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Raspé C, Flöther L, Schneider R, Bucher M, Piso P. Best practice for perioperative management of patients with cytoreductive surgery and HIPEC. Eur J Surg Oncol 2016; 43:1013-1027. [PMID: 27727026 DOI: 10.1016/j.ejso.2016.09.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/01/2016] [Accepted: 09/13/2016] [Indexed: 12/17/2022] Open
Abstract
Due to the significantly improved outcome and quality of life of patients with different tumor entities after cytoreductive surgery (CRS) and HIPEC, there is an increasing number of centers performing CRS and HIPEC procedures. As this procedure is technically challenging with potential high morbidity and mortality, respectively, institutional experience also in the anesthetic and intensive care departments is essential for optimal treatment and prevention of adverse events. Clinical pathways have to be developed to achieve also good results in more comorbid patients with border line indications and extensive surgical procedures. The anesthesiologist has deal with relevant fluid, blood and protein losses, increased intraabdominal pressure, systemic hypo-/hyperthermia, and increased metabolic rate in patients undergoing cytoreductive surgery with HIPEC. It is of utmost importance to maintain or restore an adequate volume by aggressive substitution of intravenous fluids, which counteracts the increased fluid loss and venous capacitance during this procedure. Supplementary thoracic epidural analgesia, non-invasive ventilation, and physiotherapy are recommended to guarantee adequate pain therapy and postoperative extubation as well as fast-track concepts. Advanced hemodynamic monitoring is essential to help the anesthesiologist picking up information about the real-time fluid status of the patient. Preoperative preconditioning is mandatory in patients scheduled for HIPEC surgery and will result in improved outcome. Postoperatively, volume status optimization, early nutritional support, sufficient anticoagulation, and point of care coagulation management are essential. This is an extensive update on all relevant topics for anesthetists and intensivists dealing with CRS and HIPEC.
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Affiliation(s)
- C Raspé
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany.
| | - L Flöther
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany
| | - R Schneider
- Department of General- and Visceral Surgery, Halle-Wittenberg University, Germany
| | - M Bucher
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany
| | - P Piso
- Department for General- and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
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Pagano MB, Harmon C, Cooling L, Connelly-Smith L, Mann SA, Pham HP, Marques MB, Schlueter AJ, Case R, King KE, Cataife G, Wu Y, Wong ECC, Winters JL. Use of hydroxyethyl starch in leukocytapheresis procedures does not increase renal toxicity. Transfusion 2016; 56:2848-2856. [DOI: 10.1111/trf.13795] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/17/2016] [Accepted: 07/17/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Monica B. Pagano
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Charles Harmon
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | - Laura Cooling
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | | | - Steven A. Mann
- University of Alabama School of Medicine; Birmingham Alabama
| | - Huy P. Pham
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
| | - Marisa B. Marques
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
| | | | - Rosemary Case
- Division of Transfusion Medicine; Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Karen E. King
- Division of Transfusion Medicine; Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Guido Cataife
- Health Division; IMPAQ International; Columbia Maryland
| | - Yanyun Wu
- Bloodworks Northwest; Seattle Washington
| | - Edward C. C. Wong
- Division of Laboratory Medicine, Departments of Pediatrics and Pathology, Children's National Medical Center; George Washington School of Medicine and Health Sciences; Washington DC
| | - Jeffrey L. Winters
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine; Mayo Clinic; Rochester Minnesota
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Brooks A, Thomovsky E, Johnson P. Natural and Synthetic Colloids in Veterinary Medicine. Top Companion Anim Med 2016; 31:54-60. [PMID: 27968754 DOI: 10.1053/j.tcam.2016.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/04/2016] [Indexed: 01/09/2023]
Abstract
This review article covers basic physiology underlying the clinical use of natural and artificial colloids as well as provide practice recommendations. It also touches on the recent scrutiny of these products in human medicine and how this may have an effect on their use in veterinary medicine.
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Affiliation(s)
- Aimee Brooks
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, IN, USA.
| | - Elizabeth Thomovsky
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, IN, USA
| | - Paula Johnson
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, IN, USA
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McIntyre L, Rowe BH, Walsh TS, Gray A, Arabi Y, Perner A, Gordon A, Marshall J, Cook D, Fox-Robichaud A, Bagshaw SM, Green R, Schweitzer I, Turgeon A, Zarychanski R, English S, Chassé M, Stiell I, Fergusson D. Multicountry survey of emergency and critical care medicine physicians' fluid resuscitation practices for adult patients with early septic shock. BMJ Open 2016; 6:e010041. [PMID: 27388345 PMCID: PMC4947761 DOI: 10.1136/bmjopen-2015-010041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Evidence to guide fluid resuscitation evidence in sepsis continues to evolve. We conducted a multicountry survey of emergency and critical care physicians to describe current stated practice and practice variation related to the quantity, rapidity and type of resuscitation fluid administered in early septic shock to inform the design of future septic shock fluid resuscitation trials. METHODS Using a web-based survey tool, we invited critical care and emergency physicians in Canada, the UK, Scandinavia and Saudi Arabia to complete a self-administered electronic survey. RESULTS A total of 1097 physicians' responses were included. 1 L was the most frequent quantity of resuscitation fluid physicians indicated they would administer at a time (46.9%, n=499). Most (63.0%, n=671) stated that they would administer the fluid challenges as quickly as possible. Overall, normal saline and Ringer's solutions were the preferred crystalloid fluids used 'often' or 'always' in 53.1% (n=556) and 60.5% (n=632) of instances, respectively. However, emergency physicians indicated that they would use normal saline 'often' or 'always' in 83.9% (n=376) of instances, while critical care physicians said that they would use saline 'often' or 'always' in 27.9% (n=150) of instances. Only 1.0% (n=10) of respondents indicated that they would use hydroxyethyl starch 'often' or 'always'; use of 5% (5.6% (n=59)) or 20-25% albumin (1.3% (n=14)) was also infrequent. The majority (88.4%, n=896) of respondents indicated that a large randomised controlled trial comparing 5% albumin to a crystalloid fluid in early septic shock was important to conduct. CONCLUSIONS Critical care and emergency physicians stated that they rapidly infuse volumes of 500-1000 mL of resuscitation fluid in early septic shock. Colloid use, specifically the use of albumin, was infrequently reported. Our survey identifies the need to conduct a trial on the efficacy of albumin and crystalloids on 90-day mortality in patients with early septic shock.
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Affiliation(s)
- Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Timothy S Walsh
- Department of Anaesthetics, Critical Care, and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Anders Perner
- Department of Intensive Care, Ringshospitalet, Copenhagen, Denmark
| | - Anthony Gordon
- Department of Anaesthesia, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - John Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Deborah Cook
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Alison Fox-Robichaud
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sean M Bagshaw
- Faculty of Medicine and Dentistry, Division of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Robert Green
- Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Alexis Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practice Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec Research Center, CHU de Québec (Hôpital de l'Enfant-Jésus), Laval, Québec City, Québec, Canada
| | | | - Shane English
- Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michaël Chassé
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean Fergusson
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
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Prediction and Prevention of Acute Kidney Injury after Cardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2985148. [PMID: 27419130 PMCID: PMC4935903 DOI: 10.1155/2016/2985148] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 12/17/2022]
Abstract
The incidence of acute kidney injury after cardiac surgery (CS-AKI) ranges from 33% to 94% and is associated with a high incidence of morbidity and mortality. The etiology is suggested to be multifactorial and related to almost all aspects of perioperative management. Numerous studies have reported the risk factors and risk scores and novel biomarkers of AKI have been investigated to facilitate the subclinical diagnosis of AKI. Based on the known independent risk factors, many preventive interventions to reduce the risk of CS-AKI have been tested. However, any single preventive intervention did not show a definite and persistent benefit to reduce the incidence of CS-AKI. Goal-directed therapy has been considered to be a preventive strategy with a substantial level of efficacy. Many pharmacologic agents were tested for any benefit to treat or prevent CS-AKI but the results were conflicting and evidences are still lacking. The present review will summarize the current updated evidences about the risk factors and preventive strategies for CS-AKI.
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107
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Pinsky MR. The cost of shock resuscitation treatment decisions. THE LANCET RESPIRATORY MEDICINE 2016; 4:769-770. [PMID: 27324966 DOI: 10.1016/s2213-2600(16)30140-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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108
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Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Anaesth Crit Care Pain Med 2016; 35:151-65. [PMID: 27235292 DOI: 10.1016/j.accpm.2016.03.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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109
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Roger C, Louart B, Louart G, Bobbia X, Claret PG, Perez-Martin A, Muller L, Lefrant JY. Does the infusion rate of fluid affect rapidity of mean arterial pressure restoration during controlled hemorrhage. Am J Emerg Med 2016; 34:1743-9. [PMID: 27397668 DOI: 10.1016/j.ajem.2016.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/10/2016] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE This study aimed to compare 2 fluid infusion rates of lactated Ringer (LR) and hydroxyethyl starch (HES) 130/0.4 on hemodynamic restoration at the early phase of controlled hemorrhagic shock. METHODS Fifty-six anesthetized and ventilated piglets were bled until mean arterial pressure (MAP) reached 40 mm Hg. Controlled hemorrhage was maintained for 30 minutes. After this period, 4 resuscitation groups were studied (n=14 for each group): HES infused at 1 or 4mL/kg per minute or LR1 infused at 1 or 4mL/kg per minute until baseline MAP was restored. Hemodynamic assessment using PiCCO monitoring and biological data were collected. RESULTS Time to restore baseline MAP ±10% was significantly lower in LR4 group (11±11 minutes) compared to LR1 group (41±25 minutes) (P=.0004). Time to restore baseline MAP ±10% was significantly lower in HES4 group (4±3 minutes) compared to HES1 (11±4 minutes) (P=.0003). Time to restore baseline MAP ±10% was significantly lower with HES vs LR whatever the infusion rate. No statistically significant difference was observed in cardiac output, central venous saturation, extravascular lung water, and arterial lactate between 4 and 1 mL/kg per minute groups. CONCLUSIONS In this controlled hemorrhagic shock model, a faster infusion rate (4 vs 1mL/kg per minute) significantly decreased the time for restoring baseline MAP, regardless of the type of infused fluid. The time for MAP restoration was significantly shorter for HES as compared to LR whatever the fluid infusion rate.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Benjamin Louart
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Guillaume Louart
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Xavier Bobbia
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Pierre-Geraud Claret
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France
| | - Antonia Perez-Martin
- Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Laurent Muller
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France.
| | - Jean-Yves Lefrant
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
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Ma PL, Peng XX, Du B, Hu XL, Gong YC, Wang Y, Xi XM. Sources of Heterogeneity in Trials Reporting Hydroxyethyl Starch 130/0.4 or 0.42 Associated Excess Mortality in Septic Patients: A Systematic Review and Meta-regression. Chin Med J (Engl) 2016; 128:2374-82. [PMID: 26315087 PMCID: PMC4733795 DOI: 10.4103/0366-6999.163387] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: This meta-analysis was to determine the association of the cumulative dose of 130/0.4 or 0.42 (hydroxyethyl starch [HES] 130/0.4*) or delta daily fluid balance (i.e., daily fluid balance in HES group over or below control group) with the heterogeneity of risk ratio (RR) for mortality in randomized control trials (RCTs). Methods: Three databases (PubMed, EMBASE, Cochrane) were searched to identify prospective RCTs reporting mortality in adult patients with sepsis to compare HES130/0.4* with crystalloids or albumin. Meta-analysis was performed using random effects. Sensitivity and meta-regression analyses were used to examine the heterogeneity sources of RR for mortality. Results: A total number of 4408 patients from 11 RCTs were included. The pooled RR showed no significant difference for overall mortality in patients with administration of HES130/0.4* compared with treatment of control fluids (RR: 1.02, 95% confidence interval: 0.90–1.17; P = 0.73). Heterogeneity was moderate across recruited trials (I2 = 34%, P = 0.13). But, a significant variation was demonstrated in subgroup with crystalloids as control fluids (I2= 42%, P < 0.1). Sensitivity analysis revealed that trials with high risk of bias did not significantly impact the pooled estimates for mortality. Meta-regression analysis also did not determine a dose-effect relationship of HES130/0.4* with mortality (P = 0.298), but suggested daily delta fluid balance being likely associated with mortality in septic patients receiving HES130/130/0.4* (P = 0.079). Conclusions: Inappropriate daily positive fluid balance was likely an important source of heterogeneity in these trials reporting HES130/0.4* associated with excess mortality in septic patients.
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Affiliation(s)
- Peng-Lin Ma
- Department of Critical Care Medicine, 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
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111
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Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. DATA SOURCES Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HUMAN DATA SYNTHESIS HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. VETERINARY DATA SYNTHESIS The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. CONCLUSIONS Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.
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Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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112
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Association between Initial Fluid Choice and Subsequent In-hospital Mortality during the Resuscitation of Adults with Septic Shock. Anesthesiology 2016; 123:1385-93. [PMID: 26414499 DOI: 10.1097/aln.0000000000000861] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Currently, guidelines recommend initial resuscitation with intravenous (IV) crystalloids during severe sepsis/septic shock. Albumin is suggested as an alternative. However, fluid mixtures are often used in practice, and it is unclear whether the specific mixture of IV fluids used impacts outcomes. The objective of this study is to test the hypothesis that the specific mixture of IV fluids used during initial resuscitation, in severe sepsis, is associated with important in-hospital outcomes. METHODS Retrospective cohort study includes patients with severe sepsis who were resuscitated with at least 2 l of crystalloids and vasopressors by hospital day 2, patients who had not undergone any major surgical procedures, and patients who had a hospital length of stay (LOS) of at least 2 days. Inverse probability weighting, propensity score matching, and hierarchical regression methods were used for risk adjustment. Patients were grouped into four exposure categories: recipients of isotonic saline alone ("Sal" exclusively), saline in combination with balanced crystalloids ("Sal + Bal"), saline in combination with colloids ("Sal + Col"), or saline in combination with balanced crystalloids and colloids ("Sal + Bal + Col"). In-hospital mortality was the primary outcome, and hospital LOS and costs per day (among survivors) were secondary outcomes. RESULTS In risk-adjusted Inverse Probability Weighting analyses including 60,734 adults admitted to 360 intensive care units across the United States between January 2006 and December 2010, in-hospital mortality was intermediate in the Sal group (20.2%), lower in the Sal + Bal group (17.7%, P < 0.001), higher in the Sal + Col group (24.2%, P < 0.001), and similar in the Sal + Bal + Col group (19.2%, P = 0.401). In pairwise propensity score-matched comparisons, the administration of balanced crystalloids by hospital day 2 was consistently associated with lower mortality, whether colloids were used (relative risk, 0.84; 95% CI, 0.76 to 0.92) or not (relative risk, 0.79; 95% CI, 0.70 to 0.89). The association between colloid use and in-hospital mortality was inconsistent, and survival was not uniformly affected, whereas LOS and costs per day were uniformly increased. Results were robust in sensitivity analyses. CONCLUSIONS During the initial resuscitation of adults with severe sepsis/septic shock, the types of IV fluids used may impact in-hospital mortality. When compared with the administration of isotonic saline exclusively during resuscitation, the coadministration of balanced crystalloids is associated with lower in-hospital mortality and no difference in LOS or costs per day. When colloids are coadministered, LOS and costs per day are increased without improved survival. A large randomized controlled trial evaluating crystalloid choice is warranted. Meanwhile, the use of balanced crystalloids seems reasonable. (Anesthesiology 2015; 123:1385-93).
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113
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Wiedermann CJ, Bellomo R, Perner A. Is the literature inconclusive about the harm from HES? No. Intensive Care Med 2016; 43:1523-1525. [PMID: 27007101 PMCID: PMC7728630 DOI: 10.1007/s00134-016-4275-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 02/15/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Christian J Wiedermann
- Department of Internal Medicine, Central Hospital of Bolzano, Lorenz-Böhler-Street 5, 39100, Bolzano, BZ, Italy.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
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114
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Weyker PD, Pérez XL, Liu KD. Management of Acute Kidney Injury and Acid-Base Balance in the Septic Patient. Clin Chest Med 2016; 37:277-88. [PMID: 27229644 DOI: 10.1016/j.ccm.2016.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is an abrupt decrease in kidney function that takes place over hours to days. Sepsis is the leading cause of AKI and portends a particularly high morbidity and mortality, although the severity may vary from a transient rise in serum creatinine to end-stage renal disease. With regard to acid-base management in septic AKI, caution should be used with hyperchloremic crystalloid solutions, and dialysis is often used in the setting of severe acidosis. In the future, biomarkers may help clinicians identify AKI earlier and allow for potential interventions before the development of severe AKI.
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Affiliation(s)
- Paul D Weyker
- Division of Critical Care, Department of Anesthesia, Columbia University, 630 West, 160th Street, New York, NY 10032, USA
| | - Xosé L Pérez
- Intensive Care Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Kathleen D Liu
- Division of Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA.
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Reanimación con fluidos: perspectiva actual. Med Clin (Barc) 2016; 146:128-32. [DOI: 10.1016/j.medcli.2015.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 10/19/2015] [Accepted: 10/21/2015] [Indexed: 12/30/2022]
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Williams P, Yang K, Kershaw G, Wong G, Dunkley S, Kam PCA. The effects of haemodilution with hydroxyethyl starch 130/0.4 solution on coagulation as assessed by thromboelastography and platelet receptor function studies in vitro. Anaesth Intensive Care 2016; 43:734-9. [PMID: 26603798 DOI: 10.1177/0310057x1504300611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the effects of haemodilution with either 6% hydroxyethyl starch (HES) 130/0.4 (Voluven(®)) or 0.9% normal saline (NS) on blood coagulation in vitro. Haemodilution with 6% HES 130/0.4 impaired coagulation, as indicated by the changes in thromboelastographic parameters k-time, α-angle and maximum amplitude. Light transmission aggregometry and multiple electrode aggregometry demonstrated that impaired platelet receptor function occurred only at high levels of haemodilution (40%) with both fluids, but there was no significant difference between the two fluids (P=0.05). The thromboelastographic functional fibrinogen assay showed that the fibrinogen component of clot strength was significantly impaired with haemodilution with HES 130/0.4 compared with haemodilution with NS (whole blood [14.4 ± 4.6 mm] versus 40% HES dilution [3.7 ± 1.9], [P=0.001]; versus 40% NS dilution [10.4 ± 4.6], [P=0.129]). These findings suggest that there is little difference between HES or NS in relation to coagulation or platelet function during minor or moderate haemodilution, but at high levels of haemodilution with HES, fibrinogen activity is more impaired compared with NS.
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Affiliation(s)
- 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
| | - G Wong
- Department of Anaesthetics, 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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Abstract
PURPOSE OF REVIEW In shock states, optimizing intravascular volume is crucial to promote an adequate oxygen delivery to the tissues. Our current practice in fluid management pivots on the Frank-Starling law of the heart, and the effects of fluids are measured according to the induced changes on stroke volume. The purpose of this review is to evaluate the boundaries of current macrohemodynamic approach to fluid administration, and to introduce the microcirculatory integration as a fundamental part of tissue perfusion monitoring. RECENT FINDINGS Macrocirculatory changes induced by volume expansion are not always coupled to proportional changes in microcirculatory perfusion. Loss of hemodynamic coherence limits the value of guiding fluid therapy according to macrohemodynamics, and highlights the importance of evaluating the ultimate target of volume administration, the microcirculation. SUMMARY Current approach to intravascular volume optimization is made from a macrohemodynamic perspective. However, several situations wherein macrocirculatory and microcirculatory coherence is lost have been described. Future clinical trials should explore the usefulness of integrating the microcirculatory evaluation in fluid optimization.
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118
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Prowle JR, Bellomo R. Sepsis-associated acute kidney injury: macrohemodynamic and microhemodynamic alterations in the renal circulation. Semin Nephrol 2015; 35:64-74. [PMID: 25795500 DOI: 10.1016/j.semnephrol.2015.01.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Traditionally, renal ischemia has been regarded as central to the pathogenesis of sepsis-associated acute kidney injury (SA-AKI). Accordingly, hemodynamic management of SA-AKI has emphasized restoration of renal perfusion, whereas, experimentally, ischemia reperfusion models have been emphasized. However, in human beings, SA-AKI usually is accompanied by hyperdynamic circulation. Moreover, clinical and experimental evidence now suggests the importance of inflammatory mechanisms in the development of AKI and microcirculatory dysfunction more than systemic alteration in renal perfusion. In this review, we examine systemic, regional, and microcirculatory hemodynamics in SA-AKI, and attempt to rationalize the hemodynamic management of this condition.
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Affiliation(s)
- John R Prowle
- Adult Critical Care Unit, Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, UK; William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
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Markers of endothelial damage and coagulation impairment in patients with severe sepsis resuscitated with hydroxyethyl starch 130/0.42 vs Ringer acetate. J Crit Care 2015; 32:16-20. [PMID: 26810483 DOI: 10.1016/j.jcrc.2015.11.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/10/2015] [Accepted: 11/26/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE The Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial showed increased mortality in patients resuscitated with hydroxyethyl starch 130/0.42 (HES) vs Ringer acetate. Different effects of the fluids on the endothelium may have contributed to the observed outcome. We aimed to investigate associations between HES vs Ringer and changes in plasma biomarkers reflecting endothelial damage and coagulation impairment. MATERIALS AND METHODS Six biomarkers, including soluble thrombomodulin (sTM) and plasminogen activator inhibitor 1 (PAI-1), were assessed in a subgroup of 208 patients from the 6S trial. We analyzed differences in plasma concentration in the 2 intervention groups using linear or logistic regression models. RESULTS The increase in plasma sTM was lower in the HES group (-1.8 ng/mL; 95% confidence interval, -2.9 to -0.7; P = .002). The change was not statistically significant associated with mortality whereas increase in plasminogen activator inhibitor 1 was (odds ratio for 1-unit increase, 1.04; 95% confidence interval, 1.01-1.08; P = .01). CONCLUSIONS Resuscitation with HES vs Ringer decreased early endothelial damage. Although this finding should be interpreted with caution, it indicates that the increased mortality observed with HES in the 6S trial may not be explained by endothelial damage and it emphasizes the challenge of using surrogate markers as outcome.
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120
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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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121
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Malfroy S, Wallet F, Maucort-Boulch D, Chardonnal L, Sens N, Friggeri A, Passot G, Glehen O, Piriou V. Complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis: Risk factors for ICU admission and morbidity prognostic score. Surg Oncol 2015; 25:6-15. [PMID: 26979635 DOI: 10.1016/j.suronc.2015.11.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 11/03/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES For patients suffering from peritoneal carcinomatosis, cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the only curative option. We focused on severe complications in the postoperative course of HIPEC. METHODS We studied perioperative data from patients who underwent HIPEC between January 2010 and August 2011. Our primary objective was to identify perioperative risk factors for ICU admission. Our secondary objective was to identify patient that may be re-admitted to the ICU thanks to a prognostic score. RESULTS 122 patients underwent HIPEC. 32 presented severe adverse events (26.2%) and 7 died (5.7%). Reasons for ICU admission were septic shock in 28.1% of patients, hemorrhagic shock for 21.9%, hemodynamic instability for 15.6%, respiratory causes for 6.2% and post-operative acidosis for 6.2%. Vasopressors were required for 34% and 40.6% were mechanically ventilated. CONCLUSION Peritoneal cancer index, diaphragmatic peritonectomy, the need of vasopressive therapy, total volume of fluid leakage collected in drains and total volume of fluid therapy administered at day 1 reported on ideal body weight were the 5 significant variables that we combined to build a morbidity prognostic score. One patient over 4 is likely to present severe complications. A predictive morbidity score provide informative data for clinicians.
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Affiliation(s)
- Sylvain Malfroy
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France.
| | - Florent Wallet
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Delphine Maucort-Boulch
- Biostatistic Unit, Hospices Civils de Lyon, F-69003, Lyon, France; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, F-69100, Villeurbanne, France
| | - Laurent Chardonnal
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Nicolas Sens
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Arnaud Friggeri
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Guillaume Passot
- Department of Surgical Oncology, CHU Lyon Sud, Lyon 1 University, EMR 3738, Pierre Benite, France
| | - Olivier Glehen
- Department of Surgical Oncology, CHU Lyon Sud, Lyon 1 University, EMR 3738, Pierre Benite, France
| | - Vincent Piriou
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
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122
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Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients. Br J Surg 2015; 103:14-26. [DOI: 10.1002/bjs.9943] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/24/2015] [Accepted: 08/19/2015] [Indexed: 11/10/2022]
Abstract
Abstract
Background
There is uncertainty regarding the safety of different volume replacement solutions. The aim of this study was systematically to review evidence of crystalloid versus colloid solutions, and to determine whether these results are influenced by trial design or clinical setting.
Methods
PubMed, Embase and the Cochrane Central Register of Controlled Trials were used to identify randomized clinical trials (RCTs) that compared crystalloids with colloids as volume replacement solutions in patients with traumatic injuries, those undergoing surgery and in critically ill patients. Adjusted odds ratios (ORs) for mortality and major morbidity including renal injury were pooled using fixed-effect and random-effects models.
Results
Some 59 RCTs involving 16 889 patients were included in the analysis. Forty-one studies (69 per cent) were found to have selection, detection or performance bias. Colloid administration did not lead to increased mortality (32 trials, 16 647 patients; OR 0·99, 95 per cent c.i. 0·92 to 1·06), but did increase the risk of developing acute kidney injury requiring renal replacement therapy (9 trials, 11 648 patients; OR 1·35, 1·17 to 1·57). Sensitivity analyses that excluded small and low-quality studies did not substantially alter these results. Subgroup analyses by type of colloid showed that increased mortality and renal replacement therapy were associated with use of pentastarch, and increased risk of renal injury and renal replacement therapy with use of tetrastarch. Subgroup analysis indicated that the risks of mortality and renal injury attributable to colloids were observed only in critically ill patients with sepsis.
Conclusion
Current general restrictions on the use of colloid solutions are not supported by evidence.
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Affiliation(s)
- S H Qureshi
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - S I Rizvi
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - N N Patel
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - G J Murphy
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
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123
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Owyang CG, Shah KH. Are Balanced Crystalloids the Preferred Resuscitation Fluid for Severe Sepsis and Septic Shock? Ann Emerg Med 2015; 66:523-5. [DOI: 10.1016/j.annemergmed.2015.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Indexed: 10/23/2022]
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124
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Abstract
Hospitalists are a critical link in providing evidence-based care for patients with sepsis across the disease spectrum, from early recognition to recovery. The past decade of sepsis research has led to significant findings that will change clinical practice for hospital medicine practitioners. Although the incidence of severe sepsis in the United States has continued to rise, in-hospital mortality has declined. Management of the spectrum of sepsis disorders is no longer restricted to the intensive care unit (ICU). This review article will provide an update in the management of sepsis for hospitalists based on recently published pivotal studies. The expanding evidence base in sepsis includes early goal-directed therapy/clinical endpoints/sepsis bundles, antibiotics and source control, volume resuscitation, ICU considerations (including the use of insulin and corticosteroids), mortality/complications, and the newly recognized condition of "sepsis survivorship".
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Affiliation(s)
- Benjamin T Galen
- Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Christopher Sankey
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut
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125
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Abstract
Aggressive fluid resuscitation to achieve a central venous pressure (CVP) greater than 8 mm Hg has been promoted as the standard of care, in the management of patients with severe sepsis and septic shock. However recent clinical trials have demonstrated that this approach does not improve the outcome of patients with severe sepsis and septic shock. Pathophysiologically, sepsis is characterized by vasoplegia with loss of arterial tone, venodilation with sequestration of blood in the unstressed blood compartment and changes in ventricular function with reduced compliance and reduced preload responsiveness. These data suggest that sepsis is primarily not a volume-depleted state and recent evidence demonstrates that most septic patients are poorly responsive to fluids. Furthermore, almost all of the administered fluid is sequestered in the tissues, resulting in severe oedema in vital organs and, thereby, increasing the risk of organ dysfunction. These data suggest that a physiologic, haemodynamically guided conservative approach to fluid therapy in patients with sepsis would be prudent and would likely reduce the morbidity and improve the outcome of this disease.
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Affiliation(s)
- P Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA 23507, USA
| | - R Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
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126
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Rocha LL, Pessoa CMS, Corrêa TD, Pereira AJ, de Assunção MSC, Silva E. Conceitos atuais sobre suporte hemodinâmico e terapia em choque séptico. Braz J Anesthesiol 2015; 65:395-402. [DOI: 10.1016/j.bjan.2015.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/11/2014] [Indexed: 10/23/2022] Open
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127
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Duan C, Li T, Liu L. Efficacy of limited fluid resuscitation in patients with hemorrhagic shock: a meta-analysis. Int J Clin Exp Med 2015; 8:11645-11656. [PMID: 26380001 PMCID: PMC4565384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/20/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUNDS The objective of this meta-analysis was to evaluate the efficacy of limited fluid resuscitation during active hemorrhage compared with regular fluid resuscitation and provide strong evidences for the improvement of fluid resuscitation strategies in uncontrolled hemorrhagic shock. METHODS Electronic searches were performed using PubMed, Medline, Embase and CNKI in accordance with pre-set guidelines. Clinical trials and observation studies were included or excluded according to the criteria. The endpoints examined were mortality, hemoglobin (Hb), platelets (PLT), hematocrit (Hct), prothrombin Time (PT), activated partial thromboplastin time (APTT), base excess (BE), blood lactic acid (BLA) and the main complications, such as multiple organ dysfunction syndrome (MODS) and acute Respiratory Distress Syndrome (ARDS). Risk ratios (RR), mean differences (MDs) and 95% confidence intervals (95% Cl) were calculated using fixed/random effect model. RESULTS The search indentified 11 studies including 1482 subjects. 725 hemorrhagic patients were treated with limited fluid resuscitation while 757 patients undertook regular fluid resuscitation during active hemorrhage. Limited fluid resuscitation had its advantage to reduce the mortality in hemorrhagic shock (RR = 0.67; 95% CI = 0.56-0.81; P < 0.0001) and easily controlled the blood routine index close to normal compared with regular fluid resuscitation (Hb: MD = 13.04; 95% CI = 2.69-23.38; P = 0.01. PLT: MD = 23.16; 95% CI = 6.41-39.91; P = 0.007. Hct: MD = 0.02; 95% CI = 0.02-0.03; P < 0.00001). LFR also had shorter PT and APTT compared with RFR (PT: MD = -2.81; 95% CI = -3.44--2.17; P < 0.00001 and APTT: MD = -5.14; 95% CI = -6.16--4.12; P < 0.00001). As for blood gas analysis, LFR reduced the decrease of BE (MD = 2.48; 95% CI = 1.11-3.85; P = 0.0004) and increase of BLA (MD = -0.65; 95% CI = -0.85--0.44; P < 0.00001). Besides, LFR may also reduce the occurrence of postoperative complications (MODS: RR= 0.37; 95% CI = 0.21-0.66; P = 0.0008. ARDS: RR = 0.35; 95% CI = 0.21-0.60; P < 0.0001). CONCLUSION The results provide convincing evidence that support the continued investigation and use of limited fluid resuscitation during active hemorrhage in the trauma setting.
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Affiliation(s)
- Chenyang Duan
- Department of Research Institute of Surgery, State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Third Military Medical University Chongqing 400042, P. R. China
| | - Tao Li
- Department of Research Institute of Surgery, State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Third Military Medical University Chongqing 400042, P. R. China
| | - Liangming Liu
- Department of Research Institute of Surgery, State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Third Military Medical University Chongqing 400042, P. R. China
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128
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Current concepts on hemodynamic support and therapy in septic shock. Braz J Anesthesiol 2015; 65:395-402. [PMID: 26323739 DOI: 10.1016/j.bjane.2014.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/05/2014] [Accepted: 11/11/2014] [Indexed: 01/09/2023] Open
Abstract
Severe sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration.
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129
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Hammond NE, Taylor C, Saxena M, Liu B, Finfer S, Glass P, Seppelt I, Willenberg L, Myburgh J. Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013. Intensive Care Med 2015; 41:1611-9. [PMID: 26077073 DOI: 10.1007/s00134-015-3878-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/08/2015] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Recent evidence indicates that the choice of intravenous fluids may affect outcomes in critically ill patients. METHODS We recorded the administration of resuscitation fluids in patients admitted to Australian and New Zealand adult intensive care units (ICUs) for a 24-h period at 6 time points between 2007 and 2013. Changes in patterns of fluid use over this period were determined using regression analyses. RESULTS Of the 2825 patients admitted to the 61 ICUs on the 6 study days, 754 (26.7%) patients received fluid resuscitation. Of those receiving fluid resuscitation, the proportion of patients receiving crystalloid significantly increased from 28.9% (41/142) in 2007 to 50.5% (48/95) in 2013 (adjusted odds ratio (OR) 2.93; 95% confidence intervals (CI) 1.35-6.33; p = 0.006); of these, the proportion of patients receiving buffered salt solutions significantly increased from 4.9% (7/142) in 2007 to 31.6% (30/95) in 2013 (OR 7.00; 95% CI 2.14-22.92; p = 0.001). The use of colloids significantly decreased from 59.9% (85/142) in 2007 to 42.1% (40/95) in 2013 (adjusted OR 0.34; 95% CI 0.16-0.74; p = 0.007) due to a significant decrease in the proportion of patients receiving gelatin; 28.9% (41/142) to 2.1% (2/95) (OR 0.10; 95% CI 0.03-0.29; p ≤ 0.001). CONCLUSION Fluid resuscitation practice in Australia and New Zealand adult ICUs has changed over the 6-year study period. Crystalloid use increased primarily due to an increase in the use of buffered salt solutions while overall the use of colloid has decreased.
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Affiliation(s)
- N E Hammond
- Division of Critical Care and Trauma, The George Institute for Global Health, University of Sydney, Sydney, Australia,
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130
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Garnacho-Montero J, Fernández-Mondéjar E, Ferrer-Roca R, Herrera-Gutiérrez M, Lorente J, Ruiz-Santana S, Artigas A. Cristaloides y coloides en la reanimación del paciente crítico. Med Intensiva 2015; 39:303-15. [DOI: 10.1016/j.medin.2014.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/14/2014] [Accepted: 12/18/2014] [Indexed: 12/22/2022]
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131
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Fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis. Intensive Care Med 2015; 41:1561-71. [PMID: 25904181 DOI: 10.1007/s00134-015-3794-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/31/2015] [Indexed: 02/07/2023]
Abstract
Fluid resuscitation, along with the early administration of antibiotics, is the cornerstone of treatment for patients with sepsis. However, whether differences in resuscitation fluids impact on the requirements for renal replacement therapy (RRT) remains unclear. To examine this issue, we performed a network meta-analysis (NMA), including direct and indirect comparisons, that addressed the effect of different resuscitation fluids on the use of RRT in patients with sepsis. The data sources MEDLINE, EMBASE, ACPJC, CINAHL and Cochrane Central Register were searched up to March 2014. Eligible studies included randomized trials reported in any language that enrolled adult patients with sepsis or septic shock and addressed the use of RRT associated with alternative resuscitation fluids. The risk of bias for individual studies and the overall certainty of the evidence were assessed. Ten studies (6664 patients) that included a total of nine direct comparisons were assessed. NMA at the four-node level showed that an increased risk of receiving RRT was associated with fluid resuscitation with starch versus crystalloid [odds ratio (OR) 1.39, 95% credibility interval (CrI) 1.17-1.66, high certainty]. The data suggested no difference between fluid resuscitation with albumin and crystalloid (OR 1.04, 95% CrI 0.78-1.38, moderate certainty) or starch (OR 0.74, 95% CrI 0.53-1.04, low certainty). NMA at the six-node level showed a decreased risk of receiving RRT with balanced crystalloid compared to heavy starch (OR 0.50, 95% CrI 0.34-0.74, moderate certainty) or light starch (OR 0.70, 95% CrI 0.49-0.99, high certainty). There was no significant difference between balanced crystalloid and saline (OR 0.85, 95% CrI 0.56-1.30, low certainty) or albumin (OR 0.82, 95% CrI 0.49-1.37, low certainty). Of note, these trials vary in terms of case mix, fluids evaluated, duration of fluid exposure and risk of bias. Imprecise estimates contributed to low confidence in most estimates of effect. Among the patients with sepsis, fluid resuscitation with crystalloids compared to starch resulted in reduced use of RRT; the same may be true for albumin versus starch.
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132
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Balancing between benefit and harm-what is the best solution in fluid resuscitation? Crit Care Med 2015; 43:e26-7. [PMID: 25514732 DOI: 10.1097/ccm.0000000000000645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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133
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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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Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) 2015; 4:3. [PMID: 25897397 PMCID: PMC4403901 DOI: 10.1186/s13741-015-0014-z] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered. METHODS Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them. RESULTS The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration. CONCLUSIONS We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.
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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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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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Liamis G, Filippatos TD, Elisaf MS. Correction of hypovolemia with crystalloid fluids: Individualizing infusion therapy. Postgrad Med 2015; 127:405-12. [DOI: 10.1080/00325481.2015.1029421] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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He B, Xu B, Xu X, Li L, Ren R, Chen Z, Xiao J, Wang Y, Xu B. Hydroxyethyl starch versus other fluids for non-septic patients in the intensive care unit: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:92. [PMID: 25886952 PMCID: PMC4404666 DOI: 10.1186/s13054-015-0833-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 02/20/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Use of hydroxyethyl starch (HES) in septic patients is reported to increase the mortality and incidence of renal replacement therapy (RRT). However, whether or not use of HES would induce the same result in non-septic patients in the intensive care unit (ICU) remains unclear. The objective of this meta-analysis was to evaluate 6% HES versus other fluids for non-septic ICU patients. METHODS Randomized controlled trials (RCTs) were searched from Pubmed, OvidSP, Embase database and Cochrane Library, published before November, 2013. A meta-analysis was made on the effect of 6% HES versus other fluids for non-septic ICU patients, including mortality, RRT incidence, bleeding volume, red blood cell (RBC) transfusion and fluid application for non-septic patients in ICU. RESULTS Twenty-two RCTs were included, involving 6,064 non-septic ICU patients. Compared with the other fluids, 6% HES was not associated with decreased overall mortality (RR = 1.03, 95%CI: 0.09 to 1.17; P = 0.67; I(2) = 0). There was no significant difference in RRT incidence, bleeding volume and red blood cell transfusion between 6% HES group and the other fluid groups. However, patients in HES group received less total intravenous fluids than those receiving crystalloids during the first day in ICU (SMD = -0.84; 95%CI: -1.39 to -0.30; P = 0.003, I(2) = 74%). CONCLUSIONS This meta-analysis found no increased mortality, RRT incidence, bleeding volumes or RBC transfusion in non-septic ICU patients, but the sample sizes were small and the studies generally were of poor quality.
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Affiliation(s)
- Bin He
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Bo Xu
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Xiaoxing Xu
- Department of Epidemiology, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Lixia Li
- Pharmaceutical Department, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Rongrong Ren
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Zhiyu Chen
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Jian Xiao
- Department of Hepato-Biliary-Pancreatic Surgery, Second Military Medical University, Fengyang Road 415, Shanghai, 200003, China.
| | - Yingwei Wang
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Bin Xu
- Department of Hepato-Biliary-Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Yanchang Road 301, Shanghai, 200072, China.
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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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Li L, Li Y, Xu X, Xu B, Ren R, Liu Y, Zhang J, He B. Safety evaluation on low-molecular-weight hydroxyethyl starch for volume expansion therapy in pediatric patients: a meta-analysis of randomized controlled trials. Crit Care 2015; 19:79. [PMID: 25887704 PMCID: PMC4391127 DOI: 10.1186/s13054-015-0815-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 02/13/2015] [Indexed: 02/19/2023] Open
Abstract
INTRODUCTION Hydroxyethyl starch (HES) has been widely used for volume expansion, but its safety in adult patients has been questioned recently. The aim of this meta-analysis is to see whether or not HES has any adverse effect in pediatric patients. METHODS Randomized controlled trials (RCTs) involving pediatric patients who received 6% low-molecular-weight HES, published before January 2014, were searched for in Pubmed, Embase database and Cochrane Library. Two reviewers independently extracted the valid data, including the mortality, renal function, coagulation, blood loss, hemodynamic changes, and length of hospital and ICU stay. All data were analyzed by I (2)-test, and the results of statistical analysis were displayed in forest plots. Possible publication bias was tested by funnel plots. Bayesian analysis was performed using WinBUGS with fixed and random effects models. RESULTS A total of 13 RCTs involving 1,156 pediatric patients were finally included in this meta-analysis. Compared with other fluids, HES did not significantly decrease the mortality (RR = -0.01; 95%CI: 0.05 to 0.03; P = 0.54; I(2) = 6%), creatinine level (I(2) -test: MD = 1.81; 95%CI: -0.35 to 3.98; P = 0.10;I(2) = 0%; Bayesian analysis: Fixed effect model MD = 1.77; 95%CI: -0.07 to 3.6; Random effects model MD = 1.78; 95%CI: -1.86 to 5.33), activated partial thromboplastin time (MD = 0.01; 95%CI: -1.05 to 1.07; P = 0.99; I(2) = 42%), and blood loss (MD = 17.72; 95%CI: -41.27 to 5.82; P = 0.10; I(2) = 0%) in pediatric patients. However, HES significantly decreased the blood platelet count (MD = 20.99; 95%CI: -32.08 to -9.90; P = 0.0002; I(2) = 28%) and increased the length of ICU stay (MD = 0.94; 95%CI: 0.18 to 1.70; P = 0.02; I(2) = 46%). CONCLUSIONS Volume expansion with 6% HES significantly decreased the platelet count and increased the length of ICU stay, also might have an adverse effect on renal function. Therefore HES is not recommended for pediatric patients, which safety needs more high quality RCTs and studies to confirm in future.
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Affiliation(s)
- Lixia Li
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Yongyang Li
- Department of Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China.
| | - Xiaoxing Xu
- Department of Epidemiology, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Bo Xu
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Rongrong Ren
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Yan Liu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Jian Zhang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
| | - Bin He
- Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Kongjiang Road 1665, Shanghai, 200092, China.
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PERNER A, JUNTTILA E, HANEY M, HREINSSON K, KVÅLE R, VANDVIK PO, MØLLER MH. Scandinavian clinical practice guideline on choice of fluid in resuscitation of critically ill patients with acute circulatory failure. Acta Anaesthesiol Scand 2015; 59:274-85. [PMID: 25363535 DOI: 10.1111/aas.12429] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 09/17/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND The task force on Acute Circulatory Failure of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine produced this guideline with recommendations concerning the use of crystalloid vs. colloid solutions in adult critically ill patients with acute circulatory failure. METHODS Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to grade the quality of evidence and to determine the strengths of the recommendations. As efficacy and harm may vary in different subpopulations of patients with acute circulatory failure, we produced recommendations for general intensive care unit (ICU) patients and those with sepsis, trauma and burn injury. RESULTS For general ICU patients and those with sepsis, we recommend using crystalloids for resuscitation rather than hydroxyethyl starch and we suggest using crystalloids rather than gelatin and albumin. For patients with trauma we recommend to use crystalloids for resuscitation rather than colloid solutions. For patients with burn injury we provide no recommendations as there are very limited data from randomised trials on fluid resuscitation in this patient population. CONCLUSIONS We recommend using crystalloid solutions rather than colloid solutions for resuscitation in the majority of critically ill patients with acute circulatory failure.
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Affiliation(s)
- A. PERNER
- Department of Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - E. JUNTTILA
- Department of Anaesthesiology Division of Intensive Care Oulu University Hospital and Department of Anaesthesiology Tampere University Hospital Tampere Finland
| | - M. HANEY
- Anaesthesiology and Intensive Care Medicine Umeå University Umeå Sweden
| | - K. HREINSSON
- Department of Anaesthesiology and Intensive Care Medicine Landspitali University Hospital Reykjavik Iceland
| | - R. KVÅLE
- Department of Intensive Care Haukeland University Hospital Bergen Norway
| | - P. O. VANDVIK
- Department of Medicine Innlandet Hospital Trust‐Division Gjøvik Norway and Norwegian Knowledge Centre for the Health Services Oslo Norway
| | - M. H. MØLLER
- Department of Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
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Orbegozo Cortés D, Gamarano Barros T, Njimi H, Vincent JL. Crystalloids Versus Colloids. Anesth Analg 2015; 120:389-402. [DOI: 10.1213/ane.0000000000000564] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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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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Abstract
The administration of intravenous fluids for resuscitation is the most common intervention in acute medicine. There is increasing evidence that the type of fluid may directly affect patient-centred outcomes. There is a lack of evidence that colloids confer clinical benefit over crystalloids and they may be associated with harm. Hydroxyethyl starch preparations are associated with increased mortality and use of renal replacement therapy in critically ill patients, particularly those with sepsis; albumin is associated with increased mortality in patients with severe traumatic brain injury. Crystalloids, such as saline or balanced salt solutions, are increasingly recommended as first-line resuscitation fluids for the majority of patients with hypovolaemia. There is emerging evidence that saline may be associated with adverse outcomes due to the development of hyperchloraemic metabolic acidosis, although the safety of balanced salt solutions has not been established. Fluid requirements vary over the course of critical illness. The excessive use of fluids during the resuscitative period is associated with increased cumulative fluid balance and adverse outcomes in critically ill patients. The selection of fluid depends on the clinical context in which it is administered and requires careful consideration of the dose and potential for toxicity. There is an urgent need to conduct further high-quality randomized controlled trials of currently available fluid therapy in patients with critical illness.
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Affiliation(s)
- J A Myburgh
- Department of Intensive Care Medicine, St George Clinical School, University of New South Wales, Sydney, Australia; Division of Critical Care and Trauma, The George Institute for Global Health, Sydney, Australia
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145
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Jiang L, Jiang S, Zhang M, Zheng Z, Ma Y. Albumin versus other fluids for fluid resuscitation in patients with sepsis: a meta-analysis. PLoS One 2014; 9:e114666. [PMID: 25474401 PMCID: PMC4256427 DOI: 10.1371/journal.pone.0114666] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 11/12/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early fluid resuscitation is vital to patients with sepsis. However, the choice of fluid has been a hot topic of discussion. The objective of this study was to evaluate whether the use of albumin-containing fluids for resuscitation in patients with sepsis was associated with a decreased mortality rate. METHODS We systematically searched PubMed, EMBASE and Cochrane library for eligible randomized controlled trials (RCTs) up to March 2014. The selection of eligible studies, assessment of methodological quality, and extraction of all relevant data were conducted by two authors independently. RESULTS In total, 15 RCTs were eligible for analysis. After pooling the data, we found there was no significant effect of albumin-containing fluids on mortality in patients with sepsis of any severity (RR: 0.94, 95% CI: 0.87, 1.02 and RD: -0.01, 95% CI: -0.03, 0.01). The results were robust to subgroup analyses, sensitivity analyses and trial sequential analyses. CONCLUSION The present meta-analysis did not demonstrate significant advantage of using albumin-containing fluids for resuscitation in patients with sepsis of any severity. Given the cost-effectiveness of using albumin, crystalloids should be the first choice for fluid resuscitation in septic patients.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Shouyin Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Zhongjun Zheng
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Yuefeng Ma
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
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Lira A, Pinsky MR. Choices in fluid type and volume during resuscitation: impact on patient outcomes. Ann Intensive Care 2014; 4:38. [PMID: 25625012 PMCID: PMC4298675 DOI: 10.1186/s13613-014-0038-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/14/2014] [Indexed: 01/19/2023] Open
Abstract
We summarize the emerging new literature regarding the pathophysiological principles underlying the beneficial and deleterious effects of fluid administration during resuscitation, as well as current recommendations and recent clinical evidence regarding specific colloids and crystalloids. This systematic review allows us to conclude that there is no clear benefit associated with the use of colloids compared to crystalloids and no evidence to support the unique benefit of albumin as a resuscitation fluid. Hydroxyethyl starch use has been associated with increased acute kidney injury (AKI) and use of renal replacement therapy. Other synthetic colloids (dextran and gelatins) though not well studied do not appear superior to crystalloids. Normal saline (NS) use is associated with hyperchloremic metabolic acidosis and increased risk of AKI. This risk is decreased when balanced salt solutions are used. Balanced crystalloid solutions have shown no harmful effects, and there is evidence for benefit over NS. Finally, fluid resuscitation should be applied in a goal-directed manner and targeted to physiologic needs of individual patients. The evidence supports use of fluids in volume-responsive patients whose end-organ perfusion parameters have not been met.
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Affiliation(s)
- Alena Lira
- Department of Critical Care Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh 15261, PA, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh 15261, PA, USA
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Aya AG, Ducloy-Bouthors AS, Rugeri L, Gris JC. [Anesthetic management of severe or worsening postpartum hemorrhage]. ACTA ACUST UNITED AC 2014; 43:1030-62. [PMID: 25447392 DOI: 10.1016/j.jgyn.2014.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Risk factors of maternal morbidity and mortality during postpartum hemorrhage (PPH) include non-optimal anesthetic management. As the anesthetic management of the initial phase is addressed elsewhere, the current chapter is dedicated to the management of severe PPH. METHODS A literature search was performed using PubMed and Medline databases, and the Cochrane Library, for articles published from 2003 up to and including 2013. Several keywords related to anesthetic and critical care practice, and obstetrical management were used, in various combinations. Guidelines from several societies and organisations were also read. RESULTS When PPH worsens, one should ask for additional team personnel (professional consensus). Patients should be monitored for heart rate, blood pressure, skin and mucosal pallor, bleeding at skin puncture sites, diuresis and the volume of genital bleeding (grade B). Because of the possible rapid worsening of coagulapathy, patients should undergo regular evaluation of coagulation status (professional consensus). Prevention and management of hypothermia should be considered (professional consensus), by warming intravenous fluids and blood products, and by active body warming (grade C). Antibiotics should be given, if not already administered at the initial phase (professional consensus). Vascular fluids must be given (grade B), the choice being left at the physician discretion. Blood products transfusion should be decided based on the clinical severity of PPH (professional consensus). Priority is given to red blood cells (RBC) transfusion, with the aim to maintain Hb concentration>8g/dL. The first round of products could include 3 units of RBC (professional consensus), and the following round 3 units of RBC, and 3 units of fresh frozen plasma (FFP). The FFP:RBC ratio should be kept between 1:2 and 1:1 (professional consensus). Depending on the etiology of PPH, the early administration of FFP is left at the discretion of the physician (professional consensus). Platelet count should be maintained at>50 G/L (professional consensus). During massive PPH, fibrinogen concentration should be maintained at>2g/L (professional consensus). Fibrinogen can be given without prior fibrinogen measurement in case of massive bleeding (professional consensus). General anesthesia should be considered in case of hemodynamic instability, even when an epidural catheter is in place (professional consensus). CONCLUSION The anesthetic management aims to restore and maintain optimal respiratory state and circulation, to treat coagulation disorders, and to allow invasive obstetrical and radiologic procedures. Clinical and instrumental monitoring are needed to evaluate the severity of PPH, to guide the choice of therapeutic options, and to assess treatments efficacy.
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Affiliation(s)
- A G Aya
- Département anesthésie-douleur, groupe hospitalo-universitaire Caremeau, place du Pr.-Debré, 30029 Nîmes cedex 09, France; EA2992, faculté de médecine Montpellier-Nîmes, 186, chemin du Carreau-de-Lanes, 30029 Nîmes cedex 2, France.
| | - A-S Ducloy-Bouthors
- Pôle d'anesthésie-réanimation, CHU Lille, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - L Rugeri
- Unité d'hémostase clinique, hôpital Édouard-Herriot, pavillon E 5, place d'Arsonval, 69003 Lyon, France
| | - J-C Gris
- Laboratoire et consultations d'hématologie, groupe hospitalo-universitaire Caremeau, place du Pr.-Debré, 30029 Nîmes cedex 09, France; EA2992, faculté de médecine Montpellier-Nîmes, 186, chemin du Carreau-de-Lanes, 30029 Nîmes cedex 2, France
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Raghunathan K, Murray P, Beattie W, Lobo D, Myburgh J, Sladen R, Kellum J, Mythen M, Shaw A. Choice of fluid in acute illness: what should be given? An international consensus ‡. Br J Anaesth 2014; 113:772-83. [DOI: 10.1093/bja/aeu301] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Jones CW, Keil LG, Weaver MA, Platts-Mills TF. Clinical trials registries are under-utilized in the conduct of systematic reviews: a cross-sectional analysis. Syst Rev 2014; 3:126. [PMID: 25348628 PMCID: PMC4217330 DOI: 10.1186/2046-4053-3-126] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 09/29/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Publication bias is a major threat to the validity of systematic reviews. Searches of clinical trials registries can help to identify unpublished trials, though little is known about how often these resources are utilized. We assessed the usage and results of registry searches reported in systematic reviews published in major general medical journals. METHODS This cross-sectional analysis includes data from systematic reviews assessing medical interventions which were published in one of six major general medical journals between July 2012 and June 2013. Two authors independently examined each published systematic review and all available supplementary materials to determine whether at least one clinical trials registry was searched. RESULTS Of the 117 included systematic reviews, 41 (35%) reported searching a trials registry. Of the 29 reviews which also provided detailed registry search results, 15 (52%) identified at least one completed trial and 18 (62%) identified at least one ongoing trial. CONCLUSIONS Clinical trials registry searches are not routinely included in systematic reviews published in major medical journals. Routine examination of registry databases may allow a more accurate characterization of publication and outcome reporting biases and improve the validity of estimated effects of medical treatments.
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Affiliation(s)
- Christopher W Jones
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, Suite 152, Camden, NJ 08103, USA.
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