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Fodor GH, Habre W, Balogh AL, Südy R, Babik B, Peták F. Optimal crystalloid volume ratio for blood replacement for maintaining hemodynamic stability and lung function: an experimental randomized controlled study. BMC Anesthesiol 2019; 19:21. [PMID: 30760207 PMCID: PMC6375132 DOI: 10.1186/s12871-019-0691-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 02/04/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Crystalloids are first line in fluid resuscitation therapy, however there is a lack of evidence-based recommendations on the volume to be administered. Therefore, we aimed at comparing the systemic hemodynamic and respiratory effects of volume replacement therapy with a 1:1 ratio to the historical 1:3 ratio. METHODS Anesthetized, ventilated rats randomly included in 3 groups: blood withdrawal and replacement with crystalloid in 1:1 ratio (Group 1, n = 11), traditional 1:3 ratio (Group 3, n = 12) and a control group with no interventions (Group C, n = 9). Arterial blood of 5% of the total blood volume was withdrawn 7 times, and replaced stepwise with different volume rations of Ringer's acetate, according to group assignments. Airway resistance (Raw), respiratory tissue damping (G) and tissue elastance (H), mean arterial pressure (MAP) and heart rate (HR) were assessed following each step of fluid replacement with a crystalloid (CR1-CR6). Lung edema index was measured from histological samples. RESULTS Raw decreased in Groups 1 and 3 following CR3 (p < 0.02) without differences between the groups. H elevated in all groups (p < 0.02), with significantly higher changes in Group 3 compared to Groups C and 1 (both p = 0.03). No differences in MAP or HR were present between Groups 1 and 3. Lung edema was noted in Group 3 (p < 0.05). CONCLUSIONS Fluid resuscitation therapy by administering a 1:1 blood replacement ratio revealed adequate compensation capacity and physiological homeostasis similar with no lung stiffening and pulmonary edema. Therefore, considering this ratio promotes the restrictive fluid administration in the presence of continuous and occult bleeding.
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Affiliation(s)
- Gergely H. Fodor
- Department of Medical Physics and Informatics, University of Szeged, 9 Koranyi fasor, Szeged, H-6720 Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations, Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, University of Geneva, 1 Rue Michel Servet, CH-1205 Geneva, Switzerland
| | - Adam L. Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, 8 Semmelweis str, Szeged, H-6725 Hungary
| | - Roberta Südy
- Department of Anesthesiology and Intensive Therapy, University of Szeged, 8 Semmelweis str, Szeged, H-6725 Hungary
| | - Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, 8 Semmelweis str, Szeged, H-6725 Hungary
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, 9 Koranyi fasor, Szeged, H-6720 Hungary
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Henriquez DDCA, Bloemenkamp KWM, Loeff RM, Zwart JJ, van Roosmalen JJM, Zwaginga JJ, van der Bom JG. Fluid resuscitation during persistent postpartum haemorrhage and maternal outcome: A nationwide cohort study. Eur J Obstet Gynecol Reprod Biol 2019; 235:49-56. [PMID: 30784827 DOI: 10.1016/j.ejogrb.2019.01.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the association between increasing volumes of crystalloids and colloids administered before transfusion of packed red blood cells in women with persistent postpartum haemorrhage and adverse maternal outcomes. STUDY DESIGN Retrospective cohort study in the Netherlands. Women with persistent postpartum haemorrhage and known clear fluids volume for resuscitation were included. Women who received ≤2 L of clear fluids were the reference group. We determined the effect of every additional litre of clear fluids on total blood loss, severe maternal morbidity and mortality. Results were adjusted for patient and bleeding characteristics. RESULTS Of the 883 included women, 199 received ≤2 L of clear fluids. Median blood loss for the reference group was 2.9 L (interquartile range 2.2-3.4). Adjusted mean difference in blood loss compared with the reference group was 0.2 L (95% confidence interval -0.1 to 0.5) for women in the >2 to ≤3 L, 0.4 L (0.1-0.7) for the >3 to ≤4 L category, 0.6 L (0.5-0.7) for the >4 to ≤5 L category, and 1.9 L (1.5-2.3) for the >5 to ≤7 L category. Adjusted odds ratios for adverse maternal outcomes were 1.0 (0.7-1.6), 1.2 (0.8-1.9), 1.8 (1.1-3.1) and 4.4 (2.6-7.5) for women in the 2 to ≤3 L category, >3 to ≤4 L, >4 to ≤5 L, and >5 to ≤7 L volume categories respectively. Results were similar in strata of different severities of bleeding. CONCLUSION Clear fluids volume >4 L was independently associated with adverse maternal outcome in women with persistent postpartum haemorrhage.
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Affiliation(s)
- Dacia D C A Henriquez
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands; Sanquin Research, Center for Clinical Transfusion Research and Jon J van Rood Center for Clinical Transfusion Science, Leiden University Medical Center, Leiden, the Netherlands(1); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Rosanne M Loeff
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands; Sanquin Research, Center for Clinical Transfusion Research and Jon J van Rood Center for Clinical Transfusion Science, Leiden University Medical Center, Leiden, the Netherlands(1); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost J Zwart
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - Jos J M van Roosmalen
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands; Athena Institute, VU University, Amsterdam, the Netherlands
| | - Jaap Jan Zwaginga
- Sanquin Research, Center for Clinical Transfusion Research and Jon J van Rood Center for Clinical Transfusion Science, Leiden University Medical Center, Leiden, the Netherlands(1); Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna G van der Bom
- Sanquin Research, Center for Clinical Transfusion Research and Jon J van Rood Center for Clinical Transfusion Science, Leiden University Medical Center, Leiden, the Netherlands(1); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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Fujita T, Okada N, Horikiri Y, Sato T, Fujiwara H, Mayanagi S, Kanamori J, Yamamoto H, Daiko H. Safety and efficacy of hydroxyethyl starch 6% 130/0.4/9 solution versus 5% human serum albumin in thoracic esophagectomy with 3-field lymph nodes dissection. Surg Today 2019; 49:427-434. [PMID: 30604215 DOI: 10.1007/s00595-018-1752-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/30/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE We investigated the safety and efficacy of administering hydroxyethyl starch 6% 130/0.4/9 (HES130/0.4/9) versus 5% human serum albumin (HSA), perioperatively, to patients undergoing thoracic esophagectomy with 3-field lymph-node dissection for esophageal cancer. METHODS The subjects of this study were 262 patients, scheduled to undergo thoracic esophagectomy for esophageal cancer, who were assigned to one of two groups based on the fluid replacement therapy. We compared the intraoperative and immediate postoperative hemodynamics and incidence of complications in the two groups. RESULTS Neither group suffered any adverse events. No significant differences were observed in systolic/diastolic blood pressure, heart rate, incidence of postoperative complications, postoperative urine output, or serum creatinine levels, between the groups. A mild postoperative increase (×1.5 increase) in serum creatinine levels was seen in 9.5% and 9.5% of patients in the HSA and HES130/0.4/9 groups, respectively (p = 0.99), and a moderate postoperative increase (×2.0 increase) was seen in 4.4% and 3.1%, respectively (p = 0.84). Univariate and multivariate analyses revealed that the administration of hydroxyethyl starch was not associated with a postoperative increase in serum creatinine levels. CONCLUSION Hydroxyethyl starch 6% 130/0.4/9 was well tolerated and comparable to albumin with respect to its effect on renal function during thoracic esophagectomy with 3-field lymph-node dissection.
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Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Naoya Okada
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yasumasa Horikiri
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takuji Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hisashi Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Shuhei Mayanagi
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Jun Kanamori
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiroyuki Yamamoto
- Division of Anesthesiology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Fink RJ, Young A, Yanez ND, Hom M, Mai J, Treggiari M, Merkel M. Cohort Study of Albumin versus Lactated Ringer's for Postoperative Cardiac Surgery Fluid Resuscitation in the Intensive Care Unit. Pharmacotherapy 2018; 38:1241-1249. [DOI: 10.1002/phar.2195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ryan J. Fink
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | | | - N. David Yanez
- OHSU/PSU School of Public Health Oregon Health & Science University Portland Oregon
| | - Marissa Hom
- Pharmaceutical Services University of California, San Francisco Medical Center San Francisco California
| | - Jennifer Mai
- Department of Pharmacy Services Oregon Health & Science University Portland Oregon
| | - Miriam Treggiari
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | - Matthias Merkel
- Anesthesiology & Perioperative Medicine Knight Cardiovascular Institute Oregon Health & Science University Portland Oregon
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Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients. Anesthesiology 2018; 129:1149-1158. [DOI: 10.1097/aln.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients.
Methods
The CRISTAL trial prospectively defined patients as critically ill surgical patients whenever they underwent emergency or scheduled surgery immediately before or within 24 h of intensive care unit admission and had hypovolemic shock. The primary outcome measure was death by day 28. Secondary outcome measures included death by day 90, the need for renal replacement therapy, or the need for fresh frozen plasma transfusion.
Results
There were 741 critically ill surgical patients, 356 and 385 in the crystalloid and colloid arm, respectively. Median (interquartile range) age was 66 (52 to 76) yr, and 484 (65.3%) patients were male. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) versus colloids 100 (26%; adjusted odds ratio, 0.86; 95% CI, 0.61 to 1.21; P = 0.768). Death by day 90 (111 [31.2%] vs. 122 [31.7%]; adjusted odds ratio, 0.97; 95% CI, 0.70 to 1.33; P = 0.919) did not significantly differ between groups. Renal replacement therapy was required for 42 (11.8%) patients in the crystalloids arm versus 49 (12.7%) in the colloids arm (P = 0.871).
Conclusions
The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.
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McIlroy D, Bellomo R, Billings F, Karkouti K, Prowle J, Shaw A, Myles P. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: renal endpoints. Br J Anaesth 2018; 121:1013-1024. [DOI: 10.1016/j.bja.2018.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/21/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
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Güneş I, Süngü N, Kılıçarslan A, Şıvgın V, Alkan M, Küçük A, Boyunağa H, Ünal Y, Arslan M. Effects of hydroxyethyl starch 130/0.4 on the kidney tissue of rats with ureteral obstruction. Drug Des Devel Ther 2018; 12:3061-3070. [PMID: 30275683 PMCID: PMC6157580 DOI: 10.2147/dddt.s165695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective This study was conducted since the effects of colloid solutions on the renal system remain controversial and need to be adequately studied in animals. We aimed to evaluate the effects of hydroxyethyl starch (Voluven) on the kidney tissue of rats with late renal failure due to ureteral obstruction. Materials and methods Rats were divided into four groups: Group C, control; Group HES, hydroxyethyl starch solution (HES) 130/0.4 (Voluven®); Group UUO, unilateral ureteral obstruction (UUO); and Group UUO-HES, UUO-HES 130/0.4 (Voluven®). In the groups with ureteral obstruction, the distal part of the right ureter was accessed and sutured through a lower abdominal incision under ketamine anesthesia. Any signs of late-stage renal failure were evaluated after three weeks. Rats in the HES group and the renal failure-HES group were administered with HES 130/0.4 as a single intravenous dose of 20 mL/kg. After a follow-up of 24 hours, intra-abdominal blood sample was collected, and the rats were sacrificed. Biochemical and histopathological parameters were then evaluated. Results Ureteral obstruction significantly increased urea and creatinine levels. In addition, when the UUO-HES and HES groups were compared, the administration of HES increased urea and creatinine levels in the UUO-HES group. Nitric oxide enzyme activity and malondialdehyde levels have significantly increased in the UUO groups. In addition, HES significantly increased nitric oxide activity and malondialdehyde levels in the UUO-HES group, in comparison with the HES group. The activity of caspases 3 and 8 was significantly increased in the UUO groups. In addition, HES significantly increased the activity of caspases 3 and 8 in the UUO-HES group, in comparison with the HES group. Light microscopy revealed significant changes in the UUO groups, especially in the obstructed kidneys. Conclusion If indicated, HES should be used with caution in cases of UUO, but not in the cases of bilateral ureteral obstruction. Other aspects of these findings, including the clinical significance and practical applications, merit further experimental and clinical investigation.
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Affiliation(s)
- Işın Güneş
- Department of Anaesthesiology and Reanimation, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Nuran Süngü
- Department of Pathology, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Aydan Kılıçarslan
- Department of Pathology, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Volkan Şıvgın
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
| | - Metin Alkan
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
| | - Ayşegül Küçük
- Department of Physiology, Dumlupınar University Medical Faculty, Kütahya, Turkey
| | - Hakan Boyunağa
- Department of Biochemistry, Kırıkkale University Medical Faculty, Kırıkkale, Turkey
| | - Yusuf Ünal
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
| | - Mustafa Arslan
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
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Choice of fluid type: physiological concepts and perioperative indications. Br J Anaesth 2018; 120:384-396. [DOI: 10.1016/j.bja.2017.10.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
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Sacchet-Cardozo F, Stoicea N, Joseph N, Dewhirst E, Essandoh M. Con: Hetastarch Should be Avoided for Volume Expansion in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2018; 32:576-579. [DOI: 10.1053/j.jvca.2016.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Indexed: 11/11/2022]
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Datzmann T, Hoenicka M, Reinelt H, Liebold A, Gorki H. Influence of 6% Hydroxyethyl Starch 130/0.4 Versus Crystalloid Solution on Structural Renal Damage Markers After Coronary Artery Bypass Grafting: A Post Hoc Subgroup Analysis of a Prospective Trial. J Cardiothorac Vasc Anesth 2018; 32:205-211. [DOI: 10.1053/j.jvca.2017.05.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Indexed: 12/19/2022]
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Kaserer A, Casutt M, Sprengel K, Seifert B, Spahn DR, Stein P. Comparison of two different coagulation algorithms on the use of allogenic blood products and coagulation factors in severely injured trauma patients: a retrospective, multicentre, observational study. Scand J Trauma Resusc Emerg Med 2018; 26:4. [PMID: 29310686 PMCID: PMC5759800 DOI: 10.1186/s13049-017-0463-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background At the University Hospital Zurich (USZ) and the Cantonal Hospital of Lucerne (LUKS) an individualized goal-directed coagulation and transfusion algorithm was introduced and implemented before 2012 (Coagulation algorithm of the USZ: USZ-Alg; of the LUKS: LUKS-Alg). Main differences between both algorithms are: 1) A target haematocrit-range of 0.21–0.24 (USZ-Alg) vs. a lower haematocrit limit only (LUKS-Alg). 2) Blind coagulation-package in selected cases (LUKS-Alg only). 3) Factor XIII substitution is considered earlier according to the USZ-Alg. The Aim of this study was to analyse the impact of two different coagulation algorithms on the administration of allogeneic blood products, coagulation factors, the frequency of point of care measurements and haemoglobin level during resuscitation in trauma patients. Methods This retrospective, multicentre, observational study included all adult trauma patients with an injury severity score (ISS) ≥ 16 primarily admitted to the USZ or the LUKS in the period of 2012 to 2014. Referred patients and patients with missing/incomplete records of the initial treatment at the emergency department (ED) were excluded. Two propensity score matched groups were created using a non-parsimonious logistic regression to account for potential differences in patient and trauma epidemiology. Results A total of 632 patients meeting the inclusion criteria were admitted to the two hospitals: 428 to the USZ and 204 to the LUKS. Two Propensity score matched groups (n = 172 per group) were created. Treatment with USZ-Alg compared with LUKS-Alg resulted in a lower number of patients receiving RBC transfusion (11.6% vs. 29.7%, OR 3.2, 95% CI 1.8–5.7, p < 0.001) and lower amount of RBC transfusion (0.5 SD 1.9 vs. 1.5 SD 3.9, p < 0.001). The different treatment algorithms resulted in lower mean haemoglobin levels in the USZ during resuscitation (8.0 SD 1.7 vs. 9.4 SD 1.8 g/dl, p < 0.001) and at admission to the ICU (8.3 SD 1.2 vs. 10.6 SD 1.9 g/dl, p < 0.001. Blood gas analyses to monitor treatment and haematocrit were made more frequently in the USZ (1.4 SD 0.8 vs. 1.0 SD 0.7 measurements per hour, p = 0.004). Conclusion A goal-directed coagulation algorithm including a target haematocrit-range including frequent and repeated haematocrit measurement may lead to less transfusion of RBC compared to only a lower haematocrit limit, when treating severely traumatized patients. Electronic supplementary material The online version of this article (10.1186/s13049-017-0463-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander Kaserer
- Institute of Anaesthesiology, University and University Hospital Zürich, Raemistrasse 100, 8091, Zürich, Switzerland.
| | - Mattias Casutt
- Department of Anaesthesiology and Intensive Care, Cantonal Hospital Lucerne, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Kai Sprengel
- Department of Traumatology, University and University Hospital Zürich, Raemistrasse 100, 8091, Zürich, Switzerland
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zürich, Raemistrasse 100, 8091, Zürich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, University and University Hospital Zürich, Raemistrasse 100, 8091, Zürich, Switzerland
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Oh HW, Lee JH, Kim HC, Kim EH, Song IK, Kim HS, Kim JT. The effect of 6% hydroxyethyl starch (130/0.4) on acute kidney injury in paediatric cardiac surgery: a prospective, randomised trial. Anaesthesia 2017; 73:205-215. [DOI: 10.1111/anae.14129] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2017] [Indexed: 11/28/2022]
Affiliation(s)
- H.-W. Oh
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul National University College of Medicine; Seoul Korea
| | - J.-H. Lee
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - H.-C. Kim
- Department of Anaesthesiology and Pain Medicine; Dongsan Medical Centre; Keimyung University College of Medicine; Daegu Korea
| | - E.-H. Kim
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - I.-K. Song
- Department of Anaesthesiology and Pain Medicine; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
| | - H.-S. Kim
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - J.-T. Kim
- Department of Anaesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
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Aronson S, Nisbet P, Bunke M. Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers. Perioper Med (Lond) 2017; 6:15. [PMID: 29075482 PMCID: PMC5649061 DOI: 10.1186/s13741-017-0071-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Fluid resuscitation during cardiac surgery is common with significant variability in clinical practice. Our goal was to investigate current practice patterns of fluid volume expansion in patients undergoing cardiac surgeries in the USA. Methods We conducted a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists. Survey questions were designed to assess clinical decision-making patterns of intravenous (IV) fluid utilization in cardiovascular surgery for five types of patients who need volume expansion: (1) patients undergoing cardiopulmonary bypass (CPB) without bleeding, (2) patients undergoing CPB with bleeding, (3) patients undergoing acute normovolemic hemodilution (ANH), (4) patients requiring extracorporeal membrane oxygenation (ECMO) or use of a ventricular assist device (VAD), and (5) patients undergoing either off-pump coronary artery bypass graft (OPCABG) surgery or transcatheter aortic valve replacement (TAVR). First-choice fluid used in fluid boluses for these five patient types was requested. Descriptive statistics were performed using Kruskal-Wallis test and follow-up tests, including t tests, to evaluate differences among respondent groups. Results The most commonly preferred indicators of volume status were blood pressure, urine output, cardiac output, central venous pressure, and heart rate. The first choice of fluid for patients needing volume expansion during CPB without bleeding was crystalloids, whereas 5% albumin was the most preferred first choice of fluid for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most frequently used adjunct fluid to crystalloids. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one third preferred a mixture of 25% albumin and crystalloids. Less interstitial edema and more sustained volume expansion were considered the most important colloid traits in volume expansion. Conclusions Fluid utilization practice patterns in the USA varied depending on patient characteristics and clinical specialties of health care professionals. Electronic supplementary material The online version of this article (10.1186/s13741-017-0071-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Solomon Aronson
- Department of Anesthesiology, Duke University, 201 Trent Drive, 101 Baker House, Durham, NC 27710 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungryneck Blvd. Suite C-303, Mt. Pleasant, SC 29464 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 T.W. Alexander Drive, 4101 Research Commons, Research Triangle Park, Raleigh, NC 27709 USA
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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67
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Ryhammer PK, Tang M, Hoffmann-Petersen J, Leonaviciute D, Greisen J, Storebjerg Gissel M, Jakobsen CJ. Colloids in Cardiac Surgery—Friend or Foe? J Cardiothorac Vasc Anesth 2017; 31:1639-1648. [DOI: 10.1053/j.jvca.2017.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Indexed: 01/02/2023]
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68
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Paar M, Rossmann C, Nusshold C, Wagner T, Schlagenhauf A, Leschnik B, Oettl K, Koestenberger M, Cvirn G, Hallström S. Anticoagulant action of low, physiologic, and high albumin levels in whole blood. PLoS One 2017; 12:e0182997. [PMID: 28800610 PMCID: PMC5553770 DOI: 10.1371/journal.pone.0182997] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/27/2017] [Indexed: 01/01/2023] Open
Abstract
Albumin is the most abundant plasma protein. Critical illness is often associated with altered, predominately decreased, serum albumin levels. This hypoalbuminaemia is usually corrected by administration of exogenous albumin. This study aimed to track the concentration-dependent influence of albumin on blood coagulation in vitro. Whole blood (WB) samples from 25 volunteers were prepared to contain low (19.3 ± 7.7 g/L), physiological (45.2 ± 7.8 g/L), and high (67.5 ± 18.1 g/L) levels of albumin. Haemostatic profiling was performed using a platelet function analyzer (PFA) 200, impedance aggregometry, a Cone and Platelet analyzer (CPA), calibrated automated thrombogram, and thrombelastometry (TEM). Platelet aggregation-associated ATP release was assessed via HPLC analysis. In the low albumin group, when compared to the physiological albumin group, we found: i) shortened PFA 200-derived closure times indicating increased primary haemostasis; ii) increased impedance aggregometry-derived amplitudes, slopes, ATP release, as well as CPA-derived average size indicating improved platelet aggregation; iii) increased TEM-derived maximum clot firmness and alpha angles indicating enhanced clot formation. TEM measurements indicated impaired clot formation in the high albumin group compared with the physiological albumin group. Thus, albumin exerted significant anticoagulant action. Therefore, low albumin levels, often present in cancer or critically ill patients, might contribute to the frequently occurring venous thromboembolism.
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Affiliation(s)
- Margret Paar
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Christine Rossmann
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Christoph Nusshold
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Thomas Wagner
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, Graz, Austria
| | | | - Bettina Leschnik
- Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Karl Oettl
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | | | - Gerhard Cvirn
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Seth Hallström
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
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69
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Rabin J, Meyenburg T, Lowery AV, Rouse M, Gammie JS, Herr D. Restricted Albumin Utilization Is Safe and Cost Effective in a Cardiac Surgery Intensive Care Unit. Ann Thorac Surg 2017; 104:42-48. [DOI: 10.1016/j.athoracsur.2016.10.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 09/02/2016] [Accepted: 10/07/2016] [Indexed: 11/25/2022]
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70
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Jin S, Yu G, Hou R, Shen B, Jiang H. Effect of Hemodilution In Vitro with Hydroxyethyl Starch on Hemostasis. Med Sci Monit 2017; 23:2189-2197. [PMID: 28481865 PMCID: PMC5436429 DOI: 10.12659/msm.901588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Hydroxyethyl starch (HES) solutions are used for volume expansion during surgery. We aimed to investigate how 6%HES 130/0.4 affects hemostasis. Material/Methods Blood samples were collected from 12 healthy adult volunteers, diluting with 6%HES 130/0.4 (HES group) or Ringer lactate solution (RL control group). The hemodilution ratio (HR) of citrated blood volume to plasma substitute volume was 10: 0 (undiluted), 10: 2, 10: 4, and 10: 6. Clotting factors activity was measured. Thrombin generation was monitored. Platelet function was analyzed. Results 1) Activity of coagulation factor was decreased with increasing HR compared to undiluted baseline, and the activity of FVIII was significantly decreased in HES vs. RL. 2) Calibrated automated thrombography (CAT) results showed HES extended lag time, time to peak (ttpeak), start tail, and decreased peak of thrombin generation. Although lag time and ttpeak were significantly prolonged in HES vs. RL, endogenous thrombin potential (ETP) did not change. 3) Flow cytometric (FCM) analysis showed that HES reduced platelet phospholipids serine (PS) vs. baseline and RL. 4) HES significantly decreased antithrombin activity (AT: A) of the anticoagulant system with increasing HR vs. baseline and RL. 5) For fibrinolytic system, HES did not affect fibrinogen degradation products (FDP) and D-dimers (D-D) vs. baseline, or α2-antiplasmin (α2-AP) vs. RL. Conclusions By reducing FVIII activity and platelet PS expression, HES interfered with PS combining to FXIa, FVIIIa, and FVa, which affected the acceleration and explosion stage of thrombin. The decreased velocity and peak of thrombin generation delays and reduces clot formation. Combined 6%HES 130/0.4 decreased anticoagulant activity and may have clinical utility.
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Affiliation(s)
- Shanliang Jin
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Guifang Yu
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Ruijiao Hou
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Boxiong Shen
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
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71
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Guarnieri M, Belletti A, Meroni R, Bignami E. Colloids Versus Crystalloids: Is That the Real Problem? J Cardiothorac Vasc Anesth 2017; 31:e11-e13. [DOI: 10.1053/j.jvca.2016.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Indexed: 11/11/2022]
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72
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Ghijselings I, Himpe D, Rex S. Safety of gelatin solutions for the priming of cardiopulmonary bypass in cardiac surgery: a systematic review and meta-analysis. Perfusion 2017; 32:350-362. [PMID: 28043204 DOI: 10.1177/0267659116685418] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This systematic review and meta-analysis was conducted to evaluate the safety of gelatin versus hydroxyethyl starches (HES) and crystalloids when used for cardiopulmonary bypass (CPB)-priming in cardiac surgery. MEDLINE (Pubmed), Embase and CENTRAL were searched. We included only randomized, controlled trials comparing CPB-priming with gelatin with either crystalloids or HES-solutions of the newest generation. The primary endpoint was the blood loss during the first 24 hours. Secondary outcomes included perioperative transfusion requirements, postoperative kidney function, postoperative ventilation times and length of stay on the intensive care unit. Sixteen studies were identified, of which only ten met the inclusion criteria, representing a total of 824 adult patients: 4 studies compared gelatin with crystalloid, and 6 studies gelatin with HES priming. Only 2 of the studies comparing HES and gelatin reported postoperative blood loss after 24 hours. No significant difference in postoperative blood loss was found when results of both studies were pooled (SMD -0.12; 95% CI: -0.49, 0.25; P=0.52). Likewise, the pooled results of 3 studies comparing gelatin and crystalloids as a priming solution could not demonstrate significant differences in postoperative bleeding after 24 hours (SMD -0.07; 95% CI: -0.40, 0.26; P=0.68). No differences regarding any of the secondary outcomes could be identified. This systematic review suggests gelatins to have a safety profile which is non-inferior to modern-generation tetrastarches or crystalloids. However, the grade of evidence is rated low owing to the poor methodological quality of the included studies, due to inconsistent outcome reporting and lack of uniform endpoint definitions.
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Affiliation(s)
- Idris Ghijselings
- 1 Department of Anaesthesiology, University Hospitals of Leuven, KULeuven, Leuven, Belgium
| | - Dirk Himpe
- 2 Department of Anaesthesiology, ZNA Middelheim, Antwerp, Belgium
| | - Steffen Rex
- 1 Department of Anaesthesiology, University Hospitals of Leuven, KULeuven, Leuven, Belgium.,3 Department of Cardiovascular Sciences, University Hospitals of Leuven, KU Leuven, Leuven, Belgium
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73
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Haemostasis monitored in stored red blood cells, plasma and platelet concentrates in the proportion of 4 : 4 : 1 diluted with crystalloids and colloids. Blood Coagul Fibrinolysis 2016; 27:334-9. [PMID: 26963027 DOI: 10.1097/mbc.0000000000000433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this in-vitro study was to evaluate haemostasis analysed with thromboelastometry and blood gas and blood count variables, in stored blood components and the effects after dilution with Ringer[Combining Acute Accent]s acetate, albumin and hydroxyethyl starch (HES). Aliquots from stored red blood cells, plasma and platelet concentrates were mixed in the proportion of 4 : 4 : 1 and analysed with rotational thromboelastometry (ROTEM), blood count [haemoglobin (Hb), haematocrit, platelet count] and blood gas (pH, calcium, sodium, potassium, glucose levels). The blood mix was thereafter diluted 20 and 33% with Ringer's acetate, albumin or HES. The stored blood component mix in a ratio of 4 : 4 : 1 had a low pH (7.11 ± 0.03, mean ± standard deviation), nonmeasurable calcium level, and high concentrations of sodium, potassium and glucose but ROTEM curves within normal range after recalcification. With Ringer's acetate dilution, the ROTEM variables changed almost linearly with increasing dilution volume. When albumin was used in the 33% dilution, the clot firmness of the fibrin clot (FibTEM) was further reduced, and with HES dilution, there was a pronounced impairment. The stored blood mix had a low pH and calcium level, both of which might have a significant influence on the coagulation process but normal ROTEM curves after recalcification. Dilution with Ringer's acetate and albumin resulted in moderate deterioration, while dilution with HES showed severely impaired haemostasis.
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74
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Joosten A, Tircoveanu R, Arend S, Wauthy P, Gottignies P, Van der Linden P. Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial. Br J Anaesth 2016; 117:442-449. [PMID: 28077530 DOI: 10.1093/bja/aew249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND As 6% hydroxyethyl starch (HES) 130/0.40 or 130/0.42 can originate from different vegetable sources, they might have different clinical effects. The purpose of this prospective, randomized, double-blind controlled trial was to compare two balanced tetrastarch solutions, one maize-derived and one potato-derived, on perioperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS We randomly assigned 118 patients undergoing elective cardiac surgery into two groups, to receive either a maize- or a potato-derived HES solution. Study fluids were administered perioperatively (including priming of CPB) until the second postoperative day (POD#2) using a goal directed algorithm. The primary outcome was calculated postoperative blood loss up to POD#2. Secondary outcomes included short-term incidence of acute kidney injury (AKI), and long-term effect (up to one yr) on renal function. RESULTS Preoperative and intraoperative characteristics of the subjects were similar between groups. Similar volumes of HES were administered (1950 ml [1250-2325] for maize-HES and 2000 ml [1500-2700] for potato-HES; P=0.204). Calculated blood loss (504 ml [413-672] for maize-HES vs 530 ml [468-705] for potato-HES; P=0.107) and the need for blood components were not different between groups. The incidence of AKI was similar in both groups (P=0.111). Plasma creatinine concentration and glomerular filtration rates did vary over time, although changes were minimal. CONCLUSIONS Under our study conditions, HES 130/0.4 or 130/0.42 raw material did not have a significant influence on perioperative blood loss. Moreover, we did not find any effect of tetrastarch raw material composition on short and long-term renal function. CLINICAL TRIAL REGISTRATION EudraCT number: 2011-005920-16.
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Affiliation(s)
- A Joosten
- Department of Anesthesiology and Perioperative Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - R Tircoveanu
- Department of Anesthesiology and Perioperative Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - S Arend
- Department of Anesthesiology and Perioperative Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Wauthy
- Department of Cardiac Surgery, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Gottignies
- Department of Intensive Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Van der Linden
- Department of Anesthesiology and Perioperative Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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75
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Reddy S, McGuinness S, Parke R, Young P. Choice of Fluid Therapy and Bleeding Risk After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:1094-103. [DOI: 10.1053/j.jvca.2015.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Indexed: 02/07/2023]
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76
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Rasmussen KC, Secher NH, Pedersen T. Effect of perioperative crystalloid or colloid fluid therapy on hemorrhage, coagulation competence, and outcome: A systematic review and stratified meta-analysis. Medicine (Baltimore) 2016; 95:e4498. [PMID: 27495098 PMCID: PMC4979852 DOI: 10.1097/md.0000000000004498] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A meta-analysis concerning perioperative coagulation competence, hemorrhage, and outcome was conducted including the use of hydroxyethyl starches (HESs), dextran, or albumin versus administration of a crystalloid as control to assess the efficacy and safety of colloids and crystalloids for fluid administration during major elective surgery. Surgery was restricted to cardiovascular and noncardiovascular surgery, and HESs were stratified to HES 130/0.4 and HES 200/0.5. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, ISI Web of Science, EMBASE, conference proceedings, reference lists, and databases of ongoing trials. RESULTS Thirty one primary clinical randomized controlled trials included 2287 patients undergoing major surgery from January 2000 to August 2015. The perioperative changes in coagulation competence were measured by thromboelastography (TEG) maximum amplitude (MA) in 9 studies administering crystalloids versus HES and in 4 studies administering albumin versus HES. All studies but 1 disclosed increased reduction in TEG-MA following HES administration (P = 0.0001 and 0.0002). The total loss of blood was reported in 17 studies in which crystalloids were compared to HES and 12 studies reported increased blood loss after administration of HES (P < 0.003). When administering albumin versus HES, 6 studies reported reduced hemorrhage associated with albumin administration (P = 0.005). Reoperation was not significantly reduced by the use of crystalloids, but may be more frequent after HESs compared to albumin (P < 0.03). In this analysis, more patients admitted to administration of HESs were exposed to decrease coagulation competence, compared to perioperative crystalloids and albumin administration. CONCLUSION This stratified meta-analysis showed that increased blood loss was found in noncardiovascular surgery among patients receiving HES compared with crystalloids, followed by a marked reduction in TEG-MA, and infusion of 3rd-generation HES products did not influence the results significantly.
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Affiliation(s)
| | | | - Tom Pedersen
- Center of Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Denmark
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77
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Terkawi AS, Larkin SK, Tsang S, Sheeran JS, Tiouririne M. Effects of hydroxyethyl starch 6 % (130/0.4) on blood loss during cesarean delivery: a propensity-matched analysis. J Anesth 2016; 30:796-802. [PMID: 27364518 DOI: 10.1007/s00540-016-2208-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/21/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hydroxyethyl starch is commonly used in the obstetric patient population to prevent hypotension during cesarean delivery. Evidence suggests hetastarch is associated with a dysfunction in coagulation cascade. We hypothesized that hetastarch use to prevent spinal hypotension during cesarean delivery would be associated with an increase in blood loss when compared to crystalloid use. METHODS We performed a retrospective review of patients who underwent elective cesarean delivery under spinal anesthesia at the University of Virginia between 2011 and 2014. Data from 819 patients was used. Blood loss was the primary outcome. Propensity score-matching was used to match patients who received hetastarch (treatment group) with those who did not receive hetastarch (control group). RESULTS Genetic matching resulted in 196 patients in the hetastarch group and 182 patients in the control group. There was no difference in estimated blood loss (p = 0.068), calculated blood loss (p = 0.720), total intraoperative fluid intake (p = 0.289), urine output (p = 0.421), Apgar 1 min (p = 0.830), Apgar 5 min (p = 0.138), phenylephrine consumption (p = 0.742), postoperative day 1 (POD1) hematocrit (p = 0.070) and POD1 platelets (p = 0.233). However, there was a statistically significant difference (but clinically irrelevant) in hematocrit difference between the day of admission and POD1 (mean difference 0.47, p = 0.024), and ephedrine consumption (mean difference 2 mg, p = 0.017) in favor of the control group. CONCLUSIONS Our study did not find an association between increased perioperative blood loss and hetastarch use in patients presenting for elective cesarean delivery.
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Affiliation(s)
- Abdullah S Terkawi
- Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA.,Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Sarah K Larkin
- Department of Obstetrics and Gynecology, University of Virginia, P.O. Box 800712, Charlottesville, VA, 22908, USA
| | - Siny Tsang
- Department of Epidemiology, Columbia University, 772 West 168th Street, New York, NY, 10032, USA
| | - Jessica S Sheeran
- Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA.
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78
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Rasmussen KC, Højskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Impact of Albumin on Coagulation Competence and Hemorrhage During Major Surgery: A Randomized Controlled Trial. Medicine (Baltimore) 2016; 95:e2720. [PMID: 26945358 PMCID: PMC4782842 DOI: 10.1097/md.0000000000002720] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
For patients exposed to a massive blood loss during surgery, maintained coagulation competence is important. It is less obvious whether coagulation competence influences bleeding during elective surgery where patients are exposed to infusion of a crystalloid or a colloid. This randomized controlled trial evaluates whether administration of 5% human albumin (HA) or lactated Ringer solution (LR) affects coagulation competence and in turn blood loss during cystectomy due to bladder cancer. Forty patients undergoing radical cystectomy were included to receive either 5% HA (n = 20) or LR (n = 20). Nineteen patients were analyzed in the HA group and 20 patients in the lactated Ringer group. Blinded determination of the blood loss was similar in the 2 groups of patients: 1658 (800-3300) mL with the use of HA and 1472 (700-4330) mL in the lactated Ringer group (P = 0.45). Yet, by thrombelastography (TEG) evaluated coagulation competence, albumin affected clot growth (TEG-angle 69 ± 5 vs 74° ± 3°, P < 0.01) and strength (TEG-MA: 59 ± 6 vs 67 ± 6 mm, P < 0.001) more than LR. Furthermore, by multivariate linear regression analyses reduced TEG-MA was independently associated with the blood loss (P = 0.042) while administration of albumin was related to the changes in TEG-MA (P = 0.029), aPPT (P < 0.022), and INR (P < 0.033). This randomized controlled trial demonstrates that administration of HA does not affect the blood loss as compared to infusion of LR. Also the use of HA did not affect the need for blood transfusion, the incidence of postoperative complications, or the hospital in-stay. Yet, albumin decreases coagulation competence during major surgery and the blood loss is related to TEG-MA rather than to plasma coagulation variables.
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Affiliation(s)
- Kirsten C Rasmussen
- From the Department of Anesthesiology (KCR, MH, IK, TK, HBN, BR, NHS); Department of Urology (LS); Center of Head and Orthopaedic Surgery (TP); Rigshospitalet, University of Copenhagen; Department of Transfusion Medicine, Rigshospitalet and Department of Surgery, Denmark, and University of Texas Health Medical School, Houston, TX, USA (PIJ)
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79
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Hosseinzadeh Maleki M, Derakhshan P, Rahmanian Sharifabad A, Amouzeshi A. Comparing the Effects of 5% Albumin and 6% Hydroxyethyl Starch 130/0.4 (Voluven) on Renal Function as Priming Solutions for Cardiopulmonary Bypass: A Randomized Double Blind Clinical Trial. Anesth Pain Med 2016; 6:e30326. [PMID: 27110527 PMCID: PMC4834664 DOI: 10.5812/aapm.30326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/26/2015] [Accepted: 08/17/2015] [Indexed: 11/25/2022] Open
Abstract
Background: The ideal strategy to prime the cardiopulmonary bypass (CPB) circuit in adult cardiac surgery is still a matter of debate. Objectives: In this retrospective study, we examined Albumin solution and hydroxyethyl starch (HES) for priming the CPB circuit and evaluated the differences in kidney function and bleeding and coagulation status in the two groups of patients. Patients and Methods: Sixty consecutive patients undergoing elective coronary artery bypass grafting were studied. Patients were excluded due to emergency surgery, history of cardiac surgery, history of receiving medication with antiplatelet agents except ASA 80 (mg/day) within the previous five days, preoperative coagulation disorder, left ventricular ejection fraction less than 50%, preoperative renal dysfunction (serum creatinine > 1.4 mg/dL), preoperative hepatic dysfunction (serum aspartate/alanine amino transferase > 60 U/l), preoperative electrolyte imbalance, known hypersensitivity to HES and chronic diuretic therapy. The patients were divided randomly into two groups of HES (n = 30) and Albumin (n = 30). Hemodynamic parameters, serum creatinine concentrations and glomerular filtration rate, PT, PTT and INR were measured. Early bleeding was measured according to the first 24-hour drainage from the tube. Hemodynamics and all laboratory measurements were performed after induction of anesthesia and at the morning of the first, second and third postoperative days in the ICU. Results: GFR differences were statistically lower in Albumin group in comparison with Group B at 24, 48 and 72 hours postoperation. Platelet count difference and postoperative bleeding were significantly lower in Albumin group. Conclusions: Administration of Albumin compared to HES in patients with a normal renal function results in a lower drop of GFR and platelet count, less bleeding and lower rise of serum creatinine.
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Affiliation(s)
| | - Pooya Derakhshan
- Department of Anesthesiology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Pooya Derakhshan, Department of Anesthesiology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-9123884643, Fax: +98-2164352326, E-mail:
| | - Amir Rahmanian Sharifabad
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Ahmad Amouzeshi
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences, Birjand, Iran
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Abstract
PURPOSE OF REVIEW Infusion therapy is essential in intravascular hypovolaemia and extravascular fluid deficits. Crystalloidal fluids and colloidal volume replacement affect blood coagulation when infused intravenously. The question remains if this side-effect of infusion therapy is clinically relevant in patients with and without bleeding manifestations, and if fluid-induced coagulopathy is a risk factor for anaemia, blood transfusion, and mortality, and a driver for resource use and costs. RECENT FINDINGS Pathomechanisms of dilutional coagulopathy and evidence for its clinical relevance in perioperative and critically ill patients are reviewed. Furthermore, the article discusses medicolegal aspects. SUMMARY The dose-dependent risk of dilutional coagulopathy differs between colloids (dextran > hetastarch > pentastarch > tetrastarch, gelatins > albumin). Risk awareness includes monitoring for early signs of side-effects. With rotational thromboelastometry/thrombelastography, the deterioration not only in clot strength but also in clot formation and in platelet interaction can be assessed. Fibrinogen concentrate administration may be considered in severe bleeding as well as relevant dilutional coagulopathy. Targeted doses of gelatins and tetrastarches seem to have no proven adverse effect on anaemia and allogeneic blood transfusions. Further studies are needed.
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81
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Rasmussen KC, Hoejskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Coagulation competence for predicting perioperative hemorrhage in patients treated with lactated Ringer's vs. Dextran--a randomized controlled trial. BMC Anesthesiol 2015; 15:178. [PMID: 26646213 PMCID: PMC4672483 DOI: 10.1186/s12871-015-0162-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 12/02/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Perioperative hemorrhage may depend on coagulation competence and this study evaluated the influence of coagulation competence on blood loss during cystectomy due to bladder cancer. METHODS Forty patients undergoing radical cystectomy were included in a randomized controlled trial to receive either lactated Ringer's solution or Dextran 70 (Macrodex ®) that affects coagulation competence. RESULTS By thrombelastography evaluated coagulation competence, Dextran 70 reduced "maximal amplitude" (MA) by 25 % versus a 1 % reduction with the administration of lactated Ringer's solution (P <0.001). Blinded evaluation of the blood loss was similar in the two groups of patients - 2339 ml with the use of Dextran 70 and 1822 ml in the lactated Ringer's group (P = 0.27). Yet, the blood loss was related to the reduction in MA (r = -0.427, P = 0.008) and by multiple regression analysis independently associated with MA (P = 0.01). Thus, 11 patients in the dextran group (58 %) developed a clinical significant blood loss (>1500 ml) compared to only four patients (22 %) in the lactated Ringer's group (P = 0.04). CONCLUSIONS With the use of Dextran 70 vs. lactated Ringer's solution during cystectomy, a relation between hemorrhage and coagulation competence is demonstrated. Significant bleeding develops based on an about 25 % reduction in thrombelastography determined maximal amplitude. A multivariable model including maximal amplitude discriminates patients with severe perioperative bleeding during cystectomy. TRIAL REGISTRATION The study was accepted on January 7(th), 2013 at www.clinicaltrialsregister.eu EudraCT 2012-005040-20.
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Affiliation(s)
- Kirsten C Rasmussen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Department of Anesthesiology, Rigshospitalet 2043, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
| | - Michael Hoejskov
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Per I Johansson
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Irina Kridina
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Kistorp
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Lisbeth Salling
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Henning B Nielsen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Birgitte Ruhnau
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Tom Pedersen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Niels H Secher
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Choi SS, Kim SH, Kim YK. Fluid management in living donor hepatectomy: Recent issues and perspectives. World J Gastroenterol 2015; 21:12757-12766. [PMID: 26668500 PMCID: PMC4671031 DOI: 10.3748/wjg.v21.i45.12757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/28/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.
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Na HS, Shin HJ, Lee YJ, Kim JH, Koo KH, Do SH. The effect of tranexamic acid on blood coagulation in total hip replacement arthroplasty: rotational thromboelastographic (ROTEM®) analysis. Anaesthesia 2015; 71:67-75. [PMID: 26559015 DOI: 10.1111/anae.13270] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2015] [Indexed: 11/30/2022]
Abstract
We evaluated changes in rotational thromboelastometry (ROTEM(®) ) parameters and clinical outcomes in patients undergoing total hip replacement arthroplasty, with concomitant infusions of tranexamic acid and of 6% hydroxyethyl starch 130/0.4. Fifty-five patients were randomly assigned to either the tranexamic acid (n = 29) or the control (n = 26) group. Hydroxyethyl starch was administered in the range of 10-15 ml.kg(-1) during the operation in both groups. In the control group, the clot formation time and maximum clot firmness of APTEM showed significant differences when compared with those of EXTEM at one hour postoperatively, suggestive of fibrinolysis. In the tranexamic acid group, there was no significant difference between each postoperative EXTEM and APTEM parameter. In the tranexamic acid and control group, postoperative blood loss was 308 ml (210-420 [106-745]) and 488 ml (375-620 [170-910], p = 0.002), respectively, and total blood loss was 1168 ml (922-1470 [663-2107]) and 1563 ml (1276-1708 [887-1494], p = 0.003). Haemoglobin concentration was higher in the tranexamic acid group on the second postoperative day (10.5 (9.4-12.1 [7.9-14.0]) vs. 9.6 (8.9-10.5[7.3-16.0]) g.dl(-1) , p = 0.027). In patients undergoing total hip replacement arthroplasty, postoperative fibrinolysis aggravated by hydroxyethyl starch was attenuated by co-administration of 10 mg.kg(-1) tranexamic acid, which may have led to less postoperative blood loss.
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Affiliation(s)
- H S Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - H J Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Y J Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - J H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - K H Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - S H Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
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Hill MD, Martin RH, Palesch YY, Moy CS, Tamariz D, Ryckborst KJ, Jones EB, Weisman D, Pettigrew C, Ginsberg MD. Albumin Administration in Acute Ischemic Stroke: Safety Analysis of the ALIAS Part 2 Multicenter Trial. PLoS One 2015; 10:e0131390. [PMID: 26325387 PMCID: PMC4556660 DOI: 10.1371/journal.pone.0131390] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 05/22/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Albumin treatment of ischemic stroke was associated with cardiopulmonary adverse events in previous studies and a low incidence of intracranial hemorrhage. We sought to describe the neurological and cardiopulmonary adverse events in the ALIAS Part 2 Multicenter Trial. METHODS Ischemic stroke patients, aged 18-83 and a baseline NIHSS ≥ 6, were randomized to treatment with ALB or saline control within 5 hours of stroke onset. Neurological adverse events included symptomatic intracranial hemorrhage, hemicraniectomy, neurological deterioration and neurological death. Cardiopulmonary adverse events included pulmonary edema/congestive heart failure, acute coronary syndromes, atrial fibrillation, pneumonia and pulmonary thromboembolism. RESULTS Among 830 patients, neurological and cardiopulmonary adverse events were not differentially associated with poor outcome between ALB and saline control subjects. The rate of symptomatic intracranial hemorrhage in the first 24h was low overall (2.9%, 24/830) but more common in the ALB treated subjects (RR = 2.4, CI95 1.01-5.8). The rate of pulmonary edema/CHF in the first 48h was 7.9% (59/830) and was more common among ALB treated subjects (RR = 10.7, CI95 4.3-26.6); this complication was expected and was satisfactorily managed with mandated diuretic administration and intravenous fluid guidelines. Troponin elevations in the first 48h were common, occurring without ECG change or cardiac symptoms in 52 subjects (12.5%). CONCLUSIONS ALB therapy was associated with an increase in symptomatic ICH and pulmonary edema/congestive heart failure but this did not affect final outcomes. Troponin elevation occurs routinely in the first 48 hours after acute ischemic stroke. TRIAL REGISTRATION ClincalTrials.gov NCT00235495.
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Affiliation(s)
- Michael D. Hill
- Departments of Clinical Neurosciences, Medicine, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Renee H. Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Yuko Y. Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Claudia S. Moy
- Office of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Diego Tamariz
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Karla J. Ryckborst
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Elizabeth B. Jones
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - David Weisman
- Abington Neurological Associates, Abington, Pennsylvania, United States of America
| | - Creed Pettigrew
- Department of Neurology and Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentuck, United States of America
| | - Myron D. Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
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Erdoes G, Gerster G, Colucci G, Kaiser H, Alberio L, Eberle B. Prediction of Post-Weaning Fibrinogen Status during Cardiopulmonary Bypass: An Observational Study in 110 Patients. PLoS One 2015; 10:e0126692. [PMID: 26011420 PMCID: PMC4444179 DOI: 10.1371/journal.pone.0126692] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
Background After cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels. Objective To assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning. Patients / Methods This prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy. Results Quantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83. Conclusions When measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
- * E-mail:
| | - Germaine Gerster
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | | | - Heiko Kaiser
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | - Lorenzo Alberio
- Hématologie non-maligne et Hémostase, Service et Laboratoire central d`Hématologie, University Hospital Lausanne, Lausanne, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
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86
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Evaluation of a novel transfusion algorithm employing point-of-care coagulation assays in cardiac surgery: a retrospective cohort study with interrupted time-series analysis. Anesthesiology 2015; 122:560-70. [PMID: 25485470 DOI: 10.1097/aln.0000000000000556] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cardiac surgery requiring the use of cardiopulmonary bypass is frequently complicated by coagulopathic bleeding that, largely due to the shortcomings of conventional coagulation tests, is difficult to manage. This study evaluated a novel transfusion algorithm that uses point-of-care coagulation testing. METHODS Consecutive patients who underwent cardiac surgery with bypass at one hospital before (January 1, 2012 to January 6, 2013) and after (January 7, 2013 to December 13, 2013) institution of an algorithm that used the results of point-of-care testing (ROTEM; Tem International GmBH, Munich, Germany; Plateletworks; Helena Laboratories, Beaumont, TX) during bypass to guide management of coagulopathy were included. Pre- and postalgorithm outcomes were compared using interrupted time-series analysis to control for secular time trends and other confounders. RESULTS Pre- and postalgorithm groups included 1,311 and 1,170 patients, respectively. Transfusion rates for all blood products (except for cryoprecipitate, which did not change) were decreased after algorithm institution. After controlling for secular pre- and postalgorithm time trends and potential confounders, the posttransfusion odds ratios (95% CIs) for erythrocytes, platelets, and plasma were 0.50 (0.32 to 0.77), 0.22 (0.13 to 0.37), and 0.20 (0.12 to 0.34), respectively. There were no indications that the algorithm worsened any of the measured processes of care or outcomes. CONCLUSIONS Institution of a transfusion algorithm based on point-of-care testing was associated with reduced transfusions. This suggests that the algorithm could improve the management of the many patients who develop coagulopathic bleeding after cardiac surgery. The generalizability of the findings needs to be confirmed.
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87
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Hans GA, Ledoux D, Roediger L, Hubert MB, Koch JN, Senard M. The Effect of Intraoperative 6% Balanced Hydroxyethyl Starch (130/0.4) During Cardiac Surgery on Transfusion Requirements. J Cardiothorac Vasc Anesth 2015; 29:328-32. [DOI: 10.1053/j.jvca.2014.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Indexed: 11/11/2022]
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Abstract
PURPOSE OF REVIEW The characteristics of an ideal intravenous fluid in the critically ill patient are discussed. RECENT FINDINGS Intravenous fluids are the most frequent drug administered to patients. Questioning the use of commonly administered intravenous fluids has resulted in an increased focus on their efficacy and safety. Discrimination between fluids currently in use has been the central theme of many recent large studies, and emerging from these findings is an understanding of characteristics that would make for an ideal fluid for critically ill patients. There is increased morbidity and mortality with high chloride-containing crystalloid solutions and hydroxyethyl starch preparations, with resultant international governmental agency warnings regarding hydroxyethyl starch . The ideal fluid is one which achieves the aim of administration while minimizing or negating adverse effects, is inexpensive, and sufficiently stable when stored to be used in a wide range of clinical settings. SUMMARY The ideal fluid currently does not exist. Of existing options, use of hydroxyethyl starches and high chloride-containing crystalloid solutions should be discouraged. There is a lack of direct evidence that a balanced crystalloid solution confers benefit, however, the trend of recent data would support future investigation into the advantage of balanced solution over 0.9% saline.
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Affiliation(s)
- Lyndal Russell
- Nepean Hospital, University of Sydney, Penrith, New South Wales, Australia
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89
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Opperer M, Poeran J, Rasul R, Mazumdar M, Memtsoudis SG. Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis. BMJ 2015; 350:h1567. [PMID: 25817299 PMCID: PMC4376265 DOI: 10.1136/bmj.h1567] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications. DESIGN Retrospective cohort study of population based data between 2006 and 2013. SETTING Data from 510 different hospitals across the United States participating in the Premier Perspective database. PARTICIPANTS 1,051,441 patients undergoing elective total hip and knee arthroplasties. EXPOSURES Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither. MAIN OUTCOME MEASURES Acute renal failure and thromboembolic, cardiac, and pulmonary complications. RESULTS Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased. CONCLUSIONS Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.
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Affiliation(s)
- Mathias Opperer
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rehana Rasul
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York
| | - Stavros G Memtsoudis
- Weill Cornell Medical College, Department of Healthcare Policy and Research, New York; Department of Anesthesiology, Hospital for Special Surgery, New York; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg
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Comparison of normal saline, hypertonic saline albumin and terlipressin plus hypertonic saline albumin in an infant animal model of hypovolemic shock. PLoS One 2015; 10:e0121678. [PMID: 25794276 PMCID: PMC4368553 DOI: 10.1371/journal.pone.0121678] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/03/2015] [Indexed: 11/19/2022] Open
Abstract
Introduction In series of cases and animal models suffering hemorrhagic shock, the use of vasopressors has shown potential benefits regarding hemodynamics and tissue perfusion. Terlipressin is an analogue of vasopressin with a longer half-life that can be administered by bolus injection. We have previously observed that hypertonic albumin improves resuscitation following controlled hemorrhage in piglets. The aim of the present study was to analyze whether the treatment with the combination of terlipressin and hypertonic albumin can produce better hemodynamic and tissular perfusion parameters than normal saline or hypertonic albumin alone at early stages of hemorrhagic shock in an infant animal model. Methods Experimental, randomized animal study including 39 2-to-3-month-old piglets. Thirty minutes after controlled 30 ml/kg bleed, pigs were randomized to receive either normal saline (NS) 30 ml/kg (n = 13), 5% albumin plus 3% hypertonic saline (AHS) 15 ml/kg (n = 13) or single bolus of terlipressin 15 μg/kg i.v. plus 5% albumin plus 3% hypertonic saline 15 ml/kg (TAHS) (n = 13) over 30 minutes. Global hemodynamic and tissular perfusion parameters were compared. Results After controlled bleed a significant decrease of blood pressure, cardiac index, central venous saturation, carotid and peripheral blood flow, brain saturation and an increase of heart rate, gastric PCO2 and lactate was observed. After treatment no significant differences in most hemodynamic (cardiac index, mean arterial pressure) and perfusion parameters (lactate, gastric PCO2, brain saturation, cutaneous blood flow) were observed between the three therapeutic groups. AHS and TAHS produced higher increase in stroke volume index and carotid blood flow than NS. Conclusions In this pediatric animal model of hypovolemic shock, albumin plus hypertonic saline with or without terlipressin achieved similar hemodynamics and perfusion parameters than twice the volume of NS. Addition of terlipressin did not produce better results than AHS.
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Van der Linden P, Dumoulin M, Van Lerberghe C, Torres CS, Willems A, Faraoni D. Efficacy and safety of 6% hydroxyethyl starch 130/0.4 (Voluven) for perioperative volume replacement in children undergoing cardiac surgery: a propensity-matched analysis. Crit Care 2015; 19:87. [PMID: 25886765 PMCID: PMC4376346 DOI: 10.1186/s13054-015-0830-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 02/20/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Six percent hydroxyethyl starch (HES) 130/0.4 is considered an alternative to human albumin (HA) and crystalloids for volume replacement in children undergoing cardiac surgery. In this large propensity-matched analysis, we aimed to assess the efficacy and safety of replacing HA with HES for intraoperative volume therapy in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS We retrospectively reviewed our database, including children who underwent cardiac surgery between January 2002 and December 2010. Four percent HA was used until 2005; it was replaced by HES thereafter. Demographic data, intra- and postoperative blood loss and blood component transfusions were recorded, together with the incidence of postoperative complications and mortality. We performed a propensity-matched analysis using 13 possible confounding factors to compare children who received either HES or HA intraoperatively. The primary objectives included the effects of both fluids on intraoperative fluid balance (difference between fluids in and fluids out (efficacy)) and blood loss and exposure to allogeneic blood products (safety). Secondary safety outcomes were mortality and the incidence of postoperative renal dysfunction. RESULTS Of 1,832 children reviewed, 1,495 were included in the analysis. Intraoperative use of HES was associated with a less positive fluid balance. Perioperative blood loss, volume of red blood cells and fresh frozen plasma administered, as well as the number of children who received transfusions, were also significantly lower in the HES group. No difference was observed regarding the incidence of postoperative renal failure requiring renal replacement therapy or of morbidity and mortality. CONCLUSIONS These results confirm that the use of HES for volume replacement in children during cardiac surgery with CPB is as safe as HA. In addition, its use might be associated with less fluid accumulation. Further large studies are needed to assess whether the reduction in fluid accumulation could have a significant impact on postoperative morbidity and mortality.
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Affiliation(s)
- Philippe Van der Linden
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola Children's University Hospital, Free University of Brussels, 4 Place Van Gehuchten, B-1020, Brussels, Belgium.
| | - Melanie Dumoulin
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola Children's University Hospital, Free University of Brussels, 4 Place Van Gehuchten, B-1020, Brussels, Belgium.
| | - Celine Van Lerberghe
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola Children's University Hospital, Free University of Brussels, 4 Place Van Gehuchten, B-1020, Brussels, Belgium.
| | - Cristel Sanchez Torres
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola Children's University Hospital, Free University of Brussels, 4 Place Van Gehuchten, B-1020, Brussels, Belgium.
| | - Ariane Willems
- Pediatric Intensive Care Unit, Queen Fabiola Children's University Hospital, Free University of Brussels, 15 Avenue JJ Crocq, B-1020, Brussels, Belgium.
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Pathirana S, Wong G, Williams P, Yang K, Kershaw G, Dunkley S, Kam PCA. The Effects of Haemodilution with Albumin on Coagulation in Vitro as Assessed by Rotational Thromboelastometry. Anaesth Intensive Care 2015; 43:187-92. [DOI: 10.1177/0310057x1504300207] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with 4% albumin compared with normal saline (NS) using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany). Whole blood samples obtained from 20 healthy volunteers were diluted in vitro with 4% albumin or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM® (EXTEM [screening test for the extrinsic haemostasis system], FIBTEM [EXTEM-based assay for the fibrin part of the clot]) variables including coagulation time, clot formation time (CFT), α-angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each degree of haemodilution. There was no significant difference in fibrinogen concentration at equivalent haemodilutions with normal saline and 4% albumin solutions. Forty percent haemodilution with albumin significantly prolonged coagulation time (EXTEM P=0.007, FIBTEM P=0.0001) and significantly decreased lysis index (FIBTEM P=0.009) compared with NS. A significant decrease in maximum clot firmness from undiluted measurements ( P=0.05) was observed at lower haemodilutions with albumin (20% with EXTEM, 10% with FIBTEM) compared with NS (40% with EXTEM and FIBTEM). The adverse effects of large degrees of haemodilution with 4% albumin solution are in excess of what can be explained by haemodilution alone. This study suggests that large degrees of haemodilution with albumin impair fibrinogen activity to a greater extent than equivalent degrees of haemodilution with NS.
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Affiliation(s)
- S. Pathirana
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K. Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S. Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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93
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Chana AS, Mahajan RP. BJA 2014; An overview. Br J Anaesth 2015; 114:ix-xvi. [PMID: 25500411 DOI: 10.1093/bja/aeu455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A S Chana
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
| | - R P Mahajan
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
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94
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Cazzolli D, Prittie J. The crystalloid-colloid debate: Consequences of resuscitation fluid selection in veterinary critical care. J Vet Emerg Crit Care (San Antonio) 2015; 25:6-19. [DOI: 10.1111/vec.12281] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 10/30/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Dava Cazzolli
- Animal Medical Center; Department of Emergency and Critical Care; New York NY
| | - Jennifer Prittie
- Animal Medical Center; Department of Emergency and Critical Care; New York NY
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95
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Base E, Dworschak M, Skhirtladze-Dworschak K, Lassnigg A. Comparison of the effects of albumin 5%, hydroxyethyl starch 130/0.4 6%, and Ringer's lactate: Reply to Prof Priebe. Br J Anaesth 2015; 114:342-3. [PMID: 25596220 DOI: 10.1093/bja/aeu470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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96
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Priebe HJ. Problematic comparisons. Br J Anaesth 2015; 114:341-2. [PMID: 25596219 DOI: 10.1093/bja/aeu469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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97
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Novy E, Levy B. Choc hémorragique : aspects physiopathologiques et prise en charge hémodynamique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-014-1014-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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98
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Teoh WHL, Westphal M, Kampmeier TG. Update on volume therapy in obstetrics. Best Pract Res Clin Anaesthesiol 2014; 28:297-303. [PMID: 25208964 DOI: 10.1016/j.bpa.2014.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/02/2014] [Accepted: 07/04/2014] [Indexed: 11/26/2022]
Abstract
Symptomatic hypotension (maternal nausea, vomiting, dizziness and dyspnoea) during spinal anaesthesia for caesarean delivery remains a prevalent clinical problem. Severe and sustained hypotension can lead to impairment of uteroplacental perfusion, foetal hypoxia, acidosis, neonatal depression and further adverse maternal outcomes of unconsciousness, pulmonary aspiration, apnoea and cardiac arrest. Mechanical methods aimed at countering the effects of aortocaval compression do not reliably prevent maternal hypotension. Intravenous crystalloid preloading (given prior to administration of spinal anaesthesia) has poor efficacy, and focus has changed towards decreased use of crystalloid preload and ephedrine, to increased use of coload (given at the time of spinal administration) with colloids or crystalloids, and early use of phenylephrine. The recent multicentre, randomised, double-blinded CAESAR trial demonstrated the efficacy of a mixed 500 ml 6% hydroxyethyl starch (HES) 130/0.4 + 500 ml Ringer's lactate (RL) preload in significantly reducing hypotension, compared to a 1-l RL preload, without adverse effects on coagulation and neonatal outcomes in healthy parturients undergoing caesarean delivery under spinal anaesthesia.
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Affiliation(s)
- Wendy H L Teoh
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore; Duke University - NUS Graduate Medical School, Singapore.
| | - Martin Westphal
- Department of Anaesthesiology, Pain Medicine and Intensive Care, University Hospital of Muenster, Muenster, Germany; Fresenius Kabi AG, Bad Homburg, Germany.
| | - Tim G Kampmeier
- Department of Anaesthesiology, Pain Medicine and Intensive Care, University Hospital of Muenster, Muenster, Germany.
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99
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Yates DRA, Davies SJ, Warnakulasuriya SR, Wilson RJT. Volume Management and Resuscitation in Colorectal Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0078-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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100
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Sponholz C, Schelenz C, Reinhart K, Schirmer U, Stehr SN. Catecholamine and volume therapy for cardiac surgery in Germany--results from a postal survey. PLoS One 2014; 9:e103996. [PMID: 25084362 PMCID: PMC4118968 DOI: 10.1371/journal.pone.0103996] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 07/05/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Management of cardiac surgery patients is a very standardized procedure in respective local institutions. Yet only very limited evidence exists concerning optimal indication, safety and efficacy of hemodynamic monitoring catecholamine and fluid therapy. METHODS Between April and May 2013, all 81 German anaesthesia departments involved in cardiac surgery care were asked to participate in a questionnaire addressing the institutional specific current practice in hemodynamic monitoring, catecholamine and volume therapy. RESULTS 51 (63%) questionnaires were completed and returned. All participating centers used basic hemodynamic monitoring (i.e. invasive arterial blood pressure and central venous pressure), supplemented by transesophageal echocardiography. Pulmonary arterial catheter and calibrated trend monitoring devices were also routinely available. In contrast, non-calibrated trend monitoring and esophageal doppler ultrasound devices were not commonly in use. Cerebral oximetry is increasingly emerging, but lacks clear indications. The majority of patients undergoing cardiac surgery, especially in university hospitals, required catecholamines during perioperative care, In case of low cardiac output syndrome, dobutamine (32%), epinephrine (30%) or phosphodiesterase inhibitors (8%) were first choice. In case of hypotension following vasoplegia, norepinephrine (96%) represented the most common catecholamine. 88% of the participating centers reported regular use of colloid fluids, with hydroxyethyl starches (HES) being first choice (64%). CONCLUSIONS Choice of hemodynamic monitoring is homogenous throughout German centers treating cardiac surgery patients. Norepinephrine is the first line catecholamine in cases of decrease in peripheral vascular resistance. However, catecholamine choice for low cardiac output syndrome varies considerably. HES was the primary colloid used for fluid resuscitation. After conduct of this survey, HES use was restricted by European regulatory authorities in critically ill patients and should only be considered as second-line fluid in surgical patients without renal impairment or severe coagulopathy. Large clinical studies addressing catecholamine and fluid therapy in cardiac surgery patients are lacking.
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Affiliation(s)
- Christoph Sponholz
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
- * E-mail:
| | - Christoph Schelenz
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Uwe Schirmer
- Institute of Anaesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | - Sebastian N. Stehr
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
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