Colloids versus crystalloids for fluid resuscitation in critically ill patients

Efficacy of albumin with diuretics in mechanically ventilated patients with hypoalbuminemia: A systematic review and meta-analysis

BACKGROUND

Hypoalbuminemia is associated with fluid overload, the development of acute respiratory distress syndrome, and mortality. The co-administration of albumin and diuretics for the treatment of patients with hypoalbuminemia is expected to increase urine output, without hemodynamic instability, and improve pulmonary function; however, these effects have not been systematically investigated. Here, we aimed to clarify the benefits of the co-administration of albumin and diuretics in mechanically ventilated patients.

METHODS

We searched for randomized, placebo-controlled trials that investigated the effects of the co-administration of albumin and diuretics compared with placebo and diuretics, in mechanically ventilated patients with hypoalbuminemia. We searched these trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, and EMBASE databases. Primary outcomes were hypotensive events after the intervention, all-cause mortality, and the length of mechanical ventilation. Secondary outcomes were improvement in the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (P/F ratio) at 24 hours, total urine output (mL/d), and the clinical requirement of renal replacement therapy (RRT).

RESULTS

From the 1574 records identified, we selected 3 studies for quantitative analysis. The results of albumin administration were as follows: hypotensive events (risk ratio [RR] -1.05 [95% confidence interval {CI}: 0.15-0.81]), all-cause mortality (RR 1.0 [95% CI: 0.45-2.23]), the length of mechanical ventilation in days (mean difference -1.05 [95% CI: -3.35 to 1.26]), and improvement in P/F ratio (RR 2.83 [95% CI: 1.42-5.67]). None of the randomized controlled trials reported the total urine output, and one reported that no participants required RRT. Adverse events were not reported during the trials. The certainty of evidence was low (in the hypotensive events after the intervention and all-cause mortality) to moderate (in the length of mechanical ventilation in days, improvement of P/F ratio, clinical requirement of RRT, and adverse events).

CONCLUSIONS

Although this treatment combination reduced the number of days for which mechanical ventilation was required, it did not reduce the all-cause mortality at 30 days. In conclusion, the co-administration of albumin and diuretics may reduce hypotensive events and improve the P/F ratio at 24 hours.

Evidence-based airway management protocol for a critical ill patient in medical intensive care unit: Systematic review

Background

Airway management outside the theatre is performed either to resuscitate a physiologically unstable critically ill patients or to secure an emergency airway in the absence of essential equipments. It is a life saving procedure for critically ill and injured patients. Delaying in securing airway or awaking the patient is not an option in case of difficult airway in intensive care unit. Therefore, developing and implementation of an evidence-based airway management protocol is important.

Objective

This review was conducted to develop a clear airway management protocol for a critical ill patient in medical intensive care unit.

Methods

After formulating the key questions, scope, and eligibility criteria for the evidences to be included, a comprehensive search strategy of electronic sources was conducted. The literatures were searched using advanced searching methods from data bases and websites to get evidences on airway management of a critical ill patient. Duplication of literatures was avoided by endnote. Screening of literatures was conducted based on the level of significance with proper appraisal. This review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement.

Results

A total of 626 articles were identified from data bases and websites using an electronic search. Of these articles, 95 were removed for duplication and 305 studies were excluded after reviewing their titles and abstracts. At the screening stage, 79 articles were retrieved and evaluated for the eligibility. Finally, 40 studies related to airway management of a critical ill patient in medical ICU were included in this systematic review.

Conclusion

A critical ill patient needs oxygenation and ventilation support. A focused and rapid assessment, with special attention of the airway and hemodynamic status of the critical ill patient is paramount. An appropriate airway management option should be employed to resuscitate or to control an emergency airway of a critical ill patent. This could be non invasive ventilation or invasive airway intervention.

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Airway management outside operating theatre is a common practice.

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A critical ill patient needs oxygenation and ventilation support.

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A focused airway assessment even in the most urgent situation is mandatory.

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Usage of appropriate airway management intervention is paramount.

Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy

This study aimed to investigate the effect of intraoperative fluid volume on the postoperative ileus (POI) recovery period. A retrospective review of the Korean robot-assisted radical cystectomy database identified 718 patients who underwent robot-assisted radical cystectomy (RARC). Regression analyses were performed to identify the associations between the amount of intraoperative fluid administration (crystalloid/colloid/total), POI period (time to flatus/bowel movements), and length of hospital stay (LOS) after adjusting for covariates. In addition, we analyzed the risk factors for gastrointestinal complications and prolonged POI using a logistic regression model. An increasing volume of the administered crystalloid/total fluid was associated with prolonged POI (crystalloid R² = 0.0725 and P < 0.0001; total amount R² = 0.0812 and P < 0.0001), and the total fluid volume was positively associated with the LOS (R² = 0.099 and P < 0.0001). The crystalloid amount was a risk factor for prolonged POI (P < 0.001; odds ratio, 1.361; 95% confidence interval, 1.133–1.641; P < 0.001). In the context of RARC, increased intravenous fluids are associated with prolonged POI and longer LOS.

Fat Embolism Syndrome - A Qualitative Review of its Incidence, Presentation, Pathogenesis and Management

Fat Embolism Syndrome (FES) is a poorly defined clinical phenomenon which has been attributed to fat emboli entering the circulation. It is common, and its clinical presentation may be either subtle or dramatic and life threatening. This is a review of the history, causes, pathophysiology, presentation, diagnosis and management of FES. FES mostly occurs secondary to orthopaedic trauma; it is less frequently associated with other traumatic and atraumatic conditions. There is no single test for diagnosing FES. Diagnosis of FES is often missed due to its subclinical presentation and/or confounding injuries in more severely injured patients. FES is most frequently diagnosed using the Gurd and Wilson criteria, like its rivals it is not clinically validated. Although FES is a multi-system condition, its effects in the lung, brain, cardiovascular system and skin cause most morbidity. FES is mostly a self-limiting condition and treatment is supportive in nature. Many treatments have been trialled, most notably corticosteroids and heparin, however no validated treatment has been established.

Comparing the Effects of Pre-loading with Gelatine 4% Plasma Volume Expander and 6% Hydroxyethyl Starch Solution Before Spinal Anaesthesia for Lower Limb Orthopaedic Surgery

BACKGROUND

Hypotension is a common complication following spinal anaesthesia. The administration of intravenous fluids prior to spinal anaesthesia, known as pre-loading, has been used to offset the hypotension effect; however, the ideal fluid for pre-loading is still a matter of debate. The objective of this study was to compare the effects of Gelaspan 4% and Volulyte 6% as pre-loading fluids.

METHODS

A total of 93 patients with American Society of Anaesthesiologists (ASA) physical status I or II having lower limb orthopaedic surgery under spinal anaesthesia were randomised into two groups that received either Volulyte (n = 47) or Gelaspan (n = 46). Before the spinal anaesthesia, these patients were pre-loaded with 500 mL of the fluid of their respective group. Blood samples were taken before pre-loading and again after spinal anaesthesia and sent for venous blood gas and electrolyte level measurement. Baseline and intraoperative records of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and the requirement of ephedrine to treat hypotension were also recorded.

RESULTS

Both fluids could not prevent significant reductions in SBP (P = 0.011), DBP (P = 0.002) and MAP (P = 0.001). There was also significant reduction in HR over time (P < 0.001). There was no significant difference in terms of ephedrine usage between both groups. Neither Volulyte 6% nor Gelaspan 4% caused significant changes in acid-base status.

CONCLUSION

The use of 500 mL of either Gelaspan 4% or Volulyte 6% as pre-loading fluids did not significantly prevent the incidence of post-spinal anaesthesia hypotension following orthopaedic lower limb surgery; however, both were useful in the maintenance normal acid-base balance.

Resuscitation with centhaquin and 6% hydroxyethyl starch 130/0.4 improves survival in a swine model of hemorrhagic shock: a randomized experimental study

PURPOSE

To investigate the effects of the combination of centhaquin and 6% hydroxyethyl starch 130/0.4 (HES 130/0.4) in a swine model of hemorrhagic shock.

METHODS

Twenty Landrace-Large White pigs were instrumented and subjected to hemorrhagic shock. The animals were randomly allocated in two experimental groups, the control (group CO, n = 10) and the centhaquin groups (0.015 mg/kg, n = 10, group CH). Acute hemorrhage was induced by stepwise blood withdrawal (18 mL/min) from the internal jugular vein until MAP decreased to 40-45 mmHg, whereas anesthesia remained constant. All animals received HES 130/0.4 solution in the resuscitation phase until their mean arterial pressure (MAP) reached 90% of the baseline. The animals were observed for 60 min, during which no further resuscitation was attempted.

RESULTS

The total amount of blood and the bleeding time did not differ significantly between group CO and group CH (120 ± 13 vs. 120 ± 14 mL, p = 0.6; 20 ± 2 vs. 20 ± 1 min, p = 0.62, respectively). During the hemorrhagic phase, only a difference in heart rate (97.6 ± 4.4 vs. 128.4 ± 3.6 beats/min, p = 0.038) was observed between the two groups. The time required to reach the target MAP was significantly shorter in the centhaquin group compared to controls (13.7 ± 0.4 vs. 19.6 ± 0.84 min, p = 0.012). During the resuscitation phase, a statistical significant difference was observed in MAP (75.2 ± 1.6 vs. 89.8 ± 2.1 mmHg, p = 0.02) between group CO and group CH. During the observation phase, a statistical significant difference was observed in SVR (1109 ± 32.65 vs. 774.6 ± 21.82 dyn s/cm⁵, p = 0.039) and cardiac output (5.82 ± 0.31 vs. 6.9 ± 0.78 L/min, p = 0.027) between the two groups. Two animals of group CO and seven animals of group CH survived for 24 h (p = 0.008). We observed a marked increase in microvascular capillary permeability in group CO compared to group CH, with the wet/dry weight ratio being significantly higher in group CO compared to group CH (4.8 ± 1.6 vs. 3.08 ± 0.6, p < 0.001).

CONCLUSIONS

The combination of centhaquin 0.015 mg/kg and HES 130/0.4 resulted in shorter time to target MAP, lower wet-to-dry ratio, and better survival rates after resuscitation from hemorrhagic shock.

Assessing adherence to current national guidelines for appropriate albumin use at an academic medical center

Objective:

To assess adherence to current national guidelines for appropriate albumin use at an academic medical center.

Methods:

This retrospective chart review of 150 randomly selected patients prescribed and administered at least one dose of albumin was conducted in an urban academic medical center to evaluate the adherence of albumin orders to current national guidelines. Inclusion criteria consisted of discharged patients at least 18-years-old admitted to the intensive care unit or medical/surgical unit from September 1, 2015 to August 31, 2016. The primary outcome was the number of patients who inappropriately received albumin based on national guidelines and FDA approved indications. Secondary outcomes included the number of patients who received the incorrect concentration or dose of albumin based on indication, as well as the cost associated with inappropriate albumin prescribing. Descriptive statistics were used to report outcomes.

Results:

There were 68 instances (45%) where albumin was prescribed inappropriately according to guideline recommendations. Of the 82 instances where albumin was used appropriately, 18 patients received an incorrect dose (22%), and 6 received the inappropriate concentration of albumin (7%). The cost for the 150 patients included in the study associated with inappropriate albumin prescribing was approximately $13,000.

Conclusions:

This study identified areas for pharmacist intervention to ensure appropriate albumin utilization, as well as proper dosing for the most frequently incorrectly dosed indications, including hepato-renal syndrome, spontaneous bacterial peritonitis, and paracentesis. This study also identified an unexpected indication with significant inappropriate albumin utilization, perioperative hypotension, which is an area for further intervention to monitor and decrease use.

Different resuscitation strategies and novel pharmacologic treatment with valproic acid in traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of death in young adults, and effective treatment strategies have the potential to save many lives. TBI results in coagulopathy, endothelial dysfunction, inflammation, cell death, and impaired epigenetic homeostasis, ultimately leading to morbidity and/or mortality. Commonly used resuscitation fluids such as crystalloids or colloids have several disadvantages and might even be harmful when administered in large quantities. There is a need for next-generation treatment strategies (especially in the prehospital setting) that minimize cellular damage, improve survival, and enhance neurological recovery. Pharmacologic treatment with histone deacetylase inhibitors, such as valproic acid, has shown promising results in animal studies of TBI and may therefore be an excellent example of next-generation therapy. This review briefly describes traditional resuscitation strategies for TBI combined with hemorrhagic shock and describes preclinical studies on valproic acid as a new pharmacologic agent in the treatment of TBI. It finally discusses limitations and future directions on the use of histone deacetylase inhibitors for the treatment of TBI.

Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock

Sepsis results in disruption of the endothelial glycocalyx layer and damage to the microvasculature, resulting in interstitial accumulation of fluid and subsequently edema. Fluid resuscitation is a mainstay in the initial treatment of sepsis, but the choice of fluid is unclear. The ideal resuscitative fluid is one that restores intravascular volume while minimizing edema; unfortunately, edema and edema-related complications are common consequences of current resuscitation strategies. Crystalloids are recommended as first-line therapy, but the type of crystalloid is not specified. There is increasing evidence that normal saline is associated with increased mortality and kidney injury; balanced crystalloids may be a safer alternative. Albumin is similar to crystalloids in terms of outcomes in the septic population but is costlier. Hydroxyethyl starches appear to increase mortality and kidney injury in the critically ill and are no longer indicated in these patients. In the trauma population, the shift to plasma-based resuscitation with decreased use of crystalloid and colloid in the treatment of hemorrhagic shock has led to decreased inflammatory and edema-mediated complications. Studies are needed to determine if these benefits also occur with a similar resuscitation strategy in the setting of sepsis.

Systemic and Local Management of Burn Wounds

Management of severe burn injury (SBI) requires prompt, complex, and aggressive care. Despite major advances in the management of SBI-including patient-targeted resuscitation, management of inhalation injuries, specific nutritional support, enhanced wound therapy, and infection control-the consequences of SBI often result in complex, multiorgan metabolic changes. Consensus guidelines and clinical evidence regarding specific management of small animal burn patients are lacking. This article aims to review updated therapeutic consideration for the systemic and local management of SBI that are proven effective to optimize outcomes in human burn patients and may translate to small animal patients.

[State of the art in fluid and volume therapy : A user-friendly staged concept]

Adequate fluid therapy is highly important for the perioperative outcome of our patients. Both, hypovolemia and hypervolemia can lead to an increase in perioperative complications and can impair the outcome. Therefore, perioperative infusion therapy should be target-oriented. The main target is to maintain the patient's preoperative normovolemia by using a sophisticated, rational infusion strategy.Perioperative fluid losses should be discriminated from volume losses (surgical blood loss or interstitial volume losses containing protein). Fluid losses as urine or perspiratio insensibilis (0.5-1.0 ml/kg/h) should be replaced by balanced crystalloids in a ratio of 1:1. Volume therapy step 1: Blood loss up to a maximum value of 20% of the patient's blood volume should be replaced by balanced crystalloids in a ratio of 4(-5):1. Volume therapy step 2: Higher blood losses should be treated by using iso-oncotic, preferential balanced colloids in a ratio of 1:1. For this purpose hydroxyethyl starch can also be used perioperatively if there is no respective contraindication, such as sepsis, burn injuries, critically ill patients, renal impairment or renal replacement therapy, and severe coagulopathy. Volume therapy step 3: If there is an indication for red cell concentrates or coagulation factors, a differentiated application of blood and blood products should be performed.

Preferential effects of low volume versus high volume replacement with crystalloid fluid in a hemorrhagic shock model in pigs

Background

Fluid resuscitation is a core stone of hemorrhagic shock therapy, and crystalloid fluids seem to be associated with lower mortality compared to colloids. However, as redistribution starts within minutes, it has been suggested to replace blood loss with a minimum of a three-fold amount of crystalloids. The hypothesis was that in comparison to high volume (HV), a lower crystalloid volume (LV) achieves a favorable coagulation profile and exerts sufficient haemodynamics in the acute phase of resuscitation.

Methods

In 24 anaesthetized pigs, controlled arterial blood loss of 50 % of the estimated blood volume was either (n = 12) replaced with a LV (one-fold) or a HV (three-fold) volume of a balanced, acetated crystalloid solution at room temperature. Hemodynamic parameters, dilution effects and coagulation profile by standard coagulation tests and thromboelastometry at baseline and after resuscitation were determined in both groups.

Results

LV resuscitation increased MAP significantly less compared to the HV, 61 ± 7 vs. 82 ± 14 mmHg (p < 0.001) respectively, with no difference between lactate and base excess between groups. Haematocrit after fluid replacement was 0.20 vs. 0.16 (LV vs. HV, p < 0.001), suggesting a grade of blood dilution of 32 vs. 42 % (p < 0.001) compared to baseline values. Compared to LV, HV resulted in decreased core temperature (37.5 ± 0.2 vs. 36.0 ± 0.6 °C, p < 0.001), lower platelet count (318 ± 77 vs. 231 ± 53 K/μL, p < 0.01) and lower plasma fibrinogen levels (205 ± 19 vs. 168 ± 24 mg/dL, p < 0.001). Thromboelastometric measurements showed a significant impairment on viscoelastic clot properties following HV group. While prothrombin time index decreased significantly more in the HV group, activated partial thromboplastin time did not differ between both groups. HV did not result in hyperchloraemic acidosis.

Discussion

Coagulation parameters represented by plasma fibrinogen and ROTEM parameters were also less impaired with LV. With regrad to hematocrit, 60 % of LV remained intracascular , while in HV only 30 % remained in circulation within the first hour of administration. In the acute setting of 50 % controlled blood loss, a one fold LV crystalloid replacement strategy is sufficient to adequately raise blood pressure up to a mean arterial pressure >50 mm Hg. The concept of damage control resuscitation (DCR) with permissive hypotension may be better met by using LV as compared to a three fold HV resuscitation strategy.

Conclusion

High volume administration of an acetated balanced crystalloid does not lead to hyperchloraemic acidosis, but may negatively influence clinical parameters, such as higher blood pressure, lower body temperature and impaired coagulation parameters, which could potentially increase bleeding after trauma. Replacement of acute blood loss with just an equal amount of an acetated balanced crystalloid appears to be the preferential treatment strategy in the acute phase after controlled bleeding.

Sepsis and pregnancy: do we know how to treat this situation?

Sepsis is defined as an acute inflammatory response syndrome secondary to an infectious focus. It has a high incidence, morbidity and mortality, causing substantial financial costs, especially due to complications such as septic shock and multiple organ dysfunction. The pathogen toxins associated with individual susceptibility culminate with cytokine release, which promotes a systemic inflammatory response that can progress to multiple organ dysfunction and eventual patient death.

Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women, as this group is typically younger with fewer comorbidities having a polymicrobial etiology resulting in sepsis.

Pregnant women exhibit physiological characteristics that may confer specific clinical presentation and laboratory patterns during the sepsis course. Thus, a better understanding of these changes is critical for better identification and management of these patients. The presence of a fetus also requires unique approaches in a pregnant woman with sepsis.

Sepsis treatment is based on certain guidelines that were established after major clinical trials, which, unfortunately, all classified pregnancy as a exclusion criteria.

Thus, the treatment of sepsis in the general population has been extrapolated to the pregnant population, with the following main goals: maintenance of tissue perfusion with fluid replacement and vasoactive drugs (initial resuscitation), adequate oxygenation, control of the infection source and an early start of antibiotic therapy, corticosteroid infusion and blood transfusion when properly indicated, prophylaxis, and specifically monitoring and maintenance of fetal heath.

Role of colloids in traumatic brain injury: Use or not to be used?

Trauma is a leading cause of death worldwide and traumatic brain injury is one of the commonest injuries associated with it. The need for urgent resuscitation is warranted for prevention of secondary insult to brain. However, the choice of fluid in such cases is still a matter of conflict. The literature does not provide enough data pertaining to role of colloids in head injury patients. In this article, we have tried to explore the present role of colloid resuscitation in patient with head injury.

Perioperative fluid restriction

Perioperative fluid management of the colorectal surgical patient has evolved significantly over the last five decades. Older notions espousing aggressive hydration have been shown to be associated with increased complications. Newer data regarding fluid restriction has shown an association with improved outcomes. Management of perioperative fluid administration can be considered in three primary phases: In the preoperative phase, data suggests that avoidance of preoperative bowel preparation and avoidance of undue preoperative dehydration can improve outcomes. Although the type of intraoperative fluid given does not have a significant effect on outcome, data do suggest that a restrictive fluid regimen results in improved outcomes. Finally, in the postoperative phase of fluid management, a fluid-restrictive regimen, coupled with early enteral feeding also seems to result in improved outcomes.

Management of Burns and Anesthetic Implications

Burn injuries are highly complex and affect almost every major organ system in the body. The treatment of burn patients requires the presence of a well-organized team of caregivers who understand the multifaceted consequences of burn injuries and who are adept at coordinating care. An understanding of the multitude of abnormalities that must be addressed helps to guide therapy in these patients. Careful anesthetic and perioperative management of these patients carries special importance in this fragile patient population as a part of their often lengthy recovery and rehabilitation.

Fluid management in the critically ill child

Fluid management has a major impact on the duration, severity and outcome of critical illness. The overall strategy for the acutely ill child should be biphasic. Aggressive volume expansion to support tissue oxygen delivery as part of early goal-directed resuscitation algorithms for shock--especially septic shock--has been associated with dramatic improvements in outcome. Recent data suggest that the cost-benefit of aggressive fluid resuscitation may be more complex than previously thought, and may depend on case-mix and the availability of intensive care. After the resuscitation phase, critically ill children tend to retain free water while having reduced insensible losses. Fluid regimens that limit or avoid positive fluid balance are associated with a reduced length of hospital stay and fewer complications. Identifying the point at which patients change from the 'early shock' pattern to the later 'chronic critical illness' pattern remains a major challenge. Very little data are available on the choice of fluids, and most of the information that is available arises from studies of critically ill adults. There is therefore an urgent need for high-quality trials of both resuscitation and maintenance fluid regimens in critically ill children.

Reading between the (guide)lines--the KDIGO practice guideline on acute kidney injury in the individual patient

The KDIGO guidelines for acute kidney injury (AKI) are designed to assist health-care providers around the world in managing patients with AKI. Clinical guidelines are intended to help the clinician make an informed decision based on review of the currently available evidence. Due to the generic nature of guidelines, it is sometimes difficult to translate a guideline for a particular individual patient who may have specific clinical circumstances. To illustrate this point, we have discussed the interpretation of the KDIGO guideline in patients who have subtleties in their clinical presentation, which may make treatment decisions less than straightforward.

Acid-base and electrolyte status during normovolemic hemodilution with succinylated gelatin or HES-containing volume replacement solutions in rats

Background

In the past, several studies have compared different colloidal replacement solutions, whereby the focus was usually on the respective colloid. We therefore systematically studied the influence of the carrier solution’s composition of five approved colloidal volume replacement solutions (Gelafundin, Gelafusal, Geloplasma, Voluven and Volulyte) on acid-base as well as electrolyte status during and following acute severe normovolemic hemodilution. The solutions differed in the colloid used (succinylated gelatin vs. HES) and in the presence and concentration of metabolizable anions as well as in their electrolyte composition.

Methods

Anesthetized Wistar rats were subjected to a stepwise normovolemic hemodilution with one of the solutions until a final hematocrit of 10%. Subsequent to dilution (162 min), animals were observed for an additional period (150 min). During dilution and observation time blood gas analyses were performed eight times in total. Additionally, in the Voluven and Volulyte groups as well as in 6 Gelafundin animals, electrolyte concentrations, glucose, pH and succinylated gelatin were measured in urine and histopathological evaluation of the kidney was performed.

Results

All animals survived without any indications of injury. Although the employed solutions differed in their respective composition, comparable results in all plasma acid-base and electrolyte parameters studied were obtained. Plasma pH increased from approximately 7.28 to 7.39, the plasma K⁺ concentration decreased from circa 5.20 mM to 4.80-3.90 mM and the plasma Cl⁻ concentration rose from approximately 105 mM to 111–120 mM. Urinary analysis revealed increased excretion of K⁺, H⁺ and Cl⁻.

Conclusions

The present data suggest that the carrier solution’s composition with regard to metabolizable anions as well as K⁺, Ca²⁺ only has a minor impact on acid-base and electrolyte status after application of succinylated gelatin or HES-containing colloidal volume replacement solutions.

Relative survival benefit and morbidity with fluids in severe sepsis - a network meta-analysis of alternative therapies

BACKGROUND

Fluid resuscitation is widely practiced in intensive care units for the treatment of sepsis. A comparison of the evidence base of different fluids may inform therapeutic choice.

METHODS

The risks of mortality and morbidity (the need for renal replacement therapies (RRT)) were assessed in patients with severe sepsis. A network meta-analysis compared trials for crystalloids, albumin and hydroxyethyl starch (HES). A literature search of human randomized clinical trials was conducted in databases, the bibliographies of other recent relevant systematic reviews and data reported at recent conferences. Mortality outcomes and RRT data with the longest follow up period were compared. A Bayesian network meta-analysis assessed the risk of mortality and a pair-wise metaanalysis assessed RRT using crystalloids as the reference treatment.

RESULTS

13 studies were identified. A fixed-effects meta-analysis of mortality data in the trials demonstrated an odds-ratio (OR) of 0.90 between crystalloids and albumin, 1.25 between crystalloids and HES and 1.40 between albumin and HES. The probability that albumin is associated with the highest survival was 96.4% followed by crystalloid at 3.6%, with a negligible probability for HES. Sub-group analyses demonstrated the robustness of this result to variations in fluid composition, study source and origin of septic shock. A random-effects pairwise comparison for the risk of RRT provided an OR of 1.52 favoring crystalloid over HES.

CONCLUSION

Fluid therapy with albumin was associated with the highest survival benefit. The higher morbidity with HES may affect mortality and requires consideration by prescribers.

Respiratory review of 2013: critical care medicine

Several papers on respiratory and critical care published from March 2012 to February 2013 were reviewed. From these, this study selected and summarized ten articles, in which the findings were notable, new, and interesting: effects of high-frequency oscillation ventilation on acute respiratory distress syndrome (ARDS); safety and efficacy of hydroxyethyl starch as a resuscitation fluid; long-term psychological impairments after ARDS; safety and efficacy of dexmedetomidine for sedation; B-type natriuretic peptide-guided fluid management during weaning from mechanical ventilation; adding of daily sedation interruptions to protocolized sedations for mechanical ventilation; unassisted tracheostomy collar of weaning from prolonged mechanical ventilations; and effects of nighttime intensivist staffing on the hospital mortality rates.

Fluid management in pre-eclampsia

Intravenous fluid given to women with pre-eclampsia may be a necessary form of treatment; however, intravenous fluid therapy can also cause iatrogenic pulmonary oedema. The indications for the use of intravenous fluids, the titration of the amount of fluid given and the use of invasive monitoring have not been subject to adequate examination in randomised studies. Clinical experience, combined with available evidence and a reasoned approach are the basis for a suggested management algorithm.

Trends in resource utilization associated with the inpatient treatment of neonatal congenital heart disease

INTRODUCTION

While neonates account for a significant proportion of health care expenditures related to inpatient care for congenital heart disease, key drivers of resource utilization among this population are poorly defined.

METHODS

Data from 2005 through 2011 were extracted from the Pediatric Health Information System for patients assigned a discharge All Patient Refined Diagnosis Related Group of 630 (neonates with birthweight >2499 g undergoing a major cardiovascular procedure). Mortality risk adjustment for patients undergoing operative interventions was performed with the Risk Adjusment in Congenital Heart Surgery (RACHS-1) score.

RESULTS

A total of 13 156 cases were included in the analysis. Despite only a 3% increase in case mix index and no significant change in operative acuity over the study period (RACHS classifications of 3 or greater 67% in 2005 vs. 66% in 2011, P = .64), there were inflation-adjusted increases in both total estimated cost per case of (50% to $151 760 in 2011, P < .001), and mean charge per case (33% to $433 875 in 2011, P < .001). Pharmacy charges increased by 16% (P < .001), with agents including chlorothiazide and albumin accounting for the highest patient charges over the study period. Imaging charges increased by 42% (P < .001), with an average of 5.7 echocardiograms and $6517 in associated charges per case by 2011. While the proportion of patients receiving nitric oxide remained consistent, mean duration of administration increased by 25% to 6.6 days by 2011, accounting for average charges of $52 141 per patient exposed.

CONCLUSIONS

Among neonates with serious congenital heart disease, increases in both institutional costs and charges to the patient are associated with relatively consistent utilization practices in recent years. Multiinstitutional collaboration may prove useful in aligning evidence-based reductions in practice variation with limitations in resource utilization without compromising the quality of care.

Advances in monitoring and management of shock

Early recognition and treatment of pediatric shock, regardless of cause, decreases mortality and improves outcome. In addition to the conventional parameters (eg, heart rate, systolic blood pressure, urine output, and central venous pressure), biomarkers and noninvasive methods of measuring cardiac output are available to monitor and treat shock. This article emphasizes how fluid resuscitation is the cornerstone of shock resuscitation, although the choice and amount of fluid may vary based on the cause of shock. Other emerging treatments for shock (ie, temperature control, extracorporeal membrane oxygenation/ventricular assist devices) are also discussed.

Crystalloids vs. colloids: KO at the twelfth round?

Expanded abstract

Hydroxyethyl starch for fluid resuscitation in critically ill patients

BACKGROUND

Intravenous fluid therapy is one of the most frequent interventions provided to patients in the intensive care unit; however, the type of fluid (i.e., crystalloid or colloid) used for resuscitation remains controversial. The most common type of colloid administered to resuscitate critically ill patients is hydroxyethyl starch (HES); however, its safety and efficacy have not been rigorously evaluated in large pragmatic randomized trials, and emerging data have accumulated to question its potential for toxic adverse effects.

OBJECTIVE

To evaluate the efficacy and safety of HES for fluid resuscitation in critically ill patients with a focus on survival and kidney function.

DESIGN

Multicentre (32 sites in Australia and New Zealand) blinded randomized controlled parallel-group trial.

METHODS

Seven thousand eligible adult patients (age - ≥ 18 yr) admitted to an intensive care unit and judged by their treating clinician to require fluid resuscitation were included in the study. Study treatment allocation used encrypted Web-based randomization stratified by site and an admission diagnosis of trauma.

INTERVENTION

Randomized patients were assigned to receive either 6% HES with a molecular weight of 130 kD and molar substitution ratio of 0.4 (130/0.4; Voluven(®), Fresenius Kabi) in 0.9% sodium chloride or 0.9% sodium chloride (saline) in indistinguishable Free flex 500 mL bags until intensive care unit (ICU) discharge, death, or 90 days after randomization. According to registration guidelines, the study fluid was administered to a maximum dose of 50 mL kg(-1) body weight per day and followed, if necessary, by open-label saline during the remaining 24-hr period.

MEASUREMENTS

The primary efficacy outcome was death within 90 days after randomization. The key secondary outcomes were incidence of acute kidney injury (AKI), defined by the RIFLE (Risk, Injury, Failure, Loss, Endstage) criteria; treatment with renal replacement therapy(RRT); development of new organ dysfunction, defined by the sequential organ failure assessment score; duration of mechanical ventilation; duration of RRT; cause-specific mortality; and adverse events. Tertiary outcomes were ICU and hospital lengths of stay and ICU and hospital mortality. The primary outcome was evaluated across six a prior idefined subgroups: urine output criteria for AKI; presence of sepsis; presence of trauma, with or without traumatic brain injury; acute physiology and chronic health evaluation (APACHE) score C ≥ 25; and receipt of HES prior to randomization.

MAIN RESULTS

The HES and saline groups had similar characteristics at baseline. The average age was 63 yr, 60.4% of patients were male, and 42.7% were admitted to the ICU after surgery (54.7% after elective surgery). The median [interquartile range] APACHE II score was 17[12.0-23.0] with a score C ≥ 25 in 18.2%. Sepsis and trauma were primary diagnoses in 28.8% and 7.9% of patients, respectively. Mechanical ventilation was received by 64.5% of patients, vasopressor therapy by 45.8%, and HES fluid prior to randomization by 15.1%. Enrolment occurred approximately 11 hr after ICU admission. During the first four days after randomization, the mean (standard deviation) study fluid received by the HES group was less when compared with the saline group [526 (425) mL day(-1) vs 616 (488) mL day(-1), respectively; P < 0.001]. Mortality at 90 days was 18.0% in patients receiving HES (597/3,315) and 17.0% in those receiving saline (566/3,336) (relative risk [RR] for HES, 1.06; 95% confidence interval (CI), 0.96 to 1.18; P = 0.26). There was no significant difference in 90-day mortality across the six a priori defined subgroups. Renal replacement therapy was received in 7.0% of patients in the HES group (235/3,352) and 5.8% of patients in the saline group (196/3,376) (RR for HES, 1.21; 95% CI, 1.00 to 1.45; P = 0.04). In the HES and saline groups, RIFLE - Injury occurred in 34.6% and 38.0% of patients,respectively (P = 0.005), and RIFLE - Failure occurred in 10.4% and 9.2% of patients, respectively (P = 0.12). There were no differences in mortality in ICU, in hospital, or at 28 days. Hydroxyethyl starch was associated with a decrease in new cardiovascular organ failure compared with saline (36.5% vs 39.9%, respectively; RR 0.91; 95% CI, 0.84 to 0.99; P = 0.03) and an increase in new hepatic organ failure compared with saline (1.9% vs 1.2%, respectively; RR 15.6; 95% CI, 1.03 to 2.36; P = 0.03). There were no differences between HES and saline for days in ICU or hospital or for duration of mechanical ventilation or RRT. Hydroxyethyl starch was associated with more adverse events compared with saline (5.3% vs 2.8%, respectively; RR 1.86; 95% CI, 1.46 to 2.38; P < 0.001). Adverse events were predominantly accounted for by pruritis and skin rash.

CONCLUSION

In critically ill patients receiving fluid resuscitation, there was no significant difference in 90-day mortality between 6% HES (130/0.4) or saline. Even so, more patients who received resuscitation with HES were treated with RRT and experienced adverse events.

Randomised trials of 6% tetrastarch (hydroxyethyl starch 130/0.4 or 0.42) for severe sepsis reporting mortality: systematic review and meta-analysis

PURPOSE

To assess the impact of 6% tetrastarch [hydroxyethyl starch (HES) 130/0.4 and 130/0.42] in severe sepsis patients. The primary outcome measure was 90-day mortality.

METHODS

A structured literature search was undertaken to identify prospective randomised controlled trials (RCTs) in adult patients with severe sepsis receiving 6% tetrastarch (of potato or waxy maize origin) as part of fluid resuscitation in comparison with other non-HES fluids after randomisation in the critical care setting. A systematic review and meta-analysis were performed.

RESULTS

Six RCTs were included (n = 3,033): three from 2012 (n = 2,913) had low risk of bias. Median tetrastarch exposure was 37.4 ml/kg (range 30-43 ml/kg). Ninety-day mortality was associated with tetrastarch exposure [relative risk (RR) 1.13; 95% confidence interval (CI) 1.02-1.25; p = 0.02] compared with crystalloid. The number needed to harm (NNH) was 28.8 (95 % CI 14.6-942.5). Publication bias and statistical heterogeneity (I(2) = 0%) were not present. Tetrastarch exposure was also associated with renal replacement therapy (p = 0.01; NNH 15.7) and allogeneic transfusion support (p = 0.001; NNH 9.9). No difference between groups was observed for 28-day mortality, for comparison with colloid as control, or for waxy maize-derived tetrastarch, but power was lacking. Overall mortality was associated with tetrastarch exposure (RR 1.13; 95% CI 1.02-1.25; p = 0.02).

CONCLUSIONS

In our analysis, 6% tetrastarch as part of initial fluid resuscitation for severe sepsis was associated with harm and, as alternatives exist, in our view should be avoided.

Specific antioxidant properties of human serum albumin

Human serum albumin (HSA) has been used for a long time as a resuscitation fluid in critically ill patients. It is known to exert several important physiological and pharmacological functions. Among them, the antioxidant properties seem to be of paramount importance as they may be implied in the potential beneficial effects that have been observed in the critical care and hepatological settings. The specific antioxidant functions of the protein are closely related to its structure. Indeed, they are due to its multiple ligand-binding capacities and free radical-trapping properties. The HSA molecule can undergo various structural changes modifying its conformation and hence its binding properties and redox state. Such chemical modifications can occur during bioprocesses and storage conditions of the commercial HSA solutions, resulting in heterogeneous solutions for infusion. In this review, we explore the mechanisms that are responsible for the specific antioxidant properties of HSA in its native form, chemically modified forms, and commercial formulations. To conclude, we discuss the implication of this recent literature for future clinical trials using albumin as a drug and for elucidating the effects of HSA infusion in critically ill patients.

Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy

PURPOSE

To determine whether fluid resuscitation of acutely ill adults with 6 % hydroxyethyl starch (6 % HES 130) with a molecular weight of 130 kD and a molar substitution ratio of approximately 0.4 (6 % HES 130) compared with other resuscitation fluids results in a difference in the relative risk of death or treatment with renal replacement therapy (RRT).

METHODS

Systematic review and meta-analysis of randomized controlled trials comparing intravascular fluids for resuscitation of hospitalised adults that reported mortality or treatment with RRT. The risk of bias was assessed independently by two reviewers and meta-analysis was performed using random effects.

RESULTS

Thirty-five trials enrolling 10,391 participants were included. The three largest trials had the lowest risk of bias, were published (or completed) in 2012, and together enrolled 77 % of all participants. Death occurred in 928 of 4,691 patients (19.8 %) in the 6 % HES 130 group versus 871 of 4,720 (18.5 %) in the control fluid groups relative risk (RR) in the 6 % HES 130 group 1.08, 95 % confidence interval (CI) 1.00 to 1.17, I (2) = 0 %). Treatment with RRT occurred in 378 of 4,236 patients (8.9 %) in the 6 % HES 130 group versus 306 of 4,260 (7.2 %) in the control fluid group (RR in the 6 % HES 130 group 1.25, 95 % CI 1.08 to 1.44, I (2) = 0 %).

CONCLUSIONS

The quality and quantity of data evaluating 6 % hydroxyethyl starch (130/0.4 and 130/0.42) as a resuscitation fluid has increased in the last 12 months. Patients randomly assigned to resuscitation with 6 %HES 130 are at significantly increased risk of being treated with RRT.

Fluid management in cardiac surgery: colloid or crystalloid?

The crystalloid-colloid debate has raged for decades, with the publication of many meta-analyses, yet no consensus. There are important differences between colloids and crystalloids, and these differences have direct relevance for cardiac surgical patients. Rather than asking crystalloid or colloid, we believe better questions to ask are (1) High or low chloride content? and (2) Synthetic or natural colloid? In this paper we review the published literature regarding fluid therapy in cardiac surgery and explain the background to these two important and unanswered questions.

Fluid management in thoracic surgery

Better understanding of the pathophysiology of acute lung injury (ALI) and the hazards inherent to extremes in volume status has led efforts toward goal-directed, individualized therapies designed to achieve optimal hemodynamic status. The role for colloids both as a volume expander and potential protective agent against ALI is receiving revived interest. The evidence for the impact of fluid therapy is encouraging and supports the undertaking of properly designed perioperative fluid trials in thoracic surgeries. Such work offers hope that optimal fluid strategies can be defined and reduce the adverse events that have affected patients having lung resection.

Haemorrhage control in severely injured patients

Most surgeons have adopted damage control surgery for severely injured patients, in which the initial operation is abbreviated after control of bleeding and contamination to allow ongoing resuscitation in the intensive-care unit. Developments in early resuscitation that emphasise rapid control of bleeding, restrictive volume replacement, and prevention or early management of coagulopathy are making definitive surgery during the first operation possible for many patients. Improved topical haemostatic agents and interventional radiology are becoming increasingly useful adjuncts to surgical control of bleeding. Better understanding of trauma-induced coagulopathy is paving the way for the replacement of blind, unguided protocols for blood component therapy with systemic treatments targeting specific deficiencies in coagulation. Similarly, treatments targeting dysregulated inflammatory responses to severe injury are under investigation. As point-of-care diagnostics become more suited to emergency environments, timely targeted intervention for haemorrhage control will result in better patient outcomes and reduced demand for blood products. Our Series paper describes how our understanding of the roles of the microcirculation, inflammation, and coagulation has shaped new and emerging treatment strategies.

Colloid solutions for fluid resuscitation

BACKGROUND

Colloids are widely used in the replacement of fluid volume. However, doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this, and their other characteristics, they may differ in their safety and efficacy.

OBJECTIVES

To compare the effects of different colloid solutions in patients thought to need volume replacement.

SEARCH METHODS

We searched the Cochrane Injuries Specialised Register (searched 1 December 2011), the Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 December 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 December 2011); CINAHL (EBSCO) (1982 to 1 December 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 December 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999).

SELECTION CRITERIA

Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions.

MAIN RESULTS

Eighty-six trials, with a total of 5,484 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 33 trials and poor or uncertain in the rest.Deaths were reported in 57 trials. For albumin or plasma protein fraction (PPF) versus hydroxyethyl starch (HES) 31 trials (n = 1719) reported mortality. The pooled relative risk (RR) was 1.06 (95% confidence interval (CI) 0.86 to 1.31). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or CIs. For albumin or PPF versus dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 22 trials (n = 1612) reported mortality and the RR was 1.02 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.03 (95% CI 0.84 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty-one trials recorded the amount of blood transfused; however, quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to gel and one to HES.

AUTHORS' CONCLUSIONS

From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the CIs were wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

Colloid solutions for fluid resuscitation

BACKGROUND

Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy.

OBJECTIVES

To compare the effects of different colloid solutions in patients thought to need volume replacement.

SEARCH METHODS

We searched the Cochrane Injuries Specialised Register (searched 1 Dec 2011), Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 Dec 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 Dec 2011); CINAHL (EBSCO) (1982 to 1 Dec 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 Dec 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999).

SELECTION CRITERIA

Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions.

MAIN RESULTS

Ninety trials, with a total of 5678 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 35 trials and poor or uncertain in the rest.Deaths were obtained in 61 trials. For albumin or PPF versus hydroxyethyl starch (HES) 32 trials (n = 1769) reported mortality. The pooled relative risk (RR) was 1.07 (95% CI 0.87 to 1.32). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or confidence intervals. For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 25 trials (n = 1756) reported mortality and the RR was 1.03 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.04 (95% CI 0.85 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty five trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to Gel and one to HES.

AUTHORS' CONCLUSIONS

From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.