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01-04-2004 | Review

Clinical review: Acid–base abnormalities in the intensive care unit

Authors: Lewis J Kaplan, Spiros Frangos

Published in: Critical Care | Issue 2/2005

Abstract

Acid–base abnormalities are common in the critically ill. The traditional classification of acid–base abnormalities and a modern physico-chemical method of categorizing them will be explored. Specific disorders relating to mortality prediction in the intensive care unit are examined in detail. Lactic acidosis, base excess, and a strong ion gap are highlighted as markers for increased risk of death.

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Gunnerson K, Kellum JA: Acid–base and electrolyte analysis in critically ill patients: are we ready for the new millennium? Curr Opin Crit Care 2003, 9: 468-473. 10.1097/00075198-200312000-00002CrossRefPubMed

Stewart PA: Modern quantitative acid–base chemistry. Can J Physiol Pharm 1983, 61: 1444-1461.CrossRef

Miller L, Waters JH: Mechanism of hyperchloremic nonanion gap acidosis. Anesthesiology 1997, 87: 1009-1010. 10.1097/00000542-199710000-00050CrossRefPubMed

Fencl V, Jabor A, Kazda A, Figge J: Diagnosis of metabolic acid–base disturbances in critically ill patients. Am J Respir Crit Care Med 2000, 162: 2246-2251.CrossRefPubMed

Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J: Lactate clearance and survival following injury. J Trauma 1993, 35: 584-589.CrossRefPubMed

Claridge JA, Crabtree TD, Pelletier SJ, Butler K, Sawyer RG, Young JS: Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. J Trauma 2000, 48: 8-14.CrossRefPubMed

Blow O, Magliore L, Claridge JA, Butler K, Young JS: The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999, 47: 964-969.CrossRefPubMed

James JH, Luchette FA, McCarter FD, Fischer JE: Lactate is an unreliable indicator of tissue hypoxia in injury or sepsis. Lancet 1999, 354: 505-508. 10.1016/S0140-6736(98)91132-1CrossRefPubMed

Jeng JC, Jablonski K, Bridgeman A, Jordan MH: Serum lactate, not base deficit, rapidly predicts survival after major burns. Burns 2002, 28: 161-166. 10.1016/S0305-4179(01)00098-5CrossRefPubMed

10.

Mikulaschek A, Henry SM, Donovan R, Scalea TM: Serum lactate in not predicted by anion gap or base excess after trauma resuscitation. J Trauma 1996, 40: 218-224.CrossRefPubMed

11.

Mizock BM, Falk JL: Lactic acidosis in critical illness. Crit Care Med 1992, 20: 80-93.CrossRefPubMed

12.

Kaplan L, McPartland K, Santora TA, Trooskin SZ: Start with the physical examination to identify hypoperfusion in ICU patients. J Trauma 2001, 50: 620-628.CrossRefPubMed

13.

Mizock BM: Significance of hyperlactatemia without acidosis during hypermetabloic stress. Crit Care Med 1997, 25: 1780-1781. 10.1097/00003246-199711000-00009CrossRefPubMed

14.

Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC: Serum lactate and base deficit as predictor of mortality and morbidity. Am J Surg 2003, 185: 485-491. 10.1016/S0002-9610(03)00044-8CrossRefPubMed

15.

Smith I, Kumar P, Molloy S, Rhodes A, Newman PJ, Grounds RM, Bennett ED: Base excess and lactate as prognostic indicators for patients admitted to intensive care. Int Care Med 2001, 27: 74-83. 10.1007/s001340051352CrossRef

16.

Brill SA, Stewart TR, Brundage SI, Schreiber MA: Base deficit does not predict mortality when secondary to hyperchloremic acidosis. Shock 2002, 17: 459-462. 10.1097/00024382-200206000-00003CrossRefPubMed

17.

Rutherford E, Morris JA, Reed GW, Hall KS: Base deficit stratifies mortality and determines therapy. J Trauma 1992, 33: 417-423.CrossRefPubMed

18.

Tremblay L, Feliciano DV, Rozycki G: Assessment of initial base deficit as a predictor of outcome: mechanism of injury does make a difference. Am Surg 2002, 68: 689-693.PubMed

19.

Davis J, Kaups KL, Parks SN: Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock. J Trauma 1998, 44: 114-118.CrossRefPubMed

20.

Morgan TJ, Clark C, Endre Z: Accuracy of base excess – an in vitro evaluation of the Van Slyke equation. Crit Care Med 2000, 28: 2932-2936. 10.1097/00003246-200008000-00041CrossRefPubMed

21.

Davis JW, Parks SN, Kaups KL, Gladen HE, O'Donnell-Nicol S: Admission base deficit predicts transfusion requirements and risk of complications. J Trauma 1996, 41: 769-774.CrossRefPubMed

22.

Siegel JH, Rivkind AI, Dalal S, Godzari S: Early physiologic predictors of injury severity and death in blunt multiple trauma. Arch Surg 1990, 125: 498-508.CrossRefPubMed

23.

Randolph LC, Takacs M, Davis KA: Resuscitation in the pediatric trauma population: admission base deficit remains an important prognostic indicator. J Trauma 2002, 53: 838-842.CrossRefPubMed

24.

Scheingraber S, Rehm M, Sehmisch C, Finsterer U: Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology 1999, 90: 1265-1270. 10.1097/00000542-199905000-00007CrossRefPubMed

25.

Hayhoe M, Bellomo R, Liu G, McNicol L, Buxton B: The aetiology and pathogenesis of cardiopulmonary bypass-associated metabolic acidosis using polygeline pump prime. Int Care Med 1999, 25: 680-685. 10.1007/s001340050930CrossRef

26.

Moviat M, van Haren F, van der Hoeven H: Conventional or physicochemical approach in intensive care unit patients with metabolic acidosis. Crit Care 2003, 7: R41-R45. 10.1186/cc2184PubMedCentralCrossRefPubMed

27.

Wilcox CS: Regulation of renal blood flow by plasma chloride. J Clin Invest 1983, 71: 726-735.PubMedCentralCrossRefPubMed

28.

Williams EL, Hildebrand KL, McCormick SA, Bedel MJ: The effect of intravenous lactated ringer's solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth Analg 1999, 88: 999-1003. 10.1097/00000539-199905000-00006PubMed

29.

Barie P, Hydo LJ, Fischer E: Utility of severity scoring for prediction of prolonged critical care. J Trauma 1996, 40: 513-519.CrossRefPubMed

30.

Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, Le Gall JR, Druml W: Effect of renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002, 30: 2051-2058. 10.1097/00003246-200209000-00016CrossRefPubMed

31.

Patterson T, Bailey H, Kaplan LJ: Hyperchloremia induces acidosis, increases the strong ion gap, and impairs coagulation [abstract]. Crit Care Med 2000, Suppl 28: A118.

32.

Healey MA, Davis RE, Liu FC, Loomis WH, Hoyt DB: Lactated ringers in superior to normal saline in a model of massive hemorrhage and resuscitation. J Trauma 1998, 45: 894-899.CrossRefPubMed

33.

Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR: Normal saline versus lactated ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg 2001, 93: 817-822. 10.1097/00000539-200110000-00004CrossRefPubMed

34.

Kellum JA: Fluid resuscitation and hyperchloremic acidosis in experimental sepsis: improved short-term survival and acid–base balance with Hextend compared with saline. Crit Care Med 2002, 30: 300-305. 10.1097/00003246-200202000-00006CrossRefPubMed

35.

Rhee P, Wang D, Ruff P, Austin B, DeBraux S, Wolcott K, Burris D, Ling G, Sun L: Human neutrophil activation and increased adhesion by various resuscitation fluids. Crit Care Med 2000, 28: 74-78. 10.1097/00003246-200001000-00012CrossRefPubMed

36.

Junger WG, Hoyt DB, Hamreus M, Liu FC, Herdon-Remelius C, Junger W, Altman A: Hypertonic saline activates protein kinases and mitogen-activated protein kinase p38 in T-cells. J Trauma 1997, 42: 437-443.CrossRefPubMed

37.

Pedoto A, Caruso JE, Nandi J, Oler A, Hoffmann SP, Tassiopoulos AK, McGraw DJ, Camporesi EM, Hakim TS: Acidosis stimulates nitric oxide production and lung damage in rats. Am J Respir Crit Care Med 1999, 159: 397-402.CrossRefPubMed

38.

Haque IU, Huang CJ, Scumpia PO, Nasiroglu O, Skimming JW: Intravascular infusion of acid promotes intrapulmonary inducible nitric oxide synthase activity and impairs blood oxygenation in rats. Crit Care Med 2003, 31: 1454-1460. 10.1097/01.CCM.0000065678.24064.58CrossRefPubMed

39.

Kellum JA: Metabolic acidosis in the critically ill: lessons learned from physical chemistry. Kidney Int 1998,53(Suppl 66):S81-S86.

40.

Balasubramanyan N, Havens PL, Hoffman GM: Unmeasured anions identified by the Fencl–Stewart method predict mortality better than base excess, anion gap, and lactate in patients admitted in the pediatric intensive care unit. Crit Care Med 1999, 27: 1577-1581. 10.1097/00003246-199908000-00030CrossRefPubMed

41.

Hatherill M, Waggie Z, Purves L, Reynolds L, Argent A: Mortality and the nature of metabolic acidosis in children with shock. Int Care Med 2003, 29: 286-291.CrossRef

42.

Cusack RJ, Rhodes A, Lochhead P, Jordan B, Perry S, Ball JA, Grounds RM, Bennett ED: The strong ion gap does not have prognostic value in critically ill patients in a mixed medical/surgical adult ICU. Int Care Med 2002, 28: 864-869. 10.1007/s00134-002-1318-2CrossRef

43.

Kellum JA, Ed: The Acid Base pHorum.[http://www.ccm.upmc.edu/education/resources/phorum.html]

44.

Kaplan LJ, Kellum JA: Initial pH, base deficit, lactate, anion gap, strong ion difference and strong ion gap predicts outcome from major vascular injury. Crit Care Med 2004, 32: 1120-1124. 10.1097/01.CCM.0000125517.28517.74CrossRefPubMed

45.

Kaplan LJ, Bailey H, Klein A, et al.: Strong ion gap: a predictor of early mortality following blunt or penetrating trauma [abstract]. Crit Care Med 1999, Suppl 27: A42. 10.1097/00003246-199912001-00076CrossRef

46.

Kellum JA, Kramer DJ, Pinsky MR: Strong ion gap: a methodology for exploring unexplained anions. J Crit Care 1995, 10: 51-55. 10.1016/0883-9441(95)90016-0CrossRefPubMed

47.

Kellum JA, Bellomo R, Kramer DJ, Pinsky MR: Hepatic anion flux during acute endotoxemia. J Appl Physiol 1995, 78: 2212-2217.PubMed

48.

Gunnerson KJ, Saul M, Kellum JA: Lactic versus nonlactic metabolic acidosis: outcomes in critically ill patients [abstract]. Crit Care 2003,7(Suppl 2):S8. 10.1186/cc1906CrossRef

Title: Clinical review: Acid–base abnormalities in the intensive care unit
Authors: Lewis J Kaplan
Spiros Frangos
Publication date: 01-04-2004
Publisher: BioMed Central
Published in: Critical Care / Issue 2/2005
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc2912

At a glance: The STEP trials

Springer Medicine

Clinical review: Acid–base abnormalities in the intensive care unit

Abstract

At a glance: The STEP trials

Springer Medicine

Abstract

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