Sodium acetate infusion in critically ill trauma patients for hyperchloremic acidosis

<p>Abstract</p> <p>Introduction</p> <p>Sodium acetate has been shown to cause hemodynamic instability when used as a hemodialysis buffer. The pattern of hemodynamic response to injury will be evaluated between those who received sodium acetate and those who did not.</p> <p>The primary purpose of the study is to analyze the effect of sodium acetate on hemodynamic parameters. Secondarily we looked at the effects on prevention and treatment of hyperchloremic metabolic acidosis.</p> <p>Methods</p> <p>The study arm was comprised of patients who had received sodium acetate infusions in place of normal saline between March 2005 and December 2009. A control arm was created based on matching three pre-treatment variables: injury severity score (ISS), pH (+/- 0.03) and base deficit (+/- 3). A retrospective chart review was performed for patients in both arms. Blood pressure, arterial blood gas data and chemistry values were recorded for the time points of -6, -1, 0, 1, 6, 12, 24, 48, and 72 hours from start of sodium acetate infusion. Patients were excluded based on the following criteria: patients who were given sodium bicarbonate within 48 hours of starting sodium acetate, those given sodium acetate as a bolus, non-trauma patients, burn patients, patients who expired within 24 hours of arrival to the ICU, patients diagnosed with rhabdomyolysis and patients whose medical record could not be obtained.</p> <p>Results</p> <p>A total of 78 patients were included in the study, 39 in the study arm and 39 in the control arm. There were no statistically significant drops in blood pressure within either group. The median pH between the two groups at the start of infusion was equal. Both groups trended towards normal pH with the study arm improving faster than the control arm. The median serum bicarbonate at start of sodium acetate infusion was 19 mmol/L and 20 mmol/L at time zero for the study and control arms respectively with both trending upward during the study period. Chloride trended up initially in both groups but the study arm began to correct sooner at 24 hours compared to 48 hours for the control arm.</p> <p>Conclusion</p> <p>We analyzed the use of sodium acetate as an alternative to normal saline or lactated ringers during resuscitation of critically ill trauma patients at a single center. Our data shows that the hemodynamic profile remained favorable, without evidence of instability at any point during the study period. Normalization of hyperchloremia and metabolic acidosis occurred faster in the patients who received sodium acetate.</p

Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature

Introduction: Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient.Case Series: Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED. Conclusion: Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention.&nbsp; Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site