Unmeasured anions in critically ill patients: Can they predict mortality?*

Rocktaeschel, Jens; Morimatsu, Hiroshi; Uchino, Shigehiko; Bellomo, Rinaldo

doi:10.1097/01.ccm.0000079819.27515.8e

Cited by 153 publications

(130 citation statements)

References 28 publications

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“…Induction, time point of inducing anesthesia; weaning, 5 min after weaning from CPB; closure, time point of chest closure; UMA, unmeasured anions; Change in lactate induction-weaning, change in the lactate level from induction to CPB weaning; Change in lactate weaning-closure, change in the lactate level from CPB weaning to chest closure; Change in lactate induction-closure, change in the lactate level from induction to chest closure; Change in UMA induction-weaning, change in the UMA level from induction to CPB weaning; Change in UMA weaning-closure, change in the UMA level from CPB weaning to chest closure; Change in UMA induction-closure, change in the UMA level from induction to chest closure; AUC, area under curve; Pauc, P value of the comparison of AUCs between lactate and UMA at each time point. pediatric cardiac surgery in some studies (Durward et al 2005;Murray et al 2007), whereas other studies showed that the UMA level offers no additional advantage over the lactate level in predicting surgical outcomes (Cusack et al 2002;Hatherill et al 2003;Rocktaeschel et al 2003). Both of these reports focused on postoperative or critically ill patients in the ICU.…”

Section: Fig 3 Periopetraive Hemodynamic Variables In the Mae Groupmentioning

confidence: 99%

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Intraoperative Plasma Lactate as an Early Indicator of Major Postoperative Events in Pediatric Cardiac Patients

Park

Kim

Byon

et al. 2012

Tohoku J. Exp. Med.

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Hyperlactatemia and unmeasured anions (UMA) have been suggested to be useful predictors of outcomes after pediatric cardiac surgery in the ICU. However, if we detect high-risk patient in the operating room, we could practice early intervention to decrease mortality and morbidity. The purpose of this study was to determine whether the intraoperative lactate or UMA levels can predict adverse outcomes in pediatric cardiac patients with undergoing cardiopulmonary bypass (CPB). We studied 102 patients with congenital heart disease. Arterial blood samples were obtained after inducing anesthesia, 5 min after weaning from CPB and after chest closure. Major adverse events (MAEs) were defined as cardiac compression, re-sternotomy due to hemodynamic instability, extra-corporeal membrane oxygenator support, creatinine levels greater than 2 mg/dL, or death. Patients were divided into MAE group (8 patients, 7.8%) and non-MAE group. Six patients with MAEs died. Importantly, the lactate levels (mmol/L) at weaning from CPB (4.19 vs 2.1; MAE group vs non-MAE group), chest closure (5.76 vs 2.39; MAE group vs non-MAE group) and the intraoperative increases in lactate levels were significantly higher in the MAE group than in the non-MAE group. However, there was no significant difference in the UMA levels or their changes between the groups. The increase in the lactate level from CPB weaning to chest closure was the best predictor of MAEs (AUC: 0.810). In conclusion, the intraoperative plasma lactate levels were more closely associated with MAEs, and they are more useful for predicting the outcome of pediatric cardiac patients than the UMA levels.

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Section: Fig 3 Periopetraive Hemodynamic Variables In the Mae Groupmentioning

confidence: 99%

“…Another report suggests that an elevated strong ion gap is superior to lactate levels as a predictor of mortality after cardiac surgery (Durward et al 2005). However, some reports have questioned the role of the UMA level as a predictor of outcome in critically ill patients (Cusack et al 2002;Hatherill et al 2003;Rocktaeschel et al 2003).…”

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confidence: 99%

Intraoperative Plasma Lactate as an Early Indicator of Major Postoperative Events in Pediatric Cardiac Patients

Park

Kim

Byon

et al. 2012

Tohoku J. Exp. Med.

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“…Several studies have shown conflicting results regarding the sensitivity and specificity of AG when investigating metabolic acidosis 1, 5, 25, 26, 27. In critically ill foals, a moderate correlation was demonstrated between AG and plasma [ l ‐lac − ], with AG having a good sensitivity (77%) and specificity (83%) in detection of hyperlactatemia > 5 mmol/L 1.…”

Section: Discussionmentioning

confidence: 99%

“…The severity of hyper‐ l ‐lactatemia is considered an accurate predictor of mortality in neonatal and adult humans, horses, and cattle 1, 3, 23, 24, 25, 26. Although recent studies have shown that serial measurement of plasma concentration of l ‐lactate ([ l ‐lac − ]) or measurement of [ l ‐lac − ] clearance might enable more accurate prognostication,3, 4 [ l ‐lac − ] determination at hospital admission are commonly used as a prognostic indicator.…”

mentioning

confidence: 99%

“…Clinicians could assume that commonly calculated acid–base parameters, like anion gap (AG) and strong ion gap (SIG) are sufficient alternatives for prediction of hyper‐ l ‐lactatemia, but conflicting results regarding the sensitivity and specificity of AG when investigating metabolic acidosis in human, equine, and bovine adult and neonates has been documented 1, 5, 25, 26, 27. Alternatively, SIG has shown an excellent correlation with [ l ‐lac − ] in healthy horses under exercise conditions,28 and horses with acute diarrhea 29.…”

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confidence: 99%

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Physicochemical Approach to Determine the Mechanism for Acid–Base Disorders in 793 Hospitalized Foals

Gómez

Biermann

Sanchez

2015

Veterinary Internal Medicne

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BackgroundThe quantitative effect of strong electrolytes, unmeasured strong anions (UAs), pCO 2, and plasma protein concentrations in determining plasma pH can be demonstrated using the physicochemical approach. Plasma anion gap (AG) and strong ion gap (SIG) are used to assess UAs in different species.HypothesesStrong ions are a major factor influencing changes in plasma pH of hospitalized foals. AG and SIG accurately predict severe hyper‐l‐lactatemia ([l‐lac−] > 7 mmol/L).AnimalsSeven hundred and ninety three hospitalized foals < 7 days old.MethodsRetrospective study. The relationship between measured pH and physicochemical variables, and the relationship between plasma [l‐lac−] and AG and SIG, were determined using regression analyses. Optimal AG and SIG cut points to predict hyper‐l‐lactatemia were identified using an ROC curve analysis.ResultsCombined, the measured strong ion difference and SIG accounted for 54–69% of the changes in the measured arterial pH of hospitalized foals. AG and SIG were significantly associated with plasma [l‐lac−] (P < .0001). The receiver operator characteristics (ROC) AUC of AG and SIG for prediction of severe hyper‐l‐lactatemia were 0.89 (95%CI, 0.8–0.95; P < .0001) and 0.90 (95%CI, 0.81–0.96; P < .0001), respectively. Severe hyper‐l‐lactatemia was best predicted by AG > 27 mmol/L (sensitivity 80%, 95%CI, 56–94, specificity 85%, 95%CI, 73–93; P < .0001) and SIG <−15 mmol/L (sensitivity 90%, 95%CI, 68–98; specificity 80%; 95%CI, 68–90; P < .0001).Conclusion and clinical relevanceAltered concentrations of strong ions (Na+, K+, Cl−) and UAs were the primary cause of acidemia of hospitalized foals. AG and SIG were good predictors of hyper‐l‐lactatemia and could be used as surrogate tests.

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Use of Serum Bicarbonate Measurement in Place of Arterial Base Deficit in the Surgical Intensive Care Unit

et al. 2005

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Hypothesis: Serum bicarbonate (HCO 3) measurement may accurately and reliably be substituted for the arterial base deficit (BD) assay in the surgical intensive care unit (ICU). Design: Retrospective criterion standard analysis. Setting: Surgical ICU in a tertiary care facility. Patients: Consecutive sample of non-trauma-related surgical ICU admissions from January 1996 to January 2004 with simultaneously obtained serum HCO 3 and arterial BD levels. Main Outcome Measures: Correlation between HCO 3 and BD at admission and during the ICU stay; predictive value of serum HCO 3 for significant metabolic acidosis and ICU mortality. Results: The study included 2291 patients with 26 063 sets of paired laboratory data. The mean±SD age was 52±16 years and mean ICU stay was 5.8±9.8 days. There were 174 ICU deaths (8%). Serum HCO 3 levels showed significant correlation with arterial BD levels both at admission (r=0.85, R 2 =0.72, PϽ.001) and throughout the ICU stay (r=0.88, R 2 =0.77, PϽ.001). Serum HCO 3 reliably predicted the presence of significant metabolic acidosis (BDϾ5) with an area under the receiver operating characteristic curve (AUC) of 0.93 at admission and 0.95 overall (both PϽ.001), outperforming pH (AUC, 0.80), anion gap (AUC, 0.70), and lactate (AUC, 0.70). The admission serum HCO 3 level predicted ICU mortality as accurately as the admission arterial BD (AUCs of 0.68 and 0.70, respectively) and more accurately than either admission pH or anion gap. Conclusions: Serum HCO 3 provides equivalent information to the arterial BD and may be used as an alternative predictive marker or guide to resuscitation. Low HCO 3 levels should prompt immediate metabolic acidosis evaluation and management.

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Unmeasured anions in critically ill patients: Can they predict mortality?*

Cited by 153 publications

References 28 publications

Intraoperative Plasma Lactate as an Early Indicator of Major Postoperative Events in Pediatric Cardiac Patients

Intraoperative Plasma Lactate as an Early Indicator of Major Postoperative Events in Pediatric Cardiac Patients

Physicochemical Approach to Determine the Mechanism for Acid–Base Disorders in 793 Hospitalized Foals

Use of Serum Bicarbonate Measurement in Place of Arterial Base Deficit in the Surgical Intensive Care Unit

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