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Medicina (Kaunas, Lithuania) Jul 2023Milk-alkali syndrome, which is characterized by hypercalcemia, metabolic alkalosis, and renal dysfunction, typically results from the ingestion of large amounts of...
Milk-alkali syndrome, which is characterized by hypercalcemia, metabolic alkalosis, and renal dysfunction, typically results from the ingestion of large amounts of calcium and absorbable alkaline products. However, these symptoms can also manifest when alkalosis and calcium loading occur simultaneously, owing to other factors. We report a case of milk-alkali syndrome caused by loop-diuretic-induced alkaline load and polypharmacy in an 85-year-old Japanese woman with multiple comorbidities, including osteoporosis, hypertension, type 2 diabetes, dyslipidemia, and Parkinson's disease. The patient regularly took 14 drugs, including calcium L-aspartate, eldecalcitol, celecoxib, and a fixed-dose combination of losartan and hydrochlorothiazide. Immediately before admission, furosemide was administered for the treatment of edema. The patient presented with chest discomfort, general malaise, and clinical signs of dehydration, hypercalcemia, hypophosphatemia, hypokalemia, and hypomagnesemia, accompanied by electrocardiogram abnormalities, renal dysfunction, and chloride-resistant metabolic alkalosis. The hypercalcemia was specifically induced by calcium L-aspartate and eldecalcitol. The hypomagnesaemia and hypophosphatemia were caused by diuretics and hypercalcemia. Thus, all the oral medications were discontinued, and rehydration and electrolyte correction therapy were administered. The final diagnosis was milk-alkali syndrome caused by the concomitant use of loop diuretics and other medications, without absorbable alkaline preparation use. This case underscores the importance of considering drug-related factors, checking concomitant medications, and being aware of the benefits, harmful effects, and side effects of polypharmacy in older adults with multimorbidity.
Topics: Female; Humans; Aged; Aged, 80 and over; Hypercalcemia; Diuretics; Calcium; Polypharmacy; Aspartic Acid; Diabetes Mellitus, Type 2; Alkalosis; Kidney Diseases; Hypophosphatemia
PubMed: 37512156
DOI: 10.3390/medicina59071345 -
Critical Care (London, England) Oct 2018Metabolic alkalosis is common in patients with respiratory failure and may delay weaning in mechanically ventilated patients. Carbonic anhydrase inhibitors block renal... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Metabolic alkalosis is common in patients with respiratory failure and may delay weaning in mechanically ventilated patients. Carbonic anhydrase inhibitors block renal bicarbonate reabsorption, and thus reverse metabolic alkalosis. The objective of this systematic review is to assess the benefits and harms of carbonic anhydrase inhibitor therapy in patients with respiratory failure and metabolic alkalosis.
METHODS
We searched the following electronic sources from inception to August 2017: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and SCOPUS. Randomized clinical trials were included if they assessed at least one of the following outcomes: mortality, duration of hospital stay, duration of mechanical ventilation, adverse events, and blood gas parameters. Teams of two review authors worked in an independent and duplicate manner to select eligible trials, extract data, and assess risk of bias of the included trials. We used meta-analysis to synthesize statistical data and then assessed the certainty of evidence using the GRADE methodology.
RESULTS
Six eligible studies were identified with a total of 564 participants. The synthesized data did not exclude a reduction or an increase in mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.57 to 1.56) or in duration of hospital stay (mean difference (MD) 0.42 days, 95% CI -4.82 to 5.66) with the use of carbonic anhydrase inhibitors. Carbonic anhydrase inhibitor therapy resulted in a decrease in the duration of mechanical ventilation of 27 h (95% CI -50 to -4). Also, it resulted in an increase in PaO (MD 11.37 mmHg, 95% CI 4.18 to 18.56) and a decrease in PaCO (MD -4.98 mmHg, 95% CI -9.66, -0.3), serum bicarbonate (MD -5.03 meq/L, 95% CI -6.52 to -3.54), and pH (MD -0.04, 95% CI -0.07 to -0.01). There was an increased risk of adverse events in the carbonic anhydrase inhibitor group (RR 1.71, 95% CI 0.98 to 2.99). Certainty of evidence was judged to be low for most outcomes.
CONCLUSION
In patients with respiratory failure and metabolic alkalosis, carbonic anhydrase inhibitor therapy may have favorable effects on blood gas parameters. In mechanically ventilated patients, carbonic anhydrase inhibitor therapy may decrease the duration of mechanical ventilation. A major limitation of this finding was that only two trials assessed this clinically important outcome.
Topics: Alkalosis; Carbonic Anhydrase Inhibitors; Humans; Metabolic Diseases; Odds Ratio; Randomized Controlled Trials as Topic; Respiratory Insufficiency; Ventilator Weaning
PubMed: 30371345
DOI: 10.1186/s13054-018-2207-6 -
PloS One 2021Point-of-care arterial blood gas (ABG) is a blood measurement test and a useful diagnostic tool that assists with treatment and therefore improves clinical outcomes.... (Observational Study)
Observational Study
BACKGROUND
Point-of-care arterial blood gas (ABG) is a blood measurement test and a useful diagnostic tool that assists with treatment and therefore improves clinical outcomes. However, numerically reported test results make rapid interpretation difficult or open to interpretation. The arterial blood gas algorithm (ABG-a) is a new digital diagnostics solution that can provide clinicians with real-time interpretation of preliminary data on safety features, oxygenation, acid-base disturbances and renal profile. The main aim of this study was to clinically validate the algorithm against senior experienced clinicians, for acid-base interpretation, in a clinical context.
METHODS
We conducted a prospective international multicentre observational cross-sectional study. 346 sample sets and 64 inpatients eligible for ABG met strict sampling criteria. Agreement was evaluated using Cohen's kappa index, diagnostic accuracy was evaluated with sensitivity, specificity, efficiency or global accuracy and positive predictive values (PPV) and negative predictive values (NPV) for the prevalence in the study population.
RESULTS
The concordance rates between the interpretations of the clinicians and the ABG-a for acid-base disorders were an observed global agreement of 84,3% with a Cohen's kappa coefficient 0.81; 95% CI 0.77 to 0.86; p < 0.001. For detecting accuracy normal acid-base status the algorithm has a sensitivity of 90.0% (95% CI 79.9 to 95.3), a specificity 97.2% (95% CI 94.5 to 98.6) and a global accuracy of 95.9% (95% CI 93.3 to 97.6). For the four simple acid-base disorders, respiratory alkalosis: sensitivity of 91.2 (77.0 to 97.0), a specificity 100.0 (98.8 to 100.0) and global accuracy of 99.1 (97.5 to 99.7); respiratory acidosis: sensitivity of 61.1 (38.6 to 79.7), a specificity of 100.0 (98.8 to 100.0) and global accuracy of 98.0 (95.9 to 99.0); metabolic acidosis: sensitivity of 75.8 (59.0 to 87.2), a specificity of 99.7 (98.2 to 99.9) and a global accuracy of 97.4 (95.1 to 98.6); metabolic alkalosis sensitivity of 72.2 (56.0 to 84.2), a specificity of 95.5 (92.5 to 97.3) and a global accuracy of 93.0 (88.8 to 95.3); the four complex acid-base disorders, respiratory and metabolic alkalosis, respiratory and metabolic acidosis, respiratory alkalosis and metabolic acidosis, respiratory acidosis and metabolic alkalosis, the sensitivity, specificity and global accuracy was also high. For normal acid-base status the algorithm has PPV 87.1 (95% CI 76.6 to 93.3) %, and NPV 97.9 (95% CI 95.4 to 99.0) for a prevalence of 17.4 (95% CI 13.8 to 21.8). For the four-simple acid-base disorders and the four complex acid-base disorders the PPV and NPV were also statistically significant.
CONCLUSIONS
The ABG-a showed very high agreement and diagnostic accuracy with experienced senior clinicians in the acid-base disorders in a clinical context. The method also provides refinement and deep complex analysis at the point-of-care that a clinician could have at the bedside on a day-to-day basis. The ABG-a method could also have the potential to reduce human errors by checking for imminent life-threatening situations, analysing the internal consistency of the results, the oxygenation and renal status of the patient.
Topics: Acid-Base Equilibrium; Acid-Base Imbalance; Acidosis; Adolescent; Adult; Aged; Algorithms; Alkalosis; Alkalosis, Respiratory; Arterial Pressure; Blood Gas Analysis; Child; Child, Preschool; Cross-Sectional Studies; Female; Humans; Hydrogen-Ion Concentration; Male; Middle Aged; Models, Theoretical; Point-of-Care Testing; Predictive Value of Tests; Prevalence; Prospective Studies; Reproducibility of Results; Sensitivity and Specificity
PubMed: 33690724
DOI: 10.1371/journal.pone.0248264 -
Internal Medicine (Tokyo, Japan) May 2004
Topics: Aged; Alkalosis; Bartter Syndrome; Diagnosis, Differential; Female; Humans; Hypokalemia; Magnesium Deficiency; Prognosis; Risk Assessment; Severity of Illness Index; Syndrome
PubMed: 15206544
DOI: 10.2169/internalmedicine.43.351 -
Critical Care (London, England) Apr 2005Stewart's quantitative physical chemical approach enables us to understand the acid-base properties of intravenous fluids. In Stewart's analysis, the three independent... (Review)
Review
Stewart's quantitative physical chemical approach enables us to understand the acid-base properties of intravenous fluids. In Stewart's analysis, the three independent acid-base variables are partial CO2 tension, the total concentration of nonvolatile weak acid (ATOT), and the strong ion difference (SID). Raising and lowering ATOT while holding SID constant cause metabolic acidosis and alkalosis, respectively. Lowering and raising plasma SID while clamping ATOT cause metabolic acidosis and alkalosis, respectively. Fluid infusion causes acid-base effects by forcing extracellular SID and ATOT toward the SID and ATOT of the administered fluid. Thus, fluids with vastly differing pH can have the same acid-base effects. The stimulus is strongest when large volumes are administered, as in correction of hypovolaemia, acute normovolaemic haemodilution, and cardiopulmonary bypass. Zero SID crystalloids such as saline cause a 'dilutional' acidosis by lowering extracellular SID enough to overwhelm the metabolic alkalosis of ATOT dilution. A balanced crystalloid must reduce extracellular SID at a rate that precisely counteracts the ATOT dilutional alkalosis. Experimentally, the crystalloid SID required is 24 mEq/l. When organic anions such as L-lactate are added to fluids they can be regarded as weak ions that do not contribute to fluid SID, provided they are metabolized on infusion. With colloids the presence of ATOT is an additional consideration. Albumin and gelatin preparations contain ATOT, whereas starch preparations do not. Hextend is a hetastarch preparation balanced with L-lactate. It reduces or eliminates infusion related metabolic acidosis, may improve gastric mucosal blood flow, and increases survival in experimental endotoxaemia. Stored whole blood has a very high effective SID because of the added preservative. Large volume transfusion thus causes metabolic alkalosis after metabolism of contained citrate, a tendency that is reduced but not eliminated with packed red cells. Thus, Stewart's approach not only explains fluid induced acid-base phenomena but also provides a framework for the design of fluids for specific acid-base effects.
Topics: Acid-Base Equilibrium; Acid-Base Imbalance; Acidosis; Alkalosis; Blood Transfusion; Body Fluids; Chemical Phenomena; Chemistry, Physical; Colloids; Crystalloid Solutions; Endotoxemia; Extracellular Fluid; Fluid Therapy; Gastric Mucosa; Hemodilution; Humans; Hydrogen-Ion Concentration; Infusions, Intravenous; Intensive Care Units; Isotonic Solutions; Models, Biological; Osmolar Concentration; Rehydration Solutions; Sodium Chloride; Solutions
PubMed: 15774079
DOI: 10.1186/cc2946 -
The American Journal of Medicine Nov 2020
Topics: Alkalosis; Diet; Electrocardiography; Endurance Training; Female; Humans; Hypokalemia; Long QT Syndrome; Middle Aged; Potassium Chloride; Syncope
PubMed: 32442511
DOI: 10.1016/j.amjmed.2020.04.019 -
CMAJ : Canadian Medical Association... Jun 2024
Topics: Humans; Female; Hypokalemia; Alkalosis; Young Adult; Diagnosis, Differential
PubMed: 38857937
DOI: 10.1503/cmaj.240163 -
Respiration; International Review of... 1997As a model of human hypoxia, exposure to high altitude causes a number of ventilatory, circulatory and hemopoietic adaptations. A review of the literature on blood gas... (Review)
Review
As a model of human hypoxia, exposure to high altitude causes a number of ventilatory, circulatory and hemopoietic adaptations. A review of the literature on blood gas transport responses to hypoxia indicates that they are influenced not only by altitude, but also by factors related to acclimatization. In addition, it appears that the need to oxygenate tissues conflicts with the need to maintain H+ homeostasis. Thus, the final situation represents a compromise between the respiratory adjustment aimed at increasing blood alkalosis in order to optimize the oxygen transport system, and the metabolic readjustment aimed at reestablishing normal blood pH. There are factors like red cell 2,3-diphosphoglycerate, a compound that decreases the hemoglobin affinity for oxygen, that can influence that balance by affecting arterial oxygen saturation through mechanisms independent of respiration.
Topics: 2,3-Diphosphoglycerate; Acid-Base Equilibrium; Alkalosis; Altitude; Carbon Dioxide; Erythrocytes; Humans; Hypoxia; Oxygen
PubMed: 9383817
DOI: 10.1159/000196718 -
BMJ Case Reports Mar 2018A 62-year-old woman presented with an 11-month history of worsening nasal symptoms of rhinorrhoea, anosmia, nasal congestion and intermittent epistaxis. MRI revealed a...
A 62-year-old woman presented with an 11-month history of worsening nasal symptoms of rhinorrhoea, anosmia, nasal congestion and intermittent epistaxis. MRI revealed a large mass in the upper nasal vault. Biopsy of the mass revealed an olfactory neuroblastoma. While waiting resection, she acutely developed severe proximal muscle weakness, lethargy and lower extremity oedema. Blood glucose was elevated, and hypokalaemic metabolic alkalosis was noted. Elevated serum cortisol level of 95.7 µg/dL (8.7-22.4 µg/dL) and markedly elevated 24-hour urinary cortisol level of 6962.3 µg/24 hours (4.0-50.0 µg/24 hours) with concurrent adrenocorticotropic hormone (ACTH) level of 171 pg/mL (6-58 pg/mL) were suggestive of an ACTH-dependent source of hypercortisolism. A subsequent positive high-dose dexamethasone suppression test was consistent with ectopic ACTH production. She underwent near-total resection of the right nasal mass followed by radiotherapy, resulting in complete resolution of signs and symptoms of cortisol excess.
Topics: ACTH Syndrome, Ectopic; Alkalosis; Esthesioneuroblastoma, Olfactory; Female; Humans; Hydrocortisone; Hypokalemia; Magnetic Resonance Imaging; Middle Aged; Nasal Cavity; Nose Neoplasms; Treatment Outcome
PubMed: 29535093
DOI: 10.1136/bcr-2017-221661 -
British Medical Journal Nov 1977
Topics: Alkalosis; Glycyrrhiza; Heart Arrest; Humans; Hypokalemia; Magnesium; Plant Extracts; Plants, Medicinal
PubMed: 589186
DOI: 10.1136/bmj.2.6098.1352-b