The physicochemical approach of acid base disturbances

Aim: The aim of this PhD thesis is to evaluate the value of physicochemical, base excess (BE) and plasma bicarbonate concentration ([HCO3-]) approaches on the assessment of acid-base status in patients presented to the Emergency Department (ED). Methods: Upon presentation at ED, patients whose arterial blood was deemed in need of analysis were studied. Arterial blood gases, serum electrolytes and proteins were measured and used to derive [HCO3-], BE, anion gap (AG), AG adjusted for albumin (AGadj), strong ion difference, strong ion gap (SIG) and SIG corrected for water excess/deficit (SIGcor). Results: A total of 365 patients were studied. Compared to BE (n=202) and [HCO3-] (n=151), physicochemical approach (n=279) identified significantly more patients with metabolic acid-base disturbances (p<0.0001). Significantly fewer patients with unmeasured anions acidosis were identified with AGadj than with SIGcor (p<0.0001). On the basis of BE, 75 patients had normal acid base balance and 65(87%) of them exhibited at least one hidden acid-base disturbance, identified by the physicochemical approach. The corresponding values with [HCO3-] approach were 108 and 95(88%) patients. When patients with high AGadj were excluded, 44 patients with BE and 67 with [HCO3-] approach had normal acid-base status, and the majority of them exhibited at least one acid-base disturbance with the physicochemical approach, while 12 and 21 patients, respectively, had high SIGcor. Mortality was 10.7% and logistic regression analysis identified only Sepsis–related Organ Failure Assessment and SIGcor as predictors of mortality. Conclusion: In patients presented to ED, compared to BE and [HCO3-] methods, physicochemical approach has a better diagnostic accuracy to identify metabolic acid-base disturbances and may predict mortality.Σκοπός: Ο σκοπός της διδακτορικής αυτής διατριβής είναι να εκτιμηθεί η αξία της φυσικοχημικής προσέγγισης, των προσεγγίσεων στηριζόμενων στο έλλειμμα/περίσσεια βάσης (ΒΕ) και τα διττανθρακικά ([HCO3-]) στην αξιολόγηση της οξεοβασικής ισορροπίας σε ασθενείς που προσέρχονται στο Τμήμα Επειγόντων Περιστατικών (ΤΕΠ). Μέθοδος: Οι ασθενείς, στους οποίους κατά την προσέλευση στο ΤΕΠ ελήφθη αρτηριακό αίμα, μελετήθηκαν. Αέρια αίματος, ηλεκτρολύτες και πρωτεΐνες μετρήθηκαν και χρησιμοποιήθηκαν για να υπολογισθούν τα [HCO3-], BE, anion gap (AG), AG adjusted for albumin (AGadj), strong ion difference, strong ion gap (SIG) and SIG διορθωμένο για περίσσεια/έλλειψη νερού (SIGcor). Αποτελέσματα: Ένα σύνολο 365 ασθενών μελετήθηκε. Σε σύγκριση με τη προσέγγιση των BE (n=202) και [HCO3-] (n=151), η φυσικοχημική προσέγγιση (n=279) αναγνώρισε σημαντικά περισσότερους ασθενείς με μεταβολικές διαταραχές (p<0.0001). Σημαντικά λιγότεροι ασθενείς με οξέωση οφειλόμενη στα μη μετρούμενα αναγνωρίστηκαν με το AGadj σε σχέση με το SIGcor (p<0.0001). Με βάση το BE, 75 ασθενείς είχαν φυσιολογική οξεοβασική ισορροπία και 65(87%) αυτών παρουσίαζε μία τουλάχιστον διαταραχή με τη φυσικοχημική προσέγγιση. Οι αντίστοιχες τιμές για την προσέγγιση των [HCO3-] ήταν 108 και 95(88%) ασθενείς. Όταν ασθενείς με υψηλή τιμή AGadj εξαιρέθηκαν, 44 ασθενείς με BE and 67 με την προσέγγιση των [HCO3-] είχαν φυσιολογική οξεοβασική ισορροπία, και η πλειοψηφία αυτών παρουσίαζε μία τουλάχιστον διαταραχή με τη φυσικοχημική προσέγγιση, ενώ 12 και 21 ασθενείς, αντίστοιχα, είχαν υψηλή τιμή SIGcor. Η θνησιμότητα ήταν 10.7% και η λογιστική παλινδρόμηση ανέδειξε μόνο το Sepsis–related Organ Failure Assessment και το SIGcor ως προγνωστικούς δείκτες θνησιμότητας. Συμπεράσματα: Στους ασθενείς που προσέρχονται στο ΤΕΠ, σε σύγκριση με τις μεθόδους των BE και [HCO3-], η φυσικοχημική προσέγγιση έχει καλύτερη διαγνωστική ακρίβεια να αναγνωρίζει μεταβολικές διαταραχές οξεοβασικής ισορροπίας και ίσως να προβλέπει τη θνησιμότητα

Patient-Ventilator Dyssynchrony

In mechanically ventilated patients, assisted mechanical ventilation (MV) is employed early, following the acute phase of critical illness, in order to eliminate the detrimental effects of controlled MV, most notably the development of ventilator-induced diaphragmatic dysfunction. Nevertheless, the benefits of assisted MV are often counteracted by the development of patient-ventilator dyssynchrony. Patient-ventilator dyssynchrony occurs when either the initiation and/or termination of mechanical breath is not in time agreement with the initiation and termination of neural inspiration, respectively, or if the magnitude of mechanical assist does not respond to the patient’s respiratory demand. As patient-ventilator dyssynchrony has been associated with several adverse effects and can adversely influence patient outcome, every effort should be made to recognize and correct this occurrence at bedside. To detect patient-ventilator dyssynchronies, the physician should assess patient comfort and carefully inspect the pressure- and flow-time waveforms, available on the ventilator screen of all modern ventilators. Modern ventilators offer several modifiable settings to improve patient-ventilator interaction. New proportional modes of ventilation are also very helpful in improving patient-ventilator interaction

Epidemiological characteristics and outcomes from 187 patients with COVID-19 admitted to 6 reference centers in Greece: an observational study during the first wave of the COVID-19 pandemic

Introduction: Epidemiological data from patients with COVID-19 has been recently published in several countries. Nationwide data of hospitalized patients with COVID-19 in Greece remain scarce. Material and methods: This was an observational, retrospective study from 6 reference centers between February 26 and May 15, 2020. Results: The patients were mostly males (65.7%) and never smokers (57.2%) of median age 60 (95% CI: 57.6–64) years. The majority of the subjects (98%) were treated with the standard-of-care therapeutic regimen at that time, including hydroxychlo-roquine and azithromycin. Median time of hospitalization was 10 days (95% CI: 10–12). Twenty-five (13.3%) individuals were intubated and 8 died (4.2%). The patients with high neutrophil-to-lymphocyte ratio (NLR) ( &gt; 3.58) exhibited more severe disease as indicated by significantly increased World Health Organization (WHO) R&amp;D ordinal scale (4; 95% CI: 4–4 vs 3; 95% CI: 3–4, p = 0.0001) and MaxFiO2% (50; 95% CI: 38.2–50 vs 29.5; 95% CI: 21–31, p &lt; 0.0001). The patients with increased lactate dehydrogenase (LDH) levels ( &gt; 270 IU/ml) also exhibited more advanced disease compared to the low LDH group ( &lt; 270 IU/ml) as indicated by both WHO R&amp;D ordinal scale (4; 95% CI: 4–4 vs 4; 95% CI: 3–4, p = 0.0001) and MaxFiO2% (50; 95% CI: 35–60 vs 28; 95% CI: 21–31, p &lt; 0.0001). Conclusion: We present the first epidemiological report from a low-incidence and mortality COVID-19 country. NLR and LDH may represent reliable disease prognosticators leading to timely treatment decisions

Epidemiological Characteristics and Outcomes from 187 Patients with COVID-19 Admitted to 6 Reference Centers in Greece: An Observational Study during the First Wave of the COVID-19 Pandemic

Introduction: Epidemiological data from patients with COVID-19 has been recently published in several countries. Nationwide data of hospitalized patients with COVID-19 in Greece remain scarce. Material and methods:This was an observational, retrospective study from 6 reference centers between February 26 and May 15, 2020. Results: The patients were mostly males (65.7%) and never smokers (57.2%) of median age 60 (95% CI: 57.6–64) years. The majority of the subjects (98%) were treated with the standard-of-care therapeutic regimen at that time, including hydroxychlo-roquine and azithromycin. Median time of hospitalization was 10 days (95% CI: 10–12). Twenty-five (13.3%) individuals were intubated and 8 died (4.2%). The patients with high neutrophil-to-lymphocyte ratio (NLR) (&gt; 3.58) exhibited more severe disease as indicated by significantly increased World Health Organization (WHO) R&amp;D ordinal scale (4; 95% CI: 4–4 vs. 3; 95% CI: 3–4, p = 0.0001) and MaxFiO2% (50; 95% CI: 38.2–50 vs 29.5; 95% CI: 21–31, p &lt; 0.0001). The patients with increased lactate dehydrogenase (LDH) levels (&gt; 270 IU/ml) also exhibited more advanced disease compared to the low LDH group (&lt; 270 IU/ml) as indicated by both WHO R&amp;D ordinal scale (4; 95% CI: 4–4 vs. 4; 95% CI: 3–4, p = 0.0001) and MaxFiO2% (50; 95% CI: 35–60 vs. 28; 95% CI: 21–31, p &lt; 0.0001). Conclusion: We present the first epidemiological report from a low-incidence and mortality COVID-19 country. NLR and LDH may represent reliable disease prognosticators leading to timely treatment decisions

COVID-19 in patients with pulmonary alveolar proteinosis: a European multicentre study

Adult PAP patients experience similar #COVID19 rates to the general population, and high rates of hospitalisation and deaths, underscoring their vulnerability and the need for measures to prevent infection. The impact of iGM-CSF must be considered. https://bit.ly/3M0wKnZ