IntroductionAlthough metabolic alkalosis is a common occurrence in intensive care units (ICUs), no study has evaluated its prevalence or outcomes in patients with severe sepsis or septic shock.MethodsThis is a retrospective cohort study of critically ill patients suffering from severe sepsis and septic shock admitted to the ICUs of Halmstad and Varberg County hospitals. From 910 patient records, 627 patients met the inclusion criteria. We investigated the relationship between metabolic alkalosis and mortality. Further, we studied the relationship between metabolic alkalosis and ICU length of stay (LOS).ResultsMetabolic alkalosis was associated with decreased 30-day and 12-month mortalities. This effect was however lost when a multivariate analysis was conducted, correcting for age, gender, pH on admission, base excess (BE) on admission, Simplified Acute Physiology Score III (SAPS III) and acute kidney injury (AKI). We then analyzed for any dose-response effect between the severity of metabolic alkalosis and mortality and found no relationship. Bivariate analysis showed that metabolic alkalosis had a significant effect on the length of ICU stay. When adjusting for age, sex, pH at admission, BE at admission, SAPS III and AKI in a multivariate analysis, metabolic alkalosis significantly contributed to prolonged ICU length of stay. In two separate sensitivity analyses pure metabolic alkalosis and late metabolic alkalosis (time of onset >48 hours) were the only significant predictor of increased ICU length of stay.ConclusionMetabolic alkalosis did not have any effect on 30-day and 12-month mortalities after adjusting for age, sex, SAPS III-score, pH and BE on admission and AKI in a multivariate analysis. The presence of metabolic alkalosis was independently associated with an increased ICU length of stay.

hiarrow transplant (MT) recipients can develop posttransplantation complications resulting in the need for long-term nutrition support. hiedical records of 16 MT recipients were reviewed retrospectively to determine patient characteristics, hematologic and metabolic abnormalities, complications (bleeding, infection, and gastrointestinal complaints), graft-versus-host disease (GVHD) status, nutrition data, and survival after percutaneous endoscopic gastrostomy (PEG) placement. Eleven patients received allogeneic transplants and 5 were autologous recipients. The mean age was 42 years, with PEG placement occurring 5 months (mean) after transplantation. No significant bleeding or metabolic abnormalities developed as a result of PEG placement. Eleven of 16 patients acquired infections, and 8 of these patients were immunocompromised by medications or disease status. Patients did experience intermittent nausea, diarrhea, and high gastric residuals but these usually did not prohibit further feedings. Chronic GVHD was present in 8 patients and was the precipitating factor for PEG placement in 6 patients. Weight maintenance, a common nutritional goal, was achieved. Survival was 81% and 62% at 30 days and 1 year after transplantation, respectively. Nutrition support via PEG tube is viable in MT patients.

The revised national guidelines for the analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage (UK) provide a framework for the analysis of cerebrospinal fluid samples for the purpose of investigation of subarachnoid haemorrhage. In principle, as long as samples are collected and analysed according to the guidelines, any absorbance scan thus obtained ought to be amenable to interpretation. The case presented involves a cerebrospinal fluid sample with an absorbance scan which could not be interpreted with the guidelines. An archive search for similar cases suggested interference from doxycycline therapy as the cause. Doxycycline was confirmed to be the cause through experimental in vitro reproduction of the interference. Difficulties arising from this interference are discussed. It is hoped that a future version of the guidelines may mention, and propose a means of dealing with, the issue of doxycycline interference.

Background The revised national guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage (UK) provide an objective means of assessing cerebrospinal fluid (CSF) samples to determine risk of subarachnoid haemorrhage (SAH). The guidelines are intended for general use, but samples rendered uninterpretable due to the presence of the antibiotic doxycycline have been described. Here, further cases of antibiotic- based interference, and their implications, are presented. Methods An archival search of CSF spectra performed at Hallands County Hospital Halmstad was performed for the years 2011 and 2016- 2019 in an attempt to locate instances of interference. Each case of suspected interference was further investigated with in vitro reproduction experiments as a means of confirmation and assessment of potential clinical impact. Results A total of 10 cases of CSF curve interference were discovered: 6 due to doxycycline, 3 due to metronidazole and 1 due to tetracycline. Interference due to the tetracycline class was revealed through in vitro experimentation to cause an apparent decrease in the sample’s net bilirubin absorbance(NBA); the presence of xanthochromia on visual inspection was, however, conserved. Conclusions The problem of CSF absorbance curve interference might be more common than previously suspected. Due to the potential NBA- lowering effect of tetracyclines, the author recommends visual examination of CSF samples in every case.

Background The revised national guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage (UK) provide an objective means of assessing cerebrospinal fluid samples to determine the risk of subarachnoid haemorrhage. The guidelines are intended for general use, but samples rendered uninterpretable due to the presence of the antibiotic doxycycline have been described. Here, further cases of antibiotic-based interference, and their implications, are presented. Methods An archival search of cerebrospinal fluid spectra performed at Hallands County Hospital Halmstad was performed for the years 2011 and 2016–2019 in an attempt to locate instances of interference. Each case of suspected interference was further investigated with in vitro reproduction experiments as a means of confirmation and assessment of potential clinical impact. Results A total of 10 cases of cerebrospinal fluid curve interference were discovered: six due to doxycycline, three due to metronidazole and one due to tetracycline. Interference caused by the tetracycline class was revealed through in vitro experimentation to cause an apparent decrease in the sample’s net bilirubin absorbance; the presence of xanthochromia on visual inspection was, however, conserved. Conclusions The problem of cerebrospinal fluid absorbance curve interference might be more common than previously suspected. Due to the potential net bilirubin absorbance-lowering effect of tetracyclines, the author recommends visual examination of cerebrospinal fluid samples in every case.