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Severe hyperlactatemia with normal base excess: a quantitative analysis using conventional and Stewart approaches.

Tuhay G, Pein MC, Masevicius FD, Kutscherauer DO, Dubin A - Crit Care (2008)

Bottom Line: One hundred and thirty-four (80%) patients had low [BE] levels while 34 (20%) patients did not.Patients with normal [BE] had lower plasma [Cl-] (100 +/- 6 mmol/l versus 107 +/- 5 mmol/l, P < 0.0001) and higher differences between the changes in anion gap and [HCO3-] (5 +/- 6 mmol/l versus 1 +/- 4 mmol/l, P < 0.0001).Critically ill patients may present severe hyperlactatemia with normal values of pH, [HCO3-], and [BE] as a result of associated hypochloremic alkalosis.

View Article: PubMed Central - HTML - PubMed

Affiliation: Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Buenos Aires, Argentina.

ABSTRACT

Introduction: Critically ill patients might present complex acid-base disorders, even when the pH, PCO2, [HCO3-], and base excess ([BE]) levels are normal. Our hypothesis was that the acidifying effect of severe hyperlactatemia is frequently masked by alkalinizing processes that normalize the [BE]. The goal of the present study was therefore to quantify these disorders using both Stewart and conventional approaches.

Methods: A total of 1,592 consecutive patients were prospectively evaluated on intensive care unit admission. Patients with severe hyperlactatemia (lactate level > or = 4.0 mmol/l) were grouped according to low or normal [BE] values (<-3 mmol/l or >-3 mmol/l).

Results: Severe hyperlactatemia was present in 168 of the patients (11%). One hundred and thirty-four (80%) patients had low [BE] levels while 34 (20%) patients did not. Shock was more frequently present in the low [BE] group (46% versus 24%, P = 0.02) and chronic obstructive pulmonary disease in the normal [BE] group (38% versus 4%, P < 0.0001). Levels of lactate were slightly higher in patients with low [BE] (6.4 +/- 2.4 mmol/l versus 5.6 +/- 2.1 mmol/l, P = 0.08). According to our study design, the pH, [HCO3-], and strong-ion difference values were lower in patients with low [BE]. Patients with normal [BE] had lower plasma [Cl-] (100 +/- 6 mmol/l versus 107 +/- 5 mmol/l, P < 0.0001) and higher differences between the changes in anion gap and [HCO3-] (5 +/- 6 mmol/l versus 1 +/- 4 mmol/l, P < 0.0001).

Conclusion: Critically ill patients may present severe hyperlactatemia with normal values of pH, [HCO3-], and [BE] as a result of associated hypochloremic alkalosis.

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Effective strong-ion difference, sodium-corrected chloride, albumin, and nonvolatile weak acid levels in severe hyperlactatemia patients. Values for (a) the effective strong-ion difference ([SID]effective), (b) sodium-corrected chloride levels ([Cl-]corrected), (c) the albumin concentration, and (d) nonvolatile weak acid ([Atot-]) levels in patients with severe hyperlactatemia, with normal or low base excess. *P < 0.05 versus the other group.
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Figure 2: Effective strong-ion difference, sodium-corrected chloride, albumin, and nonvolatile weak acid levels in severe hyperlactatemia patients. Values for (a) the effective strong-ion difference ([SID]effective), (b) sodium-corrected chloride levels ([Cl-]corrected), (c) the albumin concentration, and (d) nonvolatile weak acid ([Atot-]) levels in patients with severe hyperlactatemia, with normal or low base excess. *P < 0.05 versus the other group.

Mentions: Levels of lactate were slightly higher in patients with low [BE] (6.4 ± 2.4 mmol/l versus 5.6 ± 2.1 mmol/l, P = 0.08). According to the study design, the pH, [HCO3-], and [SID] levels were lower in patients with low [BE] (Figures 1 and 2). Patients with normal [BE] had lower [Cl-]corrected (Figure 2) and higher Δ[AG]corrected - [HCO3-] and Δ[AG]corrected - Δ[BE] values (5 ± 6 mmol/l versus 1 ± 4 mmol/l and 3 ± 6 mmol/l versus 4 ± 4 mmol/l, respectively; P < 0.0001 for both). These patients also had levels of [AG]corrected and [SIG]corrected that were slightly lower (21 ± 5 mmol/l versus 23 ± 5 mmol/l, P = 0.07 and 9 ± 5 mmol/l versus 11 ± 5 mmol/l, P < 0.05, respectively). The [albumin] and [Atot-] values were lower in patients with low [BE] (Figure 2).


Severe hyperlactatemia with normal base excess: a quantitative analysis using conventional and Stewart approaches.

Tuhay G, Pein MC, Masevicius FD, Kutscherauer DO, Dubin A - Crit Care (2008)

Effective strong-ion difference, sodium-corrected chloride, albumin, and nonvolatile weak acid levels in severe hyperlactatemia patients. Values for (a) the effective strong-ion difference ([SID]effective), (b) sodium-corrected chloride levels ([Cl-]corrected), (c) the albumin concentration, and (d) nonvolatile weak acid ([Atot-]) levels in patients with severe hyperlactatemia, with normal or low base excess. *P < 0.05 versus the other group.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2481449&req=5

Figure 2: Effective strong-ion difference, sodium-corrected chloride, albumin, and nonvolatile weak acid levels in severe hyperlactatemia patients. Values for (a) the effective strong-ion difference ([SID]effective), (b) sodium-corrected chloride levels ([Cl-]corrected), (c) the albumin concentration, and (d) nonvolatile weak acid ([Atot-]) levels in patients with severe hyperlactatemia, with normal or low base excess. *P < 0.05 versus the other group.
Mentions: Levels of lactate were slightly higher in patients with low [BE] (6.4 ± 2.4 mmol/l versus 5.6 ± 2.1 mmol/l, P = 0.08). According to the study design, the pH, [HCO3-], and [SID] levels were lower in patients with low [BE] (Figures 1 and 2). Patients with normal [BE] had lower [Cl-]corrected (Figure 2) and higher Δ[AG]corrected - [HCO3-] and Δ[AG]corrected - Δ[BE] values (5 ± 6 mmol/l versus 1 ± 4 mmol/l and 3 ± 6 mmol/l versus 4 ± 4 mmol/l, respectively; P < 0.0001 for both). These patients also had levels of [AG]corrected and [SIG]corrected that were slightly lower (21 ± 5 mmol/l versus 23 ± 5 mmol/l, P = 0.07 and 9 ± 5 mmol/l versus 11 ± 5 mmol/l, P < 0.05, respectively). The [albumin] and [Atot-] values were lower in patients with low [BE] (Figure 2).

Bottom Line: One hundred and thirty-four (80%) patients had low [BE] levels while 34 (20%) patients did not.Patients with normal [BE] had lower plasma [Cl-] (100 +/- 6 mmol/l versus 107 +/- 5 mmol/l, P < 0.0001) and higher differences between the changes in anion gap and [HCO3-] (5 +/- 6 mmol/l versus 1 +/- 4 mmol/l, P < 0.0001).Critically ill patients may present severe hyperlactatemia with normal values of pH, [HCO3-], and [BE] as a result of associated hypochloremic alkalosis.

View Article: PubMed Central - HTML - PubMed

Affiliation: Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Buenos Aires, Argentina.

ABSTRACT

Introduction: Critically ill patients might present complex acid-base disorders, even when the pH, PCO2, [HCO3-], and base excess ([BE]) levels are normal. Our hypothesis was that the acidifying effect of severe hyperlactatemia is frequently masked by alkalinizing processes that normalize the [BE]. The goal of the present study was therefore to quantify these disorders using both Stewart and conventional approaches.

Methods: A total of 1,592 consecutive patients were prospectively evaluated on intensive care unit admission. Patients with severe hyperlactatemia (lactate level > or = 4.0 mmol/l) were grouped according to low or normal [BE] values (<-3 mmol/l or >-3 mmol/l).

Results: Severe hyperlactatemia was present in 168 of the patients (11%). One hundred and thirty-four (80%) patients had low [BE] levels while 34 (20%) patients did not. Shock was more frequently present in the low [BE] group (46% versus 24%, P = 0.02) and chronic obstructive pulmonary disease in the normal [BE] group (38% versus 4%, P < 0.0001). Levels of lactate were slightly higher in patients with low [BE] (6.4 +/- 2.4 mmol/l versus 5.6 +/- 2.1 mmol/l, P = 0.08). According to our study design, the pH, [HCO3-], and strong-ion difference values were lower in patients with low [BE]. Patients with normal [BE] had lower plasma [Cl-] (100 +/- 6 mmol/l versus 107 +/- 5 mmol/l, P < 0.0001) and higher differences between the changes in anion gap and [HCO3-] (5 +/- 6 mmol/l versus 1 +/- 4 mmol/l, P < 0.0001).

Conclusion: Critically ill patients may present severe hyperlactatemia with normal values of pH, [HCO3-], and [BE] as a result of associated hypochloremic alkalosis.

Show MeSH
Related in: MedlinePlus