Perfil acido-base de pacientes con cirrosis descompensada por hemorragia digestiva alta en el departamento de emergencias: serie de casos

Introducción: La hemorragia digestiva (HVDA) es la principal causa de descompensación en pacientes con cirrosis. Caracterizar el estado ácido-base de estos pacientes sería útil para reflejar la severidad del sangrado e identificar pacientes con alto riesgo de complicación. Objetivo: Describir el estado ácido-base de los pacientes que consultaron a urgencias con cirrosis descompensada por HVDA y posteriormente fueron manejados en la unidad de cuidado intensivo (UCI) o fallecieron. Métodos: Se realizó el análisis del estado ácido-base a 10 pacientes con estas características, utilizando tres métodos distintos. Resultados: El perfil ácido-base encontrado fue: acidosis metabólica por iones no medidos, acidosis láctica, alcalosis por hipoalbuminemia y anión gap elevado en la mayoría de pacientes. Conclusiones: La teoría de Henderson-Hasselbach no fue suficiente para identificar pacientes con alto riesgo, debería implementarse concomitantemente el análisis anión gap, base déficit y el método físico–químico, para entender los fenómenos acido base de estos pacientes.

Descripción del estado acido base en pacientes con quemaduras térmicas agudas: serie de casos

Introducción: Los pacientes con lesiones térmicas presentan alteraciones fisiológicas complejas que hacen difícil la caracterización del estado ácido-base y así mismo alteraciones electrolíticas e hipoalbuminemia que pudieran estar relacionados con un peor pronóstico. Se ha estudiado la base déficit (BD) y el lactato, encontrando una gran divergencia en los resultados. Por lo anterior, el análisis físico-químico del estado ácido-base podría tener un rendimiento superior a los métodos tradicionales. Metodología: Se realizó el análisis de una serie de casos de 15 pacientes mayores de 15 años, con superficie corporal quemada mayor al 20% que ingresaron a una unidad de cuidado intensivo (UCI) de quemados, dentro de las siguientes 48 horas del trauma. Para el análisis se utilizaron tres métodos distintos: 1) método convencional basado en la teoría de Henderson-Hasselbalch, 2) anión-gap (AG) y anión-gap corregido por albúmina, 3) análisis físico-químico del estado ácido-base según la teoría de Stewart modificado por Fencl y Figge. Resultados: Por el método de Henderson-Hasselbalch, 8 pacientes cursaron con acidosis metabólica, 4 pacientes con una BD leve, 5 pacientes con una BD moderada y 5 pacientes con una BD severa. El AG resultó menor a 16 mmol/dl en 10 pacientes, pero al corregirlo por albumina sólo 2 pacientes cursaron con AG normal. La diferencia de iones fuertes (DIF) se encontraba anormalmente elevada en la totalidad de los pacientes. Conclusión:El análisis del AG corregido por albumina y el análisis físico-químico del estado ácido-base, podrían tener mayor rendimiento al identificar las alteraciones metabólicas de estos pacientes.

Arterial acid-base status during digestion and following vascular infusion of NaHCO3 and HCl in the South American rattlesnake, Crotalus durissus

Digestion is associated with gastric secretion that leads to an alkalinisation of the blood, termed the alkaline tide. Numerous studies on different reptiles and amphibians show that while plasma bicarbonate concentration ([HCO3-](pl)) increases substantially during digestion, arterial pH (pHa) remains virtually unchanged, due to a concurrent rise in arterial PCO2 (PaCO2) caused by a relative hypoventilation. This has led to the suggestion that postprandial amphibians and reptiles regulate pHa rather than PaCO2.Here we characterize blood gases in the South American rattlesnake (Crotalus durissus) during digestion and following systemic infusions of NaHCO3 and HCl in fasting animals to induce a metabolic alkalosis or acidosis in fasting animals. The magnitude of these acid-base disturbances were similar in magnitude to that mediated by digestion and exercise. Plasma [HCOT] increased from 18.4+/-1.5 to 23.7+/-1.0 mmol L-1 during digestion and was accompanied by a respiratory compensation where PaCO2 increased from 13.0+/-0.7 to 19.1+/-1.4 mm Hg at 24 h. As a result, pHa decreased slightly, but were significantly below fasting levels 36 h into digestion. Infusion of NaHCO3 (7 mmol kg(-1)) resulted in a 10 mmol L-1 increase in plasma [HCO3-] within 1 h and was accompanied by a rapid elevation of pHa (from 7.58+/-0.01 to 7.78+/-0.02). PaCO2, however, did not change following HCO3- infusion, which indicates a lack of respiratory compensation. Following infusion of HCl (4 mmol kg(-1)), plasma pHa decreased by 0.07 units and [HCO3-](pl) was reduced by 4.6 mmol L-1 within the first 3 h. PaCO2, however, was not affected and there was no evidence for respiratory compensation.Our data show that digesting rattlesnakes exhibit respiratory compensations to the alkaline tide, whereas artificially induced metabolic acid-base disturbances of same magnitude remain uncompensated. It seems difficult to envision that the central and peripheral chemoreceptors would experience different stimuli during these conditions. One explanation for the different ventilatory responses could be that digestion induces a more relaxed state with low responsiveness to ventilatory stimuli. (C) 2005 Elsevier B.V. All rights reserved.

Randomized, Double-Blind Trial of the Effect of Fluid Composition on Electrolyte, Acid-Base, and Fluid Homeostasis in Patients Early After Subarachnoid Hemorrhage.

Hyper- and hyponatremia are frequently observed in patients after subarachnoidal hemorrhage, and are potentially related to worse outcome. We hypothesized that the fluid regimen in these patients is associated with distinct changes in serum electrolytes, acid-base disturbances, and fluid balance.

Metabolic acidosis in patients with severe sepsis and septic shock: A longitudinal quantitative study

Objective: To describe the composition of metabolic acidosis in patients with severe sepsis and septic shock at intensive care unit admission and throughout the first 5 days of intensive care unit stay. Design: Prospective, observational study. Setting: Twelve-bed intensive care unit. Patients: Sixty patients with either severe sepsis or septic shock. Interventions: None. Measurements and Main Results: Data were collected until 5 days after intensive care unit admission. We studied the contribution of inorganic ion difference, lactate, albumin, phosphate, and strong ion gap to metabolic acidosis. At admission, standard base excess was -6.69 +/- 4.19 mEq/L in survivors vs. -11.63 +/- 4.87 mEq/L in nonsurvivors (p < .05); inorganic ion difference (mainly resulting from hyperchloremia) was responsible for a decrease in standard base excess by 5.64 +/- 4.96 mEq/L in survivors vs. 8.94 +/- 7.06 mEq/L in nonsurvivors (p < .05); strong ion gap was responsible for a decrease in standard base excess by 4.07 +/- 3.57 mEq/L in survivors vs. 4.92 +/- 5.55 mEq/L in nonsurvivors with a nonsignificant probability value; and lactate was responsible for a decrease in standard base excess to 1.34 +/- 2.07 mEq/L in survivors vs. 1.61 +/- 2.25 mEq/L in nonsurvivors with a nonsignificant probability value. Albumin had an important alkalinizing effect in both groups; phosphate had a minimal acid-base effect. Acidosis in survivors was corrected during the study period as a result of a decrease in lactate and strong ion gap levels, whereas nonsurvivors did not correct their metabolic acidosis. In addition to Acute Physiology and Chronic Health Evaluation 11 score and serum creatinine level, inorganic ion difference acidosis magnitude at intensive care unit admission was independently associated with a worse outcome. Conclusions: Patients with severe sepsis and septic shock exhibit a complex metabolic acidosis at intensive care unit admission, caused predominantly by hyperchloremic acidosis, which was more pronounced in nonsurvivors. Acidosis resolution in survivors was attributable to a decrease in strong ion gap and lactate levels. (Crit Care Med 2009; 37:2733-2739)

Factors affecting metabolic and electrolyte changes after reperfusion in liver transplantation

Background. The metabolic and electrolyte changes were evaluated after various durations of cold and warm ischemia times to correlate ASA status with hemodynamic changes that may affect the severity of the reperfusion syndrome.Patients and methods. Sixty-one patients who underwent liver transplantation (OLT) were monitored by arterial pH, PaO2, PaCO2, HCO3, BE, K+, Ca2+, Na+, GL, and serial Ht at three specific times: after the skin incision (baseline), 10 minutes before reperfusion (T-2), and 10 minutes after reperfusion (T-3). Changes in metabolic parameters were correlated with ASA status, hemodynamic changes, time of OLT, as well as cold and warm ischemia times.Results. The pH in ASA IV patients was significantly lower at T-1 and T-3, and PCO2 higher in ASA V at T-1. A significant correlation was observed between pH, PaCO2, HCO3 BE, Na+, Ca2+, and glucose with the phase of the procedure. The pH and HCO3 decreased significantly from T-1 and T-2, increasing during T-3. Ca2+ fell from T-1 to T-2 increasing in T-3. Mean glucose and sodium levels increase from T-1 to T-3. Mean BE dropped from T-1 to T-2 and increased at T-3 without a significant correlation between the metabolic parameters in any phase of the study and the cold or warm ischemia times. Patients with a high ASA status showed an increased risk for cardiovascular collapse after reperfusion.Conclusions. Patients with advanced ASA status are more prone to metabolic and acid-base disturbances during reperfusion, without any relation to the cold or warm ischemia times. High ASA status shows an increased risk for cardiovascular collapse after reperfusion.

Equilíbrio eletrolítico como estratégia nutricional para prevenir queda no desempenho de poedeiras comerciais em condições de alta temperatura

Pós-graduação em Ciência e Tecnologia Animal - FEIS

Ischemic muscle necrosis leading to life-threatening hyperkalemia. Case report and review of the literature

Objective: Description of a cat with ischemic muscle necrosis that suffered from cardiopulmonary arrest due to hyperkalemia. Pathogenesis, clinical signs and therapy of ischemic muscle necrosis are discussed and possible causes, symptoms and treatment of hyperkalemia are shown. Material and methods: case report of a four-year-old male castrated domestic shorthair cat. Results: The cat was successfully resuscitated and hyperkalemia was treated with different treatment modalities. Conclusion: Ischemic muscle necrosis can lead to severe live-threatening hyperkalemia which has to be anticipated, monitored and treated adequately. Aggressive fluid therapy might be responsible for a higher risk of hyperkalemia in predisposed cases. Clinical relevance: Potassium concentrations and acid-base disturbances must be closely monitored in patients with ischemic muscle necrosis

Transient Fanconi syndrome with severe polyuria and polydipsia in a 4-year old Shih Tzu fed chicken jerky treats.

Acquired Fanconi syndrome is characterized by inappropriate urinary loss of amino acids, bicarbonate, electrolytes, and water. It has recently been described in dogs fed chicken jerky treats from China, a new differential diagnosis to the classical inciting infectious diseases (e.g. leptospirosis, pyelonephritis) and toxins. A dog fed exclusively chicken jerky treats purchased in Switzerland was presented to our clinic with severe polyuria, polydipsia and profound electrolyte and acid base disturbances. Other inciting causes of Fanconi syndrome were ruled out. The requirement of a very intensive supportive treatment in this dog stands in contrast to treatment of chronic forms of Fanconi syndrome as described in the Basenji. This intensive therapy and the associated monitoring can be a real challenge and a limiting factor for the prognosis of acquired Fanconi syndrome. Veterinarians should be aware of the risk of excessive feeding of chicken jerky treats.

Localization of ion-regulatory epithelia in embryos and hatchlings of two cephalopods

The tissue distribution and ontogeny of Na+/K+-ATPase has been examined as an indicator for ion-regulatory epithelia in whole animal sections of embryos and hatchlings of two cephalopod species: the squid Loligo vulgaris and the cuttlefish Sepia officinalis. This is the first report of the immunohistochemical localization of cephalopod Na+/K+-ATPase with the polyclonal antibody alpha (H-300) raised against the human alpha1-subunit of Na+/K+-ATPase. Na+/K+-ATPase immunoreactivity was observed in several tissues (gills, pancreatic appendages, nerves), exclusively located in baso-lateral membranes lining blood sinuses. Furthermore, large single cells in the gill of adult L. vulgaris specimens closely resembled Na+/K+-ATPase-rich cells described in fish. Immunohistochemical observations indicated that the amount and distribution of Na+/K+-ATPase in late cuttlefish embryos was similar to that found in juvenile and adult stages. The ion-regulatory epithelia (e.g., gills, excretory organs) of the squid embryos and paralarvae exhibited less differentiation than adults. Na+/K+-ATPase activities for whole animals were higher in hatchlings of S. officinalis (157.0 ± 32.4 µmol/g FM/h) than in those of L. vulgaris (31.8 ± 3.3 µmol/g FM/h). S. officinalis gills and pancreatic appendages achieved activities of 94.8 ± 18.5 and 421.8 ± 102.3 µmol ATP/g FM/h, respectively. High concentrations of Na+/K+-ATPase in late cephalopod embryos might be important in coping with the challenging abiotic conditions (low pH, high pCO2) that these organisms encounter inside their eggs. Our results also suggest a higher sensitivity of squid vs. cuttlefish embryos to environmental acid-base disturbances.

Exact Tests for Contemporaneous Correlation of Disturbances in Seemingly Unrelated Regressions.

This paper proposes finite-sample procedures for testing the SURE specification in multi-equation regression models, i.e. whether the disturbances in different equations are contemporaneously uncorrelated or not. We apply the technique of Monte Carlo (MC) tests [Dwass (1957), Barnard (1963)] to obtain exact tests based on standard LR and LM zero correlation tests. We also suggest a MC quasi-LR (QLR) test based on feasible generalized least squares (FGLS). We show that the latter statistics are pivotal under the null, which provides the justification for applying MC tests. Furthermore, we extend the exact independence test proposed by Harvey and Phillips (1982) to the multi-equation framework. Specifically, we introduce several induced tests based on a set of simultaneous Harvey/Phillips-type tests and suggest a simulation-based solution to the associated combination problem. The properties of the proposed tests are studied in a Monte Carlo experiment which shows that standard asymptotic tests exhibit important size distortions, while MC tests achieve complete size control and display good power. Moreover, MC-QLR tests performed best in terms of power, a result of interest from the point of view of simulation-based tests. The power of the MC induced tests improves appreciably in comparison to standard Bonferroni tests and, in certain cases, outperforms the likelihood-based MC tests. The tests are applied to data used by Fischer (1993) to analyze the macroeconomic determinants of growth.

DESCRIPCIÓN DEL ESTADO ÁCIDO BASE POR MODELO DE STEWART EN PACIENTES POSTOPERATORIO DE TRASPLANTE HEPÁTICO

Introducción: Los pacientes en postoperatorio de trasplante hepático presentan múltiples cambios hemodinámicos y alteraciones hidroelectrolíticas que generan cambios en el estado ácido base. El presente trabajo, busca describir el comportamiento ácido base en pacientes pos trasplante hepático, a través del análisis del modelo de Stewart, enfocado en la búsqueda etiológica de cada trastorno y planteando posibles formas de optimizar el manejo en Cuidado Intensivo (CI). Metodología: Estudio observacional, descriptivo histórico de los gases arteriales de los pacientes en post operatorio de trasplante hepático por cualquier causa, interpretados por método de Stewart. Se realizó con el universo de pacientes ingresados en el año 2014 en la Fundación Santa Fe de Bogotá. Resultados: Ingresaron en total 24 pacientes al estudio, entre el 1 de enero al 31 de septiembre de 2014. La mediana de pH fue de 7.36 con un valor mínimo de 7.05 y el máximo de 7.49. El 41% de los pacientes al ingreso a cuidado intensivo tenían lactato normal (menor a 2), y el 88% tenían niveles de albumina bajos. El trastorno electrolítico más común fue hipercloremia (58%), seguido de hipomagnesemia (25%). Conclusiones. El análisis de gases arteriales por el modelo de Stewart permite realizar un diagnóstico de un trastorno específico y adicionalmente, permite buscar la etiología del trastorno. Esta serie de casos mostró que el 95% de los pacientes tenían algún trastorno metabólico al ingreso, siendo el más frecuente la acidosis metabólica (66%).

Robust Control of Systems Subjected to Uncertain Disturbances and Actuator Dynamics

Esta tesis está enfocada al diseño y validación de controladores robustos que pueden reducir de una manera efectiva las vibraciones structurales producidas por perturbaciones externas tales como terremotos, fuertes vientos o cargas pesadas. Los controladores están diseñados basados en teorías de control tradicionalamente usadas en esta area: Teoría de estabilidad de Lyapunov, control en modo deslizante y control clipped-optimal, una técnica reciente mente introducida : Control Backstepping y una que no había sido usada antes: Quantitative Feedback Theory. La principal contribución al usar las anteriores técnicas, es la solución de problemas de control estructural abiertos tales como dinámicas de actuador, perturbaciones desconocidas, parametros inciertos y acoplamientos dinámicos. Se utilizan estructuras típicas para validar numéricamente los controladores propuestos. Especificamente las estructuras son un edificio de base aislada, una plataforma estructural puente-camión y un puente de 2 tramos, cuya configuración de control es tal que uno o mas problemas abiertos están presentes. Se utilizan tres prototipos experimentales para implementar los controladores robustos propuestos, con el fin de validar experimentalmente su efectividad y viabilidad. El principal resultado obtenido con la presente tesis es el diseño e implementación de controladores estructurales robustos que resultan efectivos para resolver problemas abiertos en control estructural tales como dinámicas de actuador, parámetros inciertos, acoplamientos dinámicos, limitación de medidas y perturbaciones desconocidas.

The counter-propagating Rossby-wave perspective on baroclinic instability. Part III: Primitive-equation disturbances on the sphere

Baroclinic instability of perturbations described by the linearized primitive quations, growing on steady zonal jets on the sphere, can be understood in terms of the interaction of pairs of counter-propagating Rossby waves (CRWs). The CRWs can be viewed as the basic components of the dynamical system where the Hamiltonian is the pseudoenergy and each CRW has a zonal coordinate and pseudomomentum. The theory holds for adiabatic frictionless flow to the extent that truncated forms of pseudomomentum and pseudoenergy are globally conserved. These forms focus attention on Rossby wave activity. Normal mode (NM) dispersion relations for realistic jets are explained in terms of the two CRWs associated with each unstable NM pair. Although derived from the NMs, CRWs have the conceptual advantage that their structure is zonally untilted, and can be anticipated given only the basic state. Moreover, their zonal propagation, phase-locking and mutual interaction can all be understood by ‘PV-thinking’ applied at only two ‘home-bases’—potential vorticity (PV) anomalies at one home-base induce circulation anomalies, both locally and at the other home-base, which in turn can advect the PV gradient and modify PV anomalies there. At short wavelengths the upper CRW is focused in the mid-troposphere just above the steering level of the NM, but at longer wavelengths the upper CRW has a second wave-activity maximum at the tropopause. In the absence of meridional shear, CRW behaviour is very similar to that of Charney modes, while shear results in a meridional slant with height of the air-parcel displacement-structures of CRWs in sympathy with basic-state zonal angular-velocity surfaces. A consequence of this slant is that baroclinically growing eddies (on jets broader than the Rossby radius) must tilt downshear in the horizontal, giving rise to up-gradient momentum fluxes that tend to accelerate the barotropic component of the jet.

Desacoplamento de um gerador síncrono através de um controle adaptativo por modelo de referência baseado em funções de Base radial

An alternative nonlinear technique for decoupling and control is presented. This technique is based on a RBF (Radial Basis Functions) neural network and it is applied to the synchronous generator model. The synchronous generator is a coupled system, in other words, a change at one input variable of the system, changes more than one output. The RBF network will perform the decoupling, separating the control of the following outputs variables: the load angle and flux linkage in the field winding. This technique does not require knowledge of the system parameters and, due the nature of radial basis functions, it shows itself stable to parametric uncertainties, disturbances and simpler when it is applied in control. The RBF decoupler is designed in this work for decouple a nonlinear MIMO system with two inputs and two outputs. The weights between hidden and output layer are modified online, using an adaptive law in real time. The adaptive law is developed by Lyapunov s Method. A decoupling adaptive controller uses the errors between system outputs and model outputs, and filtered outputs of the system to produce control signals. The RBF network forces each outputs of generator to behave like reference model. When the RBF approaches adequately control signals, the system decoupling is achieved. A mathematical proof and analysis are showed. Simulations are presented to show the performance and robustness of the RBF network