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So who should get an AMP or two? 24 yo male with DKA pH 6.90 pCO2 45 HCO3 8
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Base Treatment for Metabolic Acidosis due to DKA and
Sepsis
Nicholas Busch Henry Ford Hospital Emergency Medicine Grand Rounds
September 17th, 2015 So who should get an AMP or two?
24 yo male with DKA pH 6.90 pCO2 45 HCO3 8 So who should get an AMP
or two?
65 yo with septic shock pH 7.10 pCO2 42 HCO3 10 Objectives Quick
Acid-Base review
Discuss the hemodynamic effects of base therapy Discuss evidence
for base therapy in: DKA Lactic acidosis/sepsis Not covered:
Pediatrics, respiratory acidosis, toxic ingestions, RTA and other
non-AG acidosis WHY? WhO? Who gives sodium bicarb therapy?
About 100 surveys completed by critical care and nephrology program
directors throughout the nation. Patients with lactic
acidosis
-67% of critical care physicians -86% of nephrologists Patients
with ketoacidosis -28% of critical care physicians -60% of
nephrologists VERY Quick Acid-Base Review
CO2 + H20 H2CO3 HCO3 + H+ Henderson Hasselbalch pK curve Using
white board Also whats an AMP?? Ampule (amp, ampoule)
NOT standardized unit of measure Single dose of medication
pre-packaged in an injectable glass or plastic vessel An amp of
Bicarb 8.4% Sodium Bicarbonate 50 mEq Na+, 50 mEq HCO3-
pH 8.0 1 mL is 84 mg Framing the Question Proposed Rationale for
Base Therapy Use:
1. A low pH, in and of itself, is harmful (most notably by
impairing cardiovascular function). 2. Sodium bicarbonate can
increase the pH when infused IV. 3. Raising the pH with sodium
bicarbonate improves cardiovascular function or some other relevant
outcome. 4. Any adverse effects of sodium bicarbonate are
outweighed by its benefits A low pH, in and of itself, is harmful
(most notably by impairing cardiovascular function)
-Isolated animal heart muscle - acidosis generally reduces
contractile function Human ventricular tissue showed modest
reduction in contractility Whole animal models: contractility
constant, decrease slightly or rise and then fall ARDS treatment :
permissive hypercapnia tolerated to 7.15 and below Protective
effect? reduced cell death in hepatocytes exposed to anoxia Sodium
bicarbonate can increase the pH when infused IV
Most animal studies show arterial pH will rise What about the
intracellular pH?
Multiple compartments with different degrees of permeability
Cerebral spinal fluid Bicarb shown in dog models to LOWER CSF pH
Intracellular Space Raising the pH with sodium bicarbonate improves
cardiovascular function or some other relevant outcome 2 studies in
humans with lactic acidosis and getting continuous vasoactive
infusions No change in hemodynamics or catecholamine responsiveness
HR, CVP, PAP, ScVo2, wedge pressure, or CO Still negative results
with most acidotic ( ) Any adverse effects of sodium bicarbonate
are outweighed by its benefits
Negative side effects Fluid and sodium overload Lowers pO2 and
oxygen delivery Increased lactate concentrations Lowers calcium LV
contractility varies directly with ionized calcium concentration
Clinical significance has not been demonstrated More direct
question Does Sodium Bicarbonate improve outcomes for patients with
severe DKA or lactic acidosis from sepsis? DKA 24 patients received
120+/-40 mmol sodium bicarbonate.
Two groups were similar at admission with regard to clinical and
biological parameters Prospective, randomized trial No difference
could be demonstrated between the two groups - 21 adult patients,
DKA with pH 6.9 to 7.14
No significant differences in Glucose or ketone levels Increase in
pH orHCO3 in blood or CSF Time to glucose 250, pH 7.3, bicarb to 15
We conclude that in severe diabetic ketoacidosis (arterial pH
6
We conclude that in severe diabetic ketoacidosis (arterial pH 6.9
to 7.14), the administration of bicarbonate does not affect
recovery outcome variables as compared with those in a control
group. No Significant Difference: Hospitalization Mortality
12 case control studies 3 RCT with 73 patients No Significant
Difference: Hospitalization Mortality No studies had any patients
with pH