Acid-Base Disturbance Analysis: Comparison of the Traditional and Stewart Approaches

Introduction: The new approach to acid-base balance which initially proposed by Stewart in 1978 was success to provide a new insight which more easy to understand what is the cause, the mechanism and the degree of acid-base disturbance. The purpose of the present study was to compare two different methods of analysis acid-base disturbance in patients admitted to Pediatric Intensive Care Unit (PICU). Methods: The study was performed in 43 patients admitted to the pediatric intensive care unit of Cipto Mangunkusumo Hospital, Jakarta. Sodium, potassium, chloride, albumin, lactate and arterial blood gases were measured. All samples were taken from artery in every patient. The anion gap (AG) was calculated using the Narins method (1977), the corrected anion gap (AGcorr) using the Moviat method (2003), the strong ion gap (SIG) using Kellum method (1995) and the base excess unmeasured anions (BEUA) using the Fencl-Stewart method simplifi ed by Story (2003). Results: The presence of unmeasured ions identifi ed by signifi cantly abnormal BEUA was poorly identifi ed by SBE. Of the 43 patients included in the study, 18 (41.9%) had a different interpretation of acid-base balance when the Fencl-Stewart method was used compared to using SBE. There was good correlation between SIG and AG (r =0.831), and there was excellent correlation between SIG and AGcorr (r =0.991). Conclusions: In the condition of electrolyte unbalance and hypoalbuminemia the Stewart approach is better than the traditional approach. Nevertheless, the calculation of SIG is more timeconsuming, therefore the corrected anion gap (AGcorr) was suggested to use in clinical practice as a combination with SBE.


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Extra-Pulmonary Sarcoidosis: Neurosarcoidosis - Case Presentation and Literature Review

More than a century after the description of sarcoidosis, the disease remains not well understood. Sarcoidosis is an infl ammatory disease of unknown etiology characterized by noncaseating granulomas with multiple organs affected. The epidemiology reveals lung involvement in 90- 95% of the patients and just 5-13% incidence of neurological involvement. We present an unusual case of a patient with medulla oblongata and retroperitoneal sarcoidosis with no other organ involvement. In addition to the case presentation and extensive up-to-date literature review on extrapulmonary sarcoidosis, we describe the diffi culties in making the diagnosis and the challenge in differentiating sarcoidosis from other illnesses such as tuberculosis.


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Non Infectious Pulmonary Complications after Bone Marrow Transplant with a Special Focus on Idiopathic Pneumonia Syndrome

Pulmonary complications are a signifi cant cause of early mortality (up to 100 days) after hematopoietic stem cell transplantation (HSCT). While infectious complications particularly due to opportunistic pathogens are common in these patients, diffuse lung injury is a non-infectious complication occurring in 25-50% of HSCT recipients. The incidence of this complication is higher with allogeneic as apposed to autologous transplants and is largely dependant on the method of graft versus host prophylaxis. The spectrum includes interstitial pneumonitis (IP), bronchiolitis obliterans (BO), diffuse alveolar hemorrhage (DAH) and noncardiogenic capillary leak syndrome (NCLS). In 1993 a panel convened by the National Institutes of Health (NIH) defi ned widespread alveolar injury following HSCT that occurs in the absence of an active lower respiratory tract infection and cardiogenic causes as the idiopathic pneumonia syndrome (IPS). IPS is a clinical syndrome with variable histopathologic correlates and several potential etiologies. Peri-engraftment respiratory distress syndrome (PERDS) and delayed pulmonary toxicity syndrome (DPTS) are also included within the defi nition of IPS. Histopathologic fi ndings associated with IPS include diffuse alveolar damage with hyaline membranes, lymphocytic bronchitis and bronchiolitis obliterans organizing pneumonia (BOOP). The pathophysiology involves four distinct mechanisms, namely: the toxic effects of chemotherapy, immune dysregulation, alloreactive donor cells and host cell responses. The roles of lipopolysaccharide (LPS), monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor (TNF) in the genesis of endothelial cell injury are being defi ned. Therapy for IPS includes supportive care and immunosuppressive agents. The role of TNF antagonists is being studied in ongoing clinical trials.


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