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Doctoral Thesis
DOI
https://doi.org/10.11606/T.5.2023.tde-08022024-155018
Document
Author
Full name
Pedro Ferro Lima Menezes
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2023
Supervisor
Committee
Silva Junior, João Manoel da (President)
Andrade Filho, Pedro Hilton de
Malbouisson, Luiz Marcelo Sá
Sabbag, Itajiba Paternosti
Title in Portuguese
Associação entre delta ânion gap/delta bicarbonato e o desfecho de pacientes cirúrgicos admitidos em terapia intensiva
Keywords in Portuguese
Acidose
Alcalose
Concentração de íons de hidrogênio
Equilíbrio ácido-base
Estudo multicêntrico
Mortalidade
Prognóstico
Unidades de terapia intensiva
Abstract in Portuguese
Introdução: o valor do ânion gap (AG) ajuda a interpretar e atuar mais adequadamente nos distúrbios de acidose metabólica. Nos casos de elevação do AG, há uma relação esperada entre a elevação do AG e a variação do bicarbonato sérico. Sendo assim, pode-se avaliar se há ainda outros distúrbios metabólicos associados calculando o deltaAG/deltaBic. Valores fora da faixa considerada normal podem indicar precocemente se há outros distúrbios associados e sugerir possíveis etiologias com mais precisão e adequados cuidados. Portanto, são os objetivos caracterizar com maior exatidão a acidose metabólica e associações em pacientes cirúrgicos e possíveis complicações relacionadas a este problema. Metodologia: foram envolvidos pacientes no pós-operatório em três UTIs de hospitais terciários e avaliados exames laboratoriais na admissão e após 24 horas de internação. Pacientes com diferentes distúrbios de acidose metabólica e a relação deltaAG/deltaBic foram comparados entre si em relação a complicações na UTI e mortalidade em 30 dias. Aos pacientes com acidose metabólica e ânion gap elevado, somente no período após as 24 horas, foi aplicada a relação deltaAG/deltaBic e separados em três grupos conforme os resultados: acidose metabólica com ânion gap elevado sem distúrbios associados, acidose metabólica com ânion gap elevado associado a hipercloremia e por fim acidose metabólica com ânion gap elevado associado a alcalose. Resultados: foram avaliados 621 pacientes cirúrgicos admitidos em UTI, com 300 (48,3%) sem acidose e 321 (51,7%) com algum tipo de acidose. Destes, 201 (32,4%) pacientes apresentavam AG elevado e 120 (19,3%) apresentavam acidose hiperclorêmica e AG não alterado. Após 24 horas, 140 pacientes permaneceram com acidose metabólica com AG elevado. Esses 140 pacientes foram submetidos ao cálculo do deltaAG/deltaBic, com seus resultados separados em três grupos: primeiro grupo com 101 pacientes e associação deltaAG/deltaBic < 1,0 (hipercloremia associada), segundo grupo com 18 pacientes e deltaAG/deltaBic de 1,0 a 1,6 (sem distúrbio misto) e por fim o grupo com deltaAG/deltaBic > 1,6 (associado a alcalose) com 21 pacientes. No geral, pacientes com acidose metabólica e AG elevado apresentaram menor sobrevida em 30 dias (HR = 3,72; IC 95% 1,11-12,89). Nos pacientes com acidose metabólica com ânion gap elevado sem distúrbios associados houve uma maior proporção de complicações cardiovasculares (p = 0,001) em relação aos outros pacientes com distúrbios mistos. Além disso, a mortalidade dos pacientes com deltaAG/deltaBic entre 1-1,6 (sem distúrbio misto) foi maior (44,4%), em relação aos pacientes com hipercloremia associada e deltaAG/deltaBic < 1,0 (17,8%) e nos pacientes com alcalose associada e deltaAG/deltaBic >1,6 (19%). Conclusão: o deltaAG/deltaBic é útil para avaliar possíveis distúrbios mistos de acidose metabólica com ânion gap aumentado e foi notado que após avaliação deltaAG/deltaBic muitos casos de acidose hiperclorêmica ainda foram identificados. A associação de acidose metabólica com ânion gap elevado sem distúrbio misto correlacionou-se com pior desfecho nos pacientes cirúrgicos
Title in English
Association between delta anion gap/delta bicarbonate and the outcome of surgical patients admitted to intensive care
Keywords in English
Acid-Base equilibrium
Acidosis
Alkalosis
Hydrogen-Ion concentration
Intensive care units
Mortality
Multicenter study
Prognosis
Abstract in English
Introduction: the Anion Gap (AG) value helps to interpret and act more appropriately in metabolic acidosis disorders. In cases of AG elevation, there is an expected relationship between AG elevation and serum bicarbonate variation. Therefore, we can assess whether there are other associated metabolic disorders by calculating the deltaAG/deltaBic. Values outside the range considered normal may indicate early whether there are other associated disorders and suggest possible etiologies with more precision and adequate care. Therefore, we aim to more accurately characterize metabolic acidosis and associations in surgical patients and possible complications related to this problem. Methodology: postoperative patients were enrolled in 3 ICUs of tertiary hospitals and laboratory tests were evaluated on admission and after 24 hours of hospitalization. Patients with different metabolic acidosis disorders and the deltaAG/deltaBic correlation were compared with each other in relation to ICU complications and 30-day mortality. For patients with metabolic acidosis and high anion gap, only in the period after 24 hours, the deltaAG/deltaBic correlation was applied and separated into 3 groups according to the results: metabolic acidosis with high anion gap without associated disorders, metabolic acidosis with high anion gap associated hyperchloremia and finally metabolic acidosis with high anion gap associated with alkalosis. Results: a total of 621 surgical patients admitted to the ICU were evaluated, with 300 (48.3%) without acidosis and 321 (51.7%) with some type of acidosis. Of these, 201 (32.4%) patients had elevated AG and 120 (19.3%) had hyperchloremic acidosis and unchanged AG. After 24 hours, 140 patients remained with high AG metabolic acidosis. These 140 patients underwent calculation of the deltaAG/deltaBic correlation, with their results separated into 3 groups: first group with 101 patients and deltaAG/deltaBic association < 1.0 (associated hyperchloremia), second group with 18 patients and deltaAG/deltaBic of 1.0 to 1.6 (without mixed disorder) and finally the group with deltaAG/deltaBic > 1.6 (associated with alkalosis) with 21 patients. Overall, patients with metabolic acidosis and elevated AG had a shorter 30-day survival (HR = 3.72; 95% CI 1.11-12.89). Patients with high anion gap metabolic acidosis without associated disorders had a higher proportion of cardiovascular complications (p = 0.001) compared to other patients with mixed disorders. In addition, the mortality of patients with deltaAG/deltaBic between 1-1.6 (without mixed disorder) was higher (44.4%), compared to patients with associated hyperchloremia and deltaAG/deltaBic < 1.0 (17.8%) and in patients with associated alkalosis and deltaAG/deltaBic >1.6 (19%). Conclusion: the deltaAG/deltaBic correlation is useful to evaluate possible mixed disorders of metabolic acidosis with increased anion gap and it was noticed that after deltaAG/deltaBic evaluation many cases of hyperchloremic acidosis were still identified. The association of metabolic acidosis with high anion gap without mixed disorder correlated with worse outcome in surgical patients
 
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Publishing Date
2024-02-19
 
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