Cardiac response is greater for colloid than saline fluid loading after cardiac or vascular surgery

OBJECTIVE

To study the effects on volume expansion and myocardial function of colloids or crystalloids in the treatment of hypovolaemic hypotension after cardiac and major vascular surgery.

DESIGN AND SETTING

A single-centre, single-blinded, randomized clinical trial at the intensive care unit of a university hospital.

PATIENTS AND METHODS

Patients (n=67) were subjected to a 90-min filling pressure-guided fluid challenge with saline 0.9% or the colloids gelatin 4%, hydroxyethyl starch 6% or albumin 5%. Biochemical variables and haemodynamics (transpulmonary thermodilution) were measured.

RESULTS

An amount of 1800 (1300-1800) ml of saline or 1600 (750-1800) ml of colloid solution (P< 0.005) was infused. Colloid osmotic pressure (COP) decreased in the saline group and increased in the colloid groups (P< 0.001). Plasma volume increased by 3.0% (-18 to 24) in the saline versus 19% (-11 to 50) in the colloid groups (P< 0.001). Cardiac index increased by median 13% (ns) in the saline group and by 22% in the colloid groups (P<0.005). The rise in left ventricular stroke work index was greater in the colloid than in the saline groups. The different colloids were equally effective. The rise in cardiac index related to the rise in plasma volume and global end-diastolic volume, confirming plasma volume and preload augmentation by the fluid loading.

CONCLUSION

After cardiac or major vascular surgery, the pressure- and time-guided fluid response is dependent on the type of fluid used. Colloid fluid loading leads to a greater increase in preload-recruitable cardiac and left ventricular stroke work indices than that with saline, because of greater plasma volume expansion following an increase in plasma COP.

“Survivre au sepsis”: où en sommes-nous?

The mortality induced by severe sepsis and septic shock remains very elevated despite progress in diagnosis and treatment. All the experts in the field consider that further progress is possible with better and more prompt use of the treatments now available. The "Surviving Sepsis" campaign reviews the diverse treatments that can be used and the best ways to prescribe them. It also proposes two bundles of objectives to be completed systematically for all patients: the first within the first 6 hours, the second between the sixth and 24th hour. Encouraging results show that applying these therapeutic principles can reduce mortality by 30% (relative percentage) compared with a treatment without specific objectives.

Volume resuscitation: crystalloid versus colloid

Adequate circulating volume to maintain mean arterial blood pressure above a critical value is necessary to reverse bradycardia by positive-pressure ventilation during resuscitation after asphyxia. A variety of circumstances can lead to visible or occult blood loss in the perinatal period; however, distinguishing hypovolemic shock from asphyxial shock can be difficult in the delivery room. Small, randomized, controlled trials support the usefulness of isotonic crystalloid rather than albumin-containing solutions for acute volume expansion; ready availability, lower cost, and lesser risk of infectious complications favor the use of isotonic crystalloid as well. No trials have compared crystalloid and colloid for volume expansion in the setting of immediate resuscitation after birth. Further work is needed to refine the approach to infants in whom adequate positive-pressure ventilation fails and to better discriminate between shock on the basis of hypovolemia versus decreased myocardial function.

Limitations of the hematocrit level to assess the need for red blood cell transfusion in hypovolemic anemic patients

BACKGROUND

The transfusion trigger that physicians use to determine whether a patient requires a red blood cell (RBC) transfusion is the peripheral venous hematocrit (Hct) value. Although this measurement is an indicator of the concentration of RBCs in the blood, it does not reveal the RBC volume, plasma volume, or total blood volume, nor does it give any indication of whether the patient is hypovolemic, normovolemic, or hypervolemic.

STUDY DESIGN AND METHODS

Two patient populations were studied: 41 consecutive patients subjected to elective vascular surgery and 20 consecutive patients subjected to cardiopulmonary bypass surgery. The RBC volume was measured with (51)Cr- or (99m)Tc-labeled autologous fresh RBCs, and the plasma volume and total blood volume were estimated from the measured RBC volume and the total body Hct level. Measurements made 1 to 2 and 24 hours after surgery were compared to the preoperative values for these two groups of patients.

RESULTS

During the 24-hour postoperative period, the RBC, plasma, and total blood volumes were reduced compared to the preoperative volumes. These patients were hypovolemic and anemic, and their Hct values during the 24-hour postoperative period were increased by a mean of 4 to 5 volume-percent compared to values that would be expected if they were normvolemic and anemic.

CONCLUSIONS

The Hct values in hypovolemic anemic patients are elevated because the plasma volume does not increase to achieve the normovolemic anemic state.

DO PLASMA SUBSTITUTES HAVE ADDITIONAL PROPERTIES BEYOND CORRECTING VOLUME DEFICITS?

The best strategy for volume therapy has been the focus of debate and there are still no unique accepted guidelines. There is increasing evidence that some plasma substitutes possess additional effects on organ perfusion, microcirculation, tissue oxygenation, inflammation, endothelial activation, capillary leakage, and tissue edema that are beyond their volume replacing properties. Whether the different plasma substitutes differ with regard this additional effects was reviewed. The additional effects of plasma substitutes have mostly been studied experimentally or in animals, much less results are available in humans. The results are not uniform ranging from beneficial to even detrimental effects of a certain volume replacement strategy. Some important results from the literature are not reflected in the actual recommendations for treating volume deficits in the critically ill: although crystalloids have been shown to have considerable negative effects on microcirculation, organ perfusion, tissue oxygenation, and endothelial integrity, they are still often recommended as first choice volume replacement strategy. In several experimental studies hypertonic solutions have been shown to have various beneficial effects, they have not been, however, translated into humans. In future, the choice of the ideal volume replacement regimen should not only be focused on its volume restoring properties, but additional effects (e.g. on organ perfusion on, tissue oxygenation, inflammation, endothelial activation, capillary leakage) should also be taken into account when treating hypovolemia in the critically ill.

Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better?

BACKGROUND/AIMS

Severe acute pancreatitis is associated with microcirculatory impairment, increased gut permeability and metabolic changes. The aim of the present study was to evaluate initial fluid resuscitation and nutritional support versus outcome in patients with severe acute pancreatitis.

METHODS

All cases of acute pancreatitis admitted 1994-2003 were analyzed retrospectively. The inclusion criteria of severe acute pancreatitis were organ failure and/or local complications according to the Atlanta classification system. Mortality was used as outcome measure.

RESULTS

Ninty-nine patients were included in the study. The hospital mortality was 17%. Hypovolemia at arrival was found in 13% (13/99) and correlated with increased hospital mortality (P=0.009). During the first three days in average 11000+/-4100 ml of fluids and 1470+/-820 calories were administered. Total parental nutrition was given to 73% (69/95) and enteral nutrition served as a complement in 29% (28/95) of the patients. Hyperglycemia was seen in 61% (55/90) of the patients and insulin was administered to 53% (29/55) at an average glucose level of 19+/-3 mmol/l. The intake of oral food was reintroduced in average 15+/-9 days after admission and was interrupted in 17% (13/75) because of pain relapse.

CONCLUSION

A nutritional treatment regime in severe acute pancreatitis including a moderate and hypocaloric initial fluid resuscitation, parental nutrition as the preferred route for nutritional support and a non-strict glucose control, with an associated mortality of 17%, indicates several modes of improving outcome.

Forderungen und Erwartungen an einen optimalen Volumenersatz

A volume replacement should compensate a reduction in the intravascular volume and counteract a hypovolemia so that hemodynamics and vital functions can be maintained. For this therapy, a physiologically-based solution comprising both osmotically and colloid osmotically active components should be administered. A consensus is proposed for this purpose which takes into consideration the following aspects: The optimum colloid, the questionable use of albumin, the physiological electrolyte pattern encompassing sodium, potassium, chloride and phosphate and their contributions to osmolality, an eventual addition of glucose, the physiological acid-base status with bicarbonate or alternately with metabolisable anions, and the importance of a clear declaration of all ingredients. The consensus distinguishes between compulsory requirements derived from evidence-based medicine and physiological data and the potential expectations of an optimal volume replacement, including well-grounded wishes and aspirations for the future.

Optimizing the fluid management of ventilated patients with suspected hypovolaemia

Fluid management is a vital component of patient care within the critical care setting; it has a range of indications and applications, one of the most important being to maintain tissue perfusion and safeguard against single/multiple organ failure. Hypovolaemia is a commonly encountered condition within critical care and has the potential to jeopardize tissue perfusion and accelerate the risk of organ failure. In an attempt to optimize the fluid management of patients within the intensive therapy unit, this article outlines the development and implementation of a fluid prescription for ventilated patients with suspected hypovolaemia.

Short- and Long-Term Outcomes of Spontaneous CSF Hypovolemia

We undertook a study to investigate the short- and long-term outcomes of spontaneous CSF hypovolemia. Fifty-three consecutive patients with spontaneous CSF hypovolemia were included. Short-term outcome was assessed 4 weeks after the treatment in all patients. Long-term outcome after a mean follow-up of 61 months (range, 13-101 months) was evaluated in 26 patients. There were 18 men and 35 women (66%) with an age range of 22-64 years (mean 37 +/- 9.5). In assessing the short-term outcome of CSF hypovolemia, we found that complete headache relief was significantly higher in 43 patients who received epidural blood patch (EBP) than in 10 patients treated with supportive measures (p < 0.05). After a mean follow-up of 61 months, 25 (96%) of the 26 patients evaluated for long-term outcome had complete headache relief. These results suggest that EBP is safe and effective, resulting in excellent short- and long-term outcomes of CSF hypovolemia.

[Indications for use of labile blood products and the physiology of blood transfusion in medicine. The French Agency for the Health Safety of Health Products]

This article presents the French national recommendations for the use of blood products in medicine.

Progressive Toxemia with Acetaldehyde in a Reactive Form of Alcohol Withdrawal Syndrome

We carried out a complex clinical and laboratory examination of 169 patients with reactive form of alcohol withdrawal syndrome. Progressive toxemia with acetaldehyde (key pathogenetic stage) and volemic changes were followed by homeostasis disorders and gradual decompensation of the natural detoxification system. The patients with this form of alcohol withdrawal syndrome did not exhibit physical and psychic dependence on alcohol. The proposed therapeutic algorithm for the treatment of various pathogenetic stages rapidly and efficiently restored homeostasis parameters and prevented the development of serious and life-threating complications.

Comparison of a small volume of hypertonic saline solution and dextran 40 on hemodynamic alternations in conscious calves

The hemodynamic effects of rapid intravenous (IV) administration of 10% dextran 40 in saline solution (D40) and 7.2% hypertonic saline solution (HSS) in calves were compared. Calves received isotonic saline solution (ISS), HSS or D40 (3 calves/group) and were monitored of blood pressure, and cardiac output (CO) for 180 min. HSS and D40 infusions induced a significant increase in relative plasma volume reaching 134.9+/-2.8 and 125.0+/-1.9%, respectively at the end of fluid infusion. In the HSS group, CO, cardiac index (CI) and stroke volume (SV) remained constant at low levels after 90 minutes despite the maximal values of CO, CI and SV at the end of infusion, reaching 21.0+/-6.3 l/min (p<0.05), 177.8+/-14.2 ml/min/kg (p<0.001) and 0.20+/-0.03 l/beat (at t=10 min, p<0.001), respectively. In contrast, CI and SV in the D40 group showed significant increases to 14.7+/-2.9 l/min and 153.5+/-17.2 ml/min/kg, respectively, at the end of fluid infusion. And those values remained constant at higher levels than those of the before infusions values throughout the experimental periods. Positive effects for hemodynamic alternations of D40 in calf practice were milder and longer than those of HSS. Therefore, the D40 infusion should be explored as a possible treatment for dehydrated calves, since rapid infusion of D40 may be safe and more beneficial for rehydrating more than HSS treatment.

Bench-to-bedside review: oxygen debt and its metabolic correlates as quantifiers of the severity of hemorrhagic and post-traumatic shock

Evidence is increasing that oxygen debt and its metabolic correlates are important quantifiers of the severity of hemorrhagic and post-traumatic shock and and may serve as useful guides in the treatment of these conditions. The aim of this review is to demonstrate the similarity between experimental oxygen debt in animals and human hemorrhage/post-traumatic conditions, and to examine metabolic oxygen debt correlates, namely base deficit and lactate, as indices of shock severity and adequacy of volume resuscitation. Relevant studies in the medical literature were identified using Medline and Cochrane Library searches. Findings in both experimental animals (dog/pig) and humans suggest that oxygen debt or its metabolic correlates may be more useful quantifiers of hemorrhagic shock than estimates of blood loss, volume replacement, blood pressure, or heart rate. This is evidenced by the oxygen debt/probability of death curves for the animals, and by the consistency of lethal dose (LD)_25,50 points for base deficit across all three species. Quantifying human post-traumatic shock based on base deficit and adjusting for Glasgow Coma Scale score, prothrombin time, Injury Severity Score and age is demonstrated to be superior to anatomic injury severity alone or in combination with Trauma and Injury Severity Score. The data examined in this review indicate that estimates of oxygen debt and its metabolic correlates should be included in studies of experimental shock and in the management of patients suffering from hemorrhagic shock.

Use of volume expansion during delivery room resuscitation in near-term and term infants

OBJECTIVE

To characterize use of volume infusion (VI) for infants who are > or =34 weeks' gestational age and receive intensive cardiopulmonary resuscitation (CPR; defined as >1 minute of positive-pressure ventilation and chest compressions, with or without the administration of medications) in the delivery room and are admitted to the NICU.

METHODS

A retrospective review of a resuscitation registry between January 1999 and June 2001 was conducted.

RESULTS

Of 37,972 infants, 23 received CPR, including 13 with VI. Ten of 13 received VI for persistent bradycardia despite CPR, and only 3 of 13 received VI for suspicion of hypovolemia with poor perfusion. More VI versus no VI infants had Apgar scores < or =2 at 5 and 10 minutes. VI versus no VI infants had lower cord arterial pH, had higher arterial partial pressure of carbon dioxide, had larger base deficit, required longer CPR, and required more epinephrine. On admission to the NICU, VI versus no VI infants had lower blood pressure and larger base deficit over the first 2 hours but did not differ in arterial pH, arterial partial pressure of carbon dioxide, heart rate, mortality, or use of additional VI or buffer.

CONCLUSIONS

VI is rarely given for overt hypovolemia and more often for asphyxiated infants who are slow to respond to intensive CPR. Persistent postnatal hypotension in VI infants suggests that other factors, eg, myocardial dysfunction, may be important contributors to lack of response to CPR.

Rapid fluid infusion therapy decreases the plasma concentration of continuously infused propofol

BACKGROUND

Rapid fluid infusion therapy to treat hypovolemia in anesthetized patients is a common practical regimen in daily clinical settings. This study investigated the effect of large volume loading on the plasma concentration of propofol (Cp), hemodynamic parameters, hemoglobin concentration (Hb), hematocrit value (Ht) and the bispectral index (BIS).

METHODS

Sixty patients were administered propofol using a target-controlled infusion technique. We studied two independent groups. Half of the patients (group F, n = 30) were administered fentanyl, and the other half (group E, n = 30) epidural administration of mepivacaine for analgesia. After achieving a pseudo-steady state of propofol anesthesia, baseline values of blood pressure, heart rate, Hb, Ht, cardiac output, Cp and BIS were measured, and 10 ml/kg Ringer's solution was infused over 15 min.

RESULTS

In group F, Cp was significantly decreased from 2.24 (0.69) [mean (SD)] to 2.07 (0.61) microg/ml and in group E from 2.02 (0.98) to 1.75 (0.51) microg/ml immediately after infusion (P < 0.05). The significant reduction lasted until 30 min in group F, whereas, Cp quickly recovered in group E. Cardiac output was increased only in group F. The dilution ratio demonstrated the prolonged diluting effect in group E and the significant correlation with the rate of decrease in Cp (P < 0.0003, R = 0.21). The BIS value showed no significant change immediately after infusion.

CONCLUSION

Large volume loading decreased Cp without a significant change in BIS values. The effect of infusion therapy on the depth of anesthesia might be small and usually negligible during propofol anesthesia.

Pre-transfusion management of children with severe malarial anaemia: a randomised controlled trial of intravascular volume expansion

Symptomatic severe malarial anaemia (SMA) has a high fatality rate of 30-40%; most deaths occur in children awaiting blood transfusion. Blood transfusion services in most of Africa are not capable of delivering adequate supplies of safe blood in a timely manner to critically ill children with SMA. Contrary to widely held belief, hypovolaemia, rather than heart failure, has emerged as a common complication in such children. We examined the safety of pre-transfusion management (PTM) by volume expansion, aimed at stabilizing children and obviating the urgency for blood transfusion. Kenyan children with severe falciparum anaemia (haemoglobin <5 g/dl) and respiratory distress were randomly assigned to 20 ml/kg of 4.5% albumin or 0.9% saline or maintenance only (control) while awaiting blood transfusion. PTM was apparently safe since it did not lead to the development of pulmonary oedema or other adverse events. There was no significant difference in the primary outcome [mean percentage reduction in base excess between admission and 8 h (95% confidence interval)] between the control group 42% (19-66%) albumin group 44% (32-57%) and saline group 36% (16-57%); adjusted analysis of variance F=0.31, P=0.7. However, the number of children requiring emergency interventions was significantly greater in the control group, four of 18 (22%) than the saline group 0 of 20 (P=0.03). We have established the safety of this PTM in children with SMA whilst awaiting blood transfusion at a hospital with an adequate blood-banking program. The impact on mortality should be assessed where blood transfusion services are unable to supply emergency transfusions.

Kinetics of liposome-encapsulated hemoglobin after 25% hypovolemic exchange transfusion

Liposome-encapsulated hemoglobin (LEH) is being developed as an oxygen therapeutic. In this work, we evaluated a neutral formulation of PEGylated LEH for its circulation and distribution properties in rodent models of 25% hypovolemic exchange transfusion. About 25% of blood in rats and rabbits was exchanged with LEH that had been previously labeled with 99mTc radionuclide. The distribution of 99mTc-LEH was followed by gamma camera imaging and intermittent blood sampling during 48 h, and counting the tissue-associated radioactivity after necropsy at 48 h. On the basis of circulation kinetics, the half-life of 99mTc-LEH in blood was 30 and 39.8 h in rats and rabbits, respectively. Apart from blood, major organs of accumulation of LEH after 48 h included liver (rats, 10.3% and rabbits, 5.4% of injected dose) and spleen (rats, 2.4% and rabbits, 0.8% of injected dose). The results demonstrate that LEH circulates for a prolonged time after administration and that the animals tolerate at least 25% of blood exchange without any distress. Subsequent to the enhanced uptake in the RES, the rats clear LEH from the circulation faster than the rabbits.

Complete left-sided absence of the pericardium in association with ruptured type A aortic dissection complicated by severe left hemothorax

We report an unusual clinical presentation of an acute type A aortic dissection as a left hemothorax in a patient with a congenital pericardial defect. Although the pericardial defect was diagnosed preoperatively, we could not exclude the possibility of a ruptured descending aorta until we discovered the site of the rupture during operation. The presence of a pericardial defect would at first appear to be a fatal disadvantage in such a situation as this, due to massive bleeding into the pleural space; but we believe that in our patient spontaneous drainage of blood into the pleural cavity prevented severe cardiac tamponade. The only reason for his deteriorating hemodynamic status was hypovolemia, which was corrected with volume replacement.

[Hydroxyethyl starch solutions]

Hypovolemia is common among surgical, trauma, and intensive care unit patients. It can occur in the absence of obvious fluid loss secondary to vasodilatation or during generalized alterations of the endothelial barrier resulting in increased capillary permeability. Hydroxyethyl starch solutions are increasingly used for the volume replacement therapy. Hydroxyethyl starch solutions are synthetic colloids with the pharmacological properties that are the closest to natural colloids. Important characteristics for these products are molecular weight, their concentration, the degree of molar substitution, and the substitution pattern. In this review article a large variety of hydroxyethyl starch solutions, their physical and chemical characteristics, pharmacokinetics and metabolism, the main route of elimination, mechanism of action, effect on blood plasma volume, safety, tolerability and side effects (the risk of adverse effects on hemostasis, platelet function, frequency of pruritus, anaphylactoid reaction, incidence of rise in serum amylase) are presented.

[Comparative evaluation of different infusion medias used in therapy for neonatal hypovolemia]

The paper comparatively evaluates the efficiency of the use of physiological sodium chloride solution, freshly-frozen plasma, 6% and 10% solutions of hydroxyethyl starch to compensate for circulating blood volume deficit in 80 neonatal infants aged 1-3 days who had hypovolemia resulting from hemorrhage during labor or abdominal delivery. 6% and 10% solutions of hydroxyethyl starch were found to be the most effective agents for compensating for circulating plasma volume deficit. They rapidly eliminate circulating blood volume deficit, long maintain the stability of systemic and peripheral hemodynamic parameters.

Heterogeneous Microcirculation in the Rat Small Intestine during Hemorrhagic Shock: Quantification of the Effects of Hypertonic-Hyperoncotic Resuscitation

PURPOSE

In the event of a spatial or temporal microvascular perfusion heterogeneity conventional methods are often inadequate to describe the microcirculatory changes. Our aim was to use a new formula to characterize and compare the microcirculatory reactions in the mucosa and longitudinal muscle of the rat small intestine in response to hypertonic/hyperoncotic and normotonic resuscitation strategies.

METHODS

Intravital videomicroscopy with an orthogonal polarization spectral (OPS) imaging technique was utilized. Microcirculatory variables were recorded during hemorrhagic shock (HS; 50 mm Hg mean arterial pressure for 60 min) and fluid replacement with 0.9% saline or with 7.2% saline containing 10% hydroxyethylstarch 200/0.5 (Osmohes; 4 ml/kg). Due to the temporal perfusion variability, microcirculatory changes were described using the calculation of the average red blood cell velocity (A-RBCV), while the spatial changes were calculated as a function of the size of the perfused capillary network.

RESULTS

During HS and the late phase of resuscitation, perfusion was characterized by capillary flow motion (i.e. variability in time) in the villi, and by spatial flow heterogeneity in the longitudinal muscle layer. The approximately 40% decrease in the calculated villus A-RBCV during HS was only partially affected by 0.9% saline, whereas Osmohes completely restored A-RBCV by increasing both the red blood cell velocity and the duration of high-flow periods at the onset of resuscitation in the villi. The approximately 60% reduction in A-RBCV in the muscle layer during HS was not followed by an appreciable recovery in either group, but Osmohes significantly increased A-RBCV in the late resuscitation phase.

CONCLUSIONS

The hypertonic/hyperoncotic solution induces a considerable microcirculatory improvement in two distinct layers of the small intestine after HS. This positive effect is related to the amelioration of the intestinal microcirculatory heterogeneity.

Hypertonic Saline

The optimal fluid for the resuscitation of critically ill and injured patients remains the subject of considerable controversy. Hypertonic crystalloid solutions such as hypertonic saline provide rapid volume expansion, have an acceptable safety profile, and are easy to store and transport. Recent meta-analyses suggest a trend toward increased survival in patients given hypertonic saline, and it has been suggested that they may have particular benefit in certain groups of patients such as hypovolaemic head injury patients. This short review examines the physiological and experimental evidence supporting the use of hypertonic saline in fluid resuscitation.

Assessment of volume depletion in children with malaria

BACKGROUND

The degree of volume depletion in severe malaria is currently unknown, although knowledge of fluid compartment volumes can guide therapy. To assist management of severely ill children, and to test the hypothesis that volume changes in fluid compartments reflect disease severity, we measured body compartment volumes in Gabonese children with malaria.

METHODS AND FINDINGS

Total body water volume (TBW) and extracellular water volume (ECW) were estimated in children with severe or moderate malaria and in convalescence by tracer dilution with heavy water and bromide, respectively. Intracellular water volume (ICW) was derived from these parameters. Bioelectrical impedance analysis estimates of TBW and ECW were calibrated against dilution methods, and bioelectrical impedance analysis measurements were taken daily until discharge. Sixteen children had severe and 19 moderate malaria. Severe childhood malaria was associated with depletion of TBW (mean [SD] of 37 [33] ml/kg, or 6.7% [6.0%]) relative to measurement at discharge. This is defined as mild dehydration in other conditions. ECW measurements were normal on admission in children with severe malaria and did not rise in the first few days of admission. Volumes in different compartments (TBW, ECW, and ICW) were not related to hyperlactataemia or other clinical and laboratory markers of disease severity. Moderate malaria was not associated with a depletion of TBW.

CONCLUSIONS

Significant hypovolaemia does not exacerbate complications of severe or moderate malaria. As rapid rehydration of children with malaria may have risks, we suggest that fluid replacement regimens should aim to correct fluid losses over 12-24 h.

A comparison of albumin and saline for fluid resuscitation in the intensive care unit

BACKGROUND

It remains uncertain whether the choice of resuscitation fluid for patients in intensive care units (ICUs) affects survival. We conducted a multicenter, randomized, double-blind trial to compare the effect of fluid resuscitation with albumin or saline on mortality in a heterogeneous population of patients in the ICU.

METHODS

We randomly assigned patients who had been admitted to the ICU to receive either 4 percent albumin or normal saline for intravascular-fluid resuscitation during the next 28 days. The primary outcome measure was death from any cause during the 28-day period after randomization.

RESULTS

Of the 6997 patients who underwent randomization, 3497 were assigned to receive albumin and 3500 to receive saline; the two groups had similar baseline characteristics. There were 726 deaths in the albumin group, as compared with 729 deaths in the saline group (relative risk of death, 0.99; 95 percent confidence interval, 0.91 to 1.09; P=0.87). The proportion of patients with new single-organ and multiple-organ failure was similar in the two groups (P=0.85). There were no significant differences between the groups in the mean (+/-SD) numbers of days spent in the ICU (6.5+/-6.6 in the albumin group and 6.2+/-6.2 in the saline group, P=0.44), days spent in the hospital (15.3+/-9.6 and 15.6+/-9.6, respectively; P=0.30), days of mechanical ventilation (4.5+/-6.1 and 4.3+/-5.7, respectively; P=0.74), or days of renal-replacement therapy (0.5+/-2.3 and 0.4+/-2.0, respectively; P=0.41).

CONCLUSIONS

In patients in the ICU, use of either 4 percent albumin or normal saline for fluid resuscitation results in similar outcomes at 28 days.

Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data

OBJECTIVE

Menorrhagia is defined as blood loss of >80 mL, but in routine clinical practice measurement is seldom undertaken. Our aim was to identify the features of the clinical history that best predict menorrhagic blood loss.

STUDY DESIGN

A questionnaire survey of 952 menstrual complaint referrals at 3 hospital gynecology clinics in Glasgow and Edinburgh included 226 women with putatively heavy periods who also had consented to the measurement of their blood loss.

RESULTS

Only 34% (95% CI, 28%-40%) of women had blood loss volume of >80 mL, but the volume was associated with subjective heaviness of period. Logistic regression with ferritin status, clots, and changing rate during full flow correctly predicts a loss of >80 mL for 76% of women (n=161 patients; sensitivity, 60%; specificity, 86%). Diagnosis and treatment of patients seem unrelated to the volume of blood loss.

CONCLUSION

The subjective judgment of the volume of blood loss is better than has been believed. Clinical features can be combined to predict losses of >80 mL.

Human albumin and starch administration in critically ill patients: A prospective randomized clinical trial

OBJECTIVE

To determine whether intravenous infusion of either human albumin or hydroxyethyl-starch (HES) in hypo-albuminemic critically ill may lead to an increase in colloid osmotic pressure and to a better clinical outcome, i.e. lower mortality and fewer complications, compared to fluid replacement with normal saline.

DESIGN

Prospective, randomized controlled clinical trial during 72 hours in 61 consecutively admitted severely ill patients. Randomisation took place by sealed envelope, kept outside of the hospital.

SETTING

Intensive care unit of the Twenteborg Hospital, Almelo, The Netherlands.

SUBJECTS

Sixty-three severely ill, hypo-albuminemic patients were selected; 27 patients had severe sepsis and 36 were post-surgical patients with SIRS. Two patients died shortly after randomization, 15 patients received human albumin, 15 HES 500 and 15 HES 1000 ml, and 16 saline.

INTERVENTIONS

The patients were randomized to receive 300 ml human albumin (20%) per day, or 1000 ml normal saline per day, or 500 ml or 1000 ml HES per day, all for 72 hours.

MAIN OUTCOME MEASURES

The primary outcome was plasma colloid osmotic pressure (COP). Secondary endpoints were fluid balance and the development of pulmonary edema.

RESULTS

Administration of human albumin was effective in raising COP (P<0.001 on day 2 and day 3, compared to saline and HES). Neither fluid balances nor the development of peripheral or pulmonary edema were different between the groups. Mortality as well as length of stay at ICU were slightly higher in the group receiving human albumin, although not statistically significant.

CONCLUSION

Raising colloid osmotic pressure with human albumin in hypoalbuminemic patients is not associated with improvement of the clinical outcome.

[Treatment of severe sepsis and septic shock]

The 3 poles of treatment. These are the hemodynamic management, early antibiotherapy and more specific treatments, based on improved physiopathological knowledge. From a hemodynamic point of view The first stage must always be to detect and correct the hypovolemia. The administration of vasopressive amines (or vasoconstricting amines) is mandatory in the case of septic shock. The choice of the antibiotics In the absence of microbiological proof, it is based on the germs most often encountered in infections of the suspected site and community or nosocomial nature of the infection. The antibiotherapy must be set-up as early as possible once the bacteriological samples have been. Treatments based on the physiopathology The activated protein C possesses pro-fibrinolytic, anticoagulant and anti-inflammatory properties; it obtained marketing Authorization in Europe for patients with severe sepsis and at least 2 organ failures or hypotension. Low-dose corticosteroids should be prescribed in the case of septic shock with prolonged use of catecholamines, and if possible following a test with Synacthène(R) (relative adrenal insufficiency). Intensive insulin therapy is aimed at maintaining normal glycemia in the patients for as long as possible.