MEASUREMENTS AND MAIN RESULT
The primary feasibility aim was to assess eligibility, recruitment rate, protocol compliance, and acid-base group separation. The primary clinical outcome was the number of hours alive and free of vasopressors on day 7. The recruitment rate and the enrollment-to-screening ratio were 1.9 patients per month and 0.13 patients, respectively. Time until BE correction (median difference, -45.86 [95% CI, -63.11 to -28.61] hr; p < 0.001) and pH correction (median difference, -10.69 [95% CI, -19.16 to -2.22] hr; p = 0.020) were shorter in the sodium bicarbonate group, and mean bicarbonate levels in the first 24 hours were higher (median difference, 6.50 [95% CI, 4.18 to 8.82] mmol/L; p < 0.001). Seven days after randomization, patients in the sodium bicarbonate and placebo group had a median of 132.2 (85.6-139.1) and 97.1 (69.3-132.4) hours alive and free of vasopressor, respectively (median difference, 35.07 [95% CI, -9.14 to 79.28]; p = 0.131). Recurrence of metabolic acidosis in the first 7 days of follow-up was lower in the sodium bicarbonate group (3 [20.0%] vs. 15 [100.0%]; p < 0.001). No adverse events were reported.
CONCLUSIONS
The findings confirm the feasibility of a larger phase III sodium bicarbonate trial; eligibility criteria may require modification to facilitate recruitment.
Topics: Humans; Sodium Bicarbonate; Pilot Projects; Acidosis; Intensive Care Units; Australia; Double-Blind Method
PubMed: 37294139
DOI: 10.1097/CCM.0000000000005955 -
Pharmacology & Therapeutics Jul 2023Sensing acidosis is an important somatosensory function in responses to ischemia, inflammation, and metabolic alteration. Accumulating evidence has shown that acidosis... (Review)
Review
Sensing acidosis is an important somatosensory function in responses to ischemia, inflammation, and metabolic alteration. Accumulating evidence has shown that acidosis is an effective factor for pain induction and that many intractable chronic pain diseases are associated with acidosis signaling. Various receptors have been known to detect extracellular acidosis and all express in the somatosensory neurons, such as acid sensing ion channels (ASIC), transient receptor potential (TRP) channels and proton-sensing G-protein coupled receptors. In addition to sense noxious acidic stimulation, these proton-sensing receptors also play a vital role in pain processing. For example, ASICs and TRPs are involved in not only nociceptive activation but also anti-nociceptive effects as well as some other non-nociceptive pathways. Herein, we review recent progress in probing the roles of proton-sensing receptors in preclinical pain research and their clinical relevance. We also propose a new concept of sngception to address the specific somatosensory function of acid sensation. This review aims to connect these acid-sensing receptors with basic pain research and clinical pain diseases, thus helping with better understanding the acid-related pain pathogenesis and their potential therapeutic roles via the mechanism of acid-mediated antinociception.
Topics: Humans; Chronic Pain; Protons; Acid Sensing Ion Channels; Signal Transduction; Acidosis
PubMed: 37210007
DOI: 10.1016/j.pharmthera.2023.108444 -
BMJ Case Reports Feb 2024Linezolid is a commonly prescribed antibiotic in clinical practice. Although thrombocytopenia and peripheral neuropathy are frequently encountered following prolonged...
Linezolid is a commonly prescribed antibiotic in clinical practice. Although thrombocytopenia and peripheral neuropathy are frequently encountered following prolonged administration of linezolid, lactic acidosis is a rare adverse drug reaction. We present the case of a patient on linezolid for disseminated multidrug-resistant tuberculosis who presented with vomiting, dyspnoea, hypotension and high anion gap metabolic acidosis. The initial presentation mimicked sepsis syndrome. Ketoacidosis and renal dysfunction were ruled out. There was no history of ingestion of toxins/toxic alcohols. Sepsis was unlikely because extensive radiological and microbiological testing could not identify an infection. Given the possibility of linezolid-induced lactic acidosis (LILA), linezolid was discontinued on admission. The patient's lactic acidosis resolved, and his overall condition improved. A retrospective diagnosis of LILA was thus established. LILA should be considered when patients on linezolid present with lactic acidosis and other causes for the lactic acidosis have been ruled out.
Topics: Humans; Linezolid; Acidosis, Lactic; Retrospective Studies; Anti-Bacterial Agents; Acidosis
PubMed: 38331448
DOI: 10.1136/bcr-2023-259335 -
The Veterinary Clinics of North... Jul 2023Beef cattle are less prone to metabolic diseases as compared with dairy cattle; however, there are disease entities of concern in feedlot and cow-calf beef cattle... (Review)
Review
Beef cattle are less prone to metabolic diseases as compared with dairy cattle; however, there are disease entities of concern in feedlot and cow-calf beef cattle operations. In one study, a prevalence of 2% was found for ruminant acidosis in a feedlot; however, there is little prevalence information published with regard to metabolic diseases in beef cattle.1 Metabolic diseases covered in this article are hypomagnesemia, ruminal acidosis, and all of the common sequelae, polioencephalomalacia, manganese deficiency, and protein-energy malnutrition (PEM).
Topics: Female; Cattle; Animals; Cattle Diseases; Metabolic Diseases; Acidosis
PubMed: 37032297
DOI: 10.1016/j.cvfa.2023.02.011