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Al Raizah A, Alayoubi F, Abdelnaby GH, Alzahrani H, Bakheet MF, Alskaini MA, Buhumaid R, Al Awadhi S, Kazim SN, Jaiganesh T, Naguib MHH, Al Aseri Z. Clinical Care Pathway and Management of Major Bleeding Associated with Nonvitamin K Antagonist Oral Anticoagulants: A Modified Delphi Consensus from Saudi Arabia and UAE. Mediterr J Hematol Infect Dis 2024; 16:e2024038. [PMID: 38882457 PMCID: PMC11178050 DOI: 10.4084/mjhid.2024.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/13/2024] [Indexed: 06/18/2024] Open
Abstract
Background The nonvitamin K antagonist oral anticoagulants (NOACs) have become the mainstay anticoagulation therapy for patients requiring oral anticoagulants (OACs) in the Gulf Council Cooperation (GCC) countries. The frequency of NOAC-associated major bleeding is expected to increase in the Emergency Department (ED). Nonetheless, we still lack local guidelines and recommendations for bleeding management in the region. The present Delphi-based consensus aims to establish a standardized and evidence-based clinical care pathway for managing NOAC-associated major bleeding in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). Methods We adopted a three-step modified Delphi method to develop evidence-based recommendations through two voting rounds and an advisory meeting between the two rounds. A panel of 11 experts from the KSA and UAE participated in the consensus development. Results Twenty-eight statements reached the consensus level. These statements addressed key aspects of managing major bleeding events associated with NOACs, including the increased use of NOAC in clinical practice, clinical care pathways, and treatment options. Conclusion The present Delphi consensus provides evidence-based recommendations and protocols for the management of NOAC-associated bleeding in the region. Patients with major DOAC-induced bleeding should be referred to a well-equipped ED with standardized management protocols. A multidisciplinary approach is recommended for establishing the association between NOAC use and major bleeding. Treating physicians should have prompt access to specific reversal agents to optimize patient outcomes. Real-world evidence and national guidelines are needed to aid all stakeholders involved in NOAC-induced bleeding management.
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Affiliation(s)
- Abdulrahman Al Raizah
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia
| | | | | | - Hazzaa Alzahrani
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - Mohammed A Alskaini
- Department of Neurology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Rasha Buhumaid
- Mohammed Bin Rashid University of Medicine and Health Science, Dubai, United Arab Emirates
| | - Sameer Al Awadhi
- Digestive Diseases Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Sara Nooruddin Kazim
- Department of Emergency Medicine, Rashid Hospital and Trauma Centre, Dubai Health Authority, Dubai, United Arab Emirates
| | | | | | - Zohair Al Aseri
- Department Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, Saudi Arabia
- Therapeutic Deputyship, Ministry of Health, Riyadh, Saudi Arabia
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2
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Tang Q, Li X, Sun CR. Predictive value of serum albumin levels on cancer survival: a prospective cohort study. Front Oncol 2024; 14:1323192. [PMID: 38500655 PMCID: PMC10944876 DOI: 10.3389/fonc.2024.1323192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/22/2024] [Indexed: 03/20/2024] Open
Abstract
Background Serum albumin levels and cancer mortality are closely related, yet large-sample studies encompassing a broad spectrum of cancer types are lacking. Methods This study encompassed patients diagnosed with cancer across the continuous 10 cycles of NHANES surveys from 1999 to 2018. The study population was stratified into two groups based on median albumin levels (≤ 4.2g/dL and > 4.2 g/dL) or cancer aggressiveness (well-survived cancers and poorly-survived cancers). Survival rates were estimated using the Kaplan-Meier method. The Cox proportional hazards model was employed to evaluate the association between serum albumin levels and cancer mortality. Restricted cubic spline (RCS) analysis was conducted to assess the nonlinear relationship between serum albumin levels and the risk of cancer mortality. Results Kaplan-Meier curves demonstrated that patients with albumin levels ≤ 4.2 g/dL exhibited lower survival rates compared to those with levels > 4.2 g/dL, irrespective of cancer aggressiveness. Following adjustment for confounders, decreased albumin levels were associated with an elevated risk of cancer mortality across all groups [all cancers, HR (95%CI) = 2.03(1.73, 2.37); well survived cancers, HR (95%CI) = 1.78(1.38, 2.32); and poorly survived cancers, HR (95%CI) = 1.99(1.64, 2.42)]. RCS analyses revealed a stable nonlinear negative association between albumin levels and cancer mortality in all groups, regardless of confounder adjustment. Conclusion Low serum albumin levels predict higher cancer mortality. Furthermore, a nonlinear negative association was observed between serum albumin levels and the risk of cancer mortality.
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Affiliation(s)
- Quan Tang
- Department of General Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, China
| | - Xu Li
- Division of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chun-Rong Sun
- Department of General Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, China
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3
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Safeek R, Bryan J, Heath F, Satteson E, Maurer A, Safa B, Sorice-Virk S. Evidence based recommendations for perioperative vasopressor use and fluid resuscitation in microsurgery. Microsurgery 2023. [PMID: 37052570 DOI: 10.1002/micr.31047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023]
Abstract
Blood pressure regulation is critical in patients undergoing microsurgical free tissue transfer; however, guidelines for addressing and preventing perioperative hypotension remain highly debated, with two current thought paradigms: (1) intravenous fluid administration with a balanced salt solution (e.g., lactate ringer and normal saline) and/or colloid (e.g., albumin) and (2) vasoactive pharmacological support with vasopressors (e.g., dobutamine, norepinephrine, epinephrine), with fluid administration being the preferred conventional approach. Here, we review the most up to date available literature and summarize currents perspectives and practices for fluid resuscitation and vasopressor use, while offering evidence-based guidelines to each.
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Affiliation(s)
- Rachel Safeek
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Jaimie Bryan
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Frederick Heath
- Stanford University School of Medicine, Stanford, California, USA
| | - Ellen Satteson
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Adrian Maurer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Bauback Safa
- The Buncke Clinic, San Francisco, California, USA
| | - Sarah Sorice-Virk
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
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4
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Hoang TN, Musquiz BN, Tubog TD. Impact of Goal-Directed Fluid Therapy on Postoperative Outcomes in Colorectal Surgery: An Evidence-Based Review. J Perianesth Nurs 2023:S1089-9472(22)00596-2. [PMID: 36858859 DOI: 10.1016/j.jopan.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/26/2022] [Accepted: 11/06/2022] [Indexed: 03/03/2023]
Abstract
PURPOSE To investigate the effects of goal-directed fluid therapy (GDFT) or conventional fluid therapy (CFT) in improving postoperative outcomes in patients undergoing colorectal surgeries. DESIGN Evidence-Based Review. METHODS Following the guidelines outlined in the PRISMA statement, a comprehensive search was conducted using PubMed, Elsevier ScienceDirect, Oxford Academic, EBSCO, Google Scholar, Cochrane Library, and gray literature. Only randomized controlled studies and pre-appraised evidence such as systematic review with meta-analysis examining the effects of GDFT and CFT in colorectal surgery were included. The quality appraisal of the literature was conducted using the proposed algorithm described in the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide. FINDINGS Two systematic reviews with meta-analyses and four randomized controlled trials (RCT) involving 2018 patients were included in this review. Overall, the use of GDFT did not shorten the hospital length of stay (LOS), reduce 30-day mortality, lower overall morbidity rates, or decrease incidence of postoperative ileus. Additionally, the return of bowel function was not improved using GDFT or CFT. However, when GDFT was implemented within enhanced recovery after surgery (ERAS) programs, there was a significant reduction in hospital LOS. . When GDFT was used in a non-ERAS patient care setting, there was a significant reduction in overall morbidity rate and faster time to first flatus. All studies included in the review were categorized as Level I and rated Grade A, implying strong confidence in the true effects of GDFT on all outcome measures in the review. CONCLUSIONS The benefits of GDFT in colorectal surgery are still unclear. Considerable heterogeneity based on the types of GDFT devices, patient outcome parameters, and fluid protocols limit the application to clinical practice. Furthermore, there was limited data on the effects of GDFT in high-risk patients for colorectal surgery.
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Affiliation(s)
- Tuyet N Hoang
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Brittney N Musquiz
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Tito D Tubog
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX.
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5
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Flick M, Sand U, Bergholz A, Kouz K, Reiter B, Flotzinger D, Saugel B, Kubitz JC. Right ventricular and pulmonary artery pulse pressure variation and systolic pressure variation for the prediction of fluid responsiveness: an interventional study in coronary artery bypass surgery patients. J Clin Monit Comput 2022; 36:1817-1825. [PMID: 35233702 DOI: 10.1007/s10877-022-00830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/07/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Predicting fluid responsiveness is essential when treating surgical or critically ill patients. When using a pulmonary artery catheter, pulse pressure variation and systolic pressure variation can be calculated from right ventricular and pulmonary artery pressure waveforms. METHODS We conducted a prospective interventional study investigating the ability of right ventricular pulse pressure variation (PPVRV) and systolic pressure variation (SPVRV) as well as pulmonary artery pulse pressure variation (PPVPA) and systolic pressure variation (SPVPA) to predict fluid responsiveness in coronary artery bypass (CABG) surgery patients. Additionally, radial artery pulse pressure variation (PPVART) and systolic pressure variation (SPVART) were calculated. The area under the receiver operating characteristics (AUROC) curve with 95%-confidence interval (95%-CI) was used to assess the capability to predict fluid responsiveness (defined as an increase in cardiac index of > 15%) after a 500 mL crystalloid fluid challenge. RESULTS Thirty-three patients were included in the final analysis. Thirteen patients (39%) were fluid-responders with a mean increase in cardiac index of 25.3%. The AUROC was 0.60 (95%-CI 0.38 to 0.81) for PPVRV, 0.63 (95%-CI 0.43 to 0.83) for SPVRV, 0.58 (95%-CI 0.38 to 0.78) for PPVPA, and 0.71 (95%-CI 0.52 to 0.89) for SPVPA. The AUROC for PPVART was 0.71 (95%-CI 0.53 to 0.89) and for SPVART 0.78 (95%-CI 0.62 to 0.94). The correlation between pulse pressure variation and systolic pressure variation measurements derived from the different waveforms was weak. CONCLUSIONS Right ventricular and pulmonary artery pulse pressure variation and systolic pressure variation seem to be weak predictors of fluid responsiveness in CABG surgery patients.
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Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike Sand
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Beate Reiter
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Jens Christian Kubitz
- Department of Anesthesiology and Intensive Care Medicine, Paracelsus Medical University Nuremberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany.
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6
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Turkut N, Altun D, Canbolat N, Uzuntürk C, Şen C, Çamcı AE. Comparison of Stroke Volume Variation-based goal-directed Therapy Versus Standard Fluid Therapy in Patients Undergoing Head and Neck Surgery: A Randomized Controlled Study. Balkan Med J 2022; 39:351-357. [PMID: 35965423 PMCID: PMC9469670 DOI: 10.4274/balkanmedj.galenos.2022.2022-1-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Aims: Study Design: Methods: Results: Conclusion:
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7
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Fluid Management, Intra-Abdominal Hypertension and the Abdominal Compartment Syndrome: A Narrative Review. Life (Basel) 2022; 12:life12091390. [PMID: 36143427 PMCID: PMC9502789 DOI: 10.3390/life12091390] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. Objectives: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). Methods: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. Results: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. Conclusions: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.
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8
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Dhatariya KK. The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care. Diabet Med 2022; 39:e14788. [PMID: 35224769 DOI: 10.1111/dme.14788] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022]
Abstract
This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medicine School, University of East Anglia, Norwich, UK
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9
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Li X, Ma Q, Yin J, Zheng Y, Chen R, Chen Y, Li T, Wang Y, Yang K, Zhang H, Tang Y, Chen Y, Dong H, Gu Q, Guo D, Hu X, Xie L, Li B, Li Y, Lin T, Liu F, Liu Z, Lyu L, Mei Q, Shao J, Xin H, Yang F, Yang H, Yang W, Yao X, Yu C, Zhan S, Zhang G, Wang M, Zhu Z, Zhou B, Gu J, Xian M, Lyu Y, Li Z, Zheng H, Cui C, Deng S, Huang C, Li L, Liu P, Men P, Shao C, Wang S, Ma X, Wang Q, Zhai S. A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020). Front Pharmacol 2022; 13:845689. [PMID: 35418863 PMCID: PMC8996305 DOI: 10.3389/fphar.2022.845689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.
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Affiliation(s)
- Xiaotong Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Jia Yin
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ya'an Zheng
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Rongchang Chen
- State Key Laboratory for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Institute of Emergency and Critical Care Medicine of Shandong University, Ji'nan, China
| | - Tianzuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yuqin Wang
- Pharmacy Department, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hongjun Zhang
- Departments of Nursing, Peking University Third Hospital, Beijing, China
| | - Yida Tang
- Department of Internal Medicine, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Qinglong Gu
- Department of Otolaryngology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Daihong Guo
- Pharmacy Department, Chinese PL A General Hospital, Beijing, China
| | - Xuehui Hu
- Department of Nursing, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lixin Xie
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Baohua Li
- Departments of Nursing, Peking University Third Hospital, Beijing, China
| | - Yuzhen Li
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Tongyu Lin
- State Key Laboratory of Oncology in South China, Department of Medical Oncology, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fang Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lanting Lyu
- School of Public Administration and Policy, Renmin University of China, Beijing, China.,Health Technology Assessment and Health Policy Research Group at Renmin University of China, Beijing, China
| | - Quanxi Mei
- Department of Pharmacy, Shenzhen Bao'an Pure Chinese Medicine Treatment Hospital, Shenzhen, China
| | - Jie Shao
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Huawen Xin
- Department of Clinical Pharmacology, General Hospital of Central Theater Command of PLA, Wuhan, China
| | - Fan Yang
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China
| | - Hui Yang
- Departments of Nursing, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Wanhua Yang
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xu Yao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Chunshui Yu
- Department of Radiology and Tianjin Key Laboratory of Functional Imaging, Tianjin Medical University General Hospital, Tianjin, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Guoqiang Zhang
- Department of Emergency, China-Japan Friendship Hospital, Beijing, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China
| | - Zhu Zhu
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Baoguo Zhou
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jianqing Gu
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mo Xian
- State Key Laboratory for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuan Lyu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Institute of Emergency and Critical Care Medicine of Shandong University, Ji'nan, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Hangci Zheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China
| | - Chang Cui
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China
| | - Shuhua Deng
- Departments of Nursing, Peking University Third Hospital, Beijing, China
| | - Chao Huang
- National Center for Medical Service Administration, National Health Commission of the People's Republic of China, Beijing, China
| | - Lisha Li
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pengfei Liu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China
| | - Chunli Shao
- Department of Internal Medicine, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sai Wang
- Pharmacy Department, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xiang Ma
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Physiology, Oklahoma University Health Science Center, Oklahoma City, OK, United States
| | - Qiang Wang
- National Center for Medical Service Administration, National Health Commission of the People's Republic of China, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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10
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Wajda-Pokrontka M, Nadziakiewicz P, Krauchuk A, Ochman M, Zawadzki F, Przybyłowski P. Influence of Fluid Therapy on Kidney Function in the Early Postoperative Period After Lung Transplantation. Transplant Proc 2022; 54:1115-1119. [DOI: 10.1016/j.transproceed.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/18/2022] [Indexed: 12/15/2022]
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11
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Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes. Nutrients 2022; 14:nu14050919. [PMID: 35267894 PMCID: PMC8912377 DOI: 10.3390/nu14050919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/18/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Mathew A, Rai E. Pediatric perioperative fluid management. Saudi J Anaesth 2021; 15:435-440. [PMID: 34658733 PMCID: PMC8477784 DOI: 10.4103/sja.sja_140_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/12/2022] Open
Abstract
Appropriate fluid management is vital for adequate tissue perfusion and balancing the internal milieu especially in perioperative settings and critically ill children. Pediatric population is heterogeneous so one formula may not suffice and hence both the quantitative and qualitative perspective of fluid management should be based on physiology and pathology of the child along with their perioperative needs. In perioperative setup, the fluid is administered to meet fluid deficits (fasting, and other daily based losses), blood losses and third space losses. Anesthetists have always followed pediatric maintenance fluid calculations based on Holiday and Segar formula; based on studies conducted on healthy children more than 70 years ago. Recently, there has been a lot of debate about this concept, especially as there are serious concerns regarding the development of complications like hyponatremia and hyperglycemia, both of which can result in neurological damage or even mortality in a sick child. This review is an attempt to provide a historical perspective and current evidence-based approach to peri-operative pediatric fluid management. We performed a PUBMED search for articles using keywords including ‘children’, ‘intravenous fluid therapy’, ‘crystalloids’, ‘colloids’, ‘fluid homeostasis’, ‘blood loss’, ‘estimation of blood loss’, ‘blood loss management’, ‘perioperative fluid ‘ to get our source articles.
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Affiliation(s)
- Amit Mathew
- Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ekta Rai
- Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
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Krishnamoorthy V, Motika CO, Ohnuma T, McLean D, Ellis AR, Raghunathan K. Perioperative colloid choice and bleeding in patients undergoing musculoskeletal surgery: An observational administrative database study. Int J Crit Illn Inj Sci 2021; 11:223-228. [PMID: 35070912 PMCID: PMC8725802 DOI: 10.4103/ijciis.ijciis_178_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/27/2020] [Accepted: 02/02/2021] [Indexed: 11/04/2022] Open
Abstract
Background The synthetic colloid hydroxyethyl starch (HES) received a black box warning, issued by the US Food and Drug Administration (FDA) in June 2013, in patients with sepsis, due to increased risk of bleeding, renal injury, and death. Risks of HES in populations undergoing noncardiac surgery are unclear. Here, we examine the association of colloid choice - human-derived albumin versus HES - with bleeding in musculoskeletal surgery. Methods Inpatient musculoskeletal surgical patients who received colloids on the day of surgery were included during a time period before the FDA warning on HES using the Premier Healthcare database. The exposure was type of colloids administered on the day of surgery: HES versus albumin. The primary outcome was major perioperative bleeding, measured on the 1st postoperative day through hospital discharge. The secondary outcomes included acute renal failure and postoperative length of stay >75th percentile. Results We identified 41,211 patients who received albumin (n = 12,803) and HES (n = 28,408) on the day of surgery. The propensity-weighted multivariable analysis demonstrated a reduced risk of major perioperative bleeding on the day after surgery following treatment with albumin versus HES (relative risk: 0.89 [95% confidence interval, 0.84-0.93]). No significant differences were observed in the secondary outcomes. Conclusion When compared with albumin, treatment with HES on the day of musculoskeletal surgery was associated with an increased risk of major perioperative bleeding on subsequent days. Given that HES continues to be used as a colloid in multiple patient populations worldwide, further studies examining the safety of HES versus albumin solutions are needed.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Critical Care and Perioperative Population Health Research Unit, Duke University, Durham, NC, USA
| | - Calvin O Motika
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Critical Care and Perioperative Population Health Research Unit, Duke University, Durham, NC, USA
| | - Duncan McLean
- Department of Anesthesiology, The University of North Carolina, Chapel Hill, NC, USA
| | - Alan R Ellis
- School of Social Work, North Carolina State University, Raleigh, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Critical Care and Perioperative Population Health Research Unit, Duke University, Durham, NC, USA
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15
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Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
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Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9958073. [PMID: 34307683 PMCID: PMC8282389 DOI: 10.1155/2021/9958073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.
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Gulati A, Choudhuri R, Gupta A, Singh S, Noushad Ali SK, Sidhu GK, Haque PD, Rahate P, Bothra AR, Singh GP, Maheshwari S, Jeswani D, Haveri S, Agarwal A, Agrawal NR. A multicentric, randomized, controlled phase III study of centhaquine (Lyfaquin ® ) as a resuscitative agent in hypovolemic shock patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2020.07.30.20068114. [PMID: 33173916 PMCID: PMC7654912 DOI: 10.1101/2020.07.30.20068114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
INTRODUCTION Centhaquine (Lyfaquin ® ) showed significant safety and efficacy in preclinical and clinical phase I and II studies. METHODS A prospective, multicentric, randomized phase III study was conducted in patients with hypovolemic shock having systolic blood pressure (SBP) of ≤90 mm Hg and blood lactate levels of ≥2 mmol/L. Patients were randomized in a 2:1 ratio, 71 patients to the centhaquine group and 34 patients to the control (saline) group. Every patient received standard of care (SOC) and was followed for 28 days. The study drug (normal saline or centhaquine (0.01 mg/kg)) was administered in 100 mL of normal saline infusion over 1 hour. The primary objectives were to determine changes (mean through 48 hours) in SBP, diastolic blood pressure (DBP), blood lactate levels, and base deficit. The secondary objectives included the amount of fluids, blood products, vasopressors administered in the first 48 hours, duration of hospital stay, time in ICU, time on the ventilator support, change in patient's Acute Respiratory Distress Syndrome (ARDS), Multiple Organ Dysfunction Syndrome (MODS) scores, and the proportion of patients with 28-day all-cause mortality. RESULTS The demographics of patients and baseline vitals in both groups were comparable. Trauma was the cause of hypovolemic shock in 29.41% of control and 47.06% of centhaquine, gastroenteritis in 44.12% of control, and 29.41% of centhaquine patients. An equal amount of fluids and blood products were administered in both groups during the first 48 hours of resuscitation. A lesser amount of vasopressors was needed in the first 48 hours of resuscitation in the centhaquine group. An increase in SBP from the baseline was consistently higher in the centhaquine group than in the control. A significant increase in pulse pressure in the centhaquine group than the control group suggests improved stroke volume due to centhaquine. The shock index was significantly lower in the centhaquine group than control from 1 hour (p=0.0320) till 4 hours (p=0.0494) of resuscitation. Resuscitation with centhaquine had a significantly greater number of patients with improved blood lactate and the base deficit than the control group. ARDS and MODS improved with centhaquine, and an 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group. CONCLUSION Centhaquine is a highly efficacious resuscitative agent for treating hypovolemic shock. The efficacy of centhaquine in distributive shock due to sepsis and COVID-19 is being explored. TRIAL REGISTRATION Clinical Trials Registry, India; ctri.icmr.org.in, CTRI/2019/01/017196; clinicaltrials.gov, NCT04045327 . KEY SUMMARY POINTS A multicentric, randomized, controlled trial was conducted to evaluate the efficacy of centhaquine in hypovolemic shock patients.One hundred and five patients were randomized 2:1 to receive centhaquine or saline. Centhaquine was administered at a dose of 0.01 mg/kg in 100 mL saline and infused over 1 hour. The control group received 100 mL of saline over a 1-hour infusion.Centhaquine improved blood pressure, shock index, reduced blood lactate levels, and improved base deficit. Acute Respiratory Distress Syndrome (ARDS) and Multiple Organ Dysfunction Syndrome (MODS) score improved with centhaquine.An 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group. There were no drug-related adverse events in the study.
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El Khatib A, Jeschke MG. Contemporary Aspects of Burn Care. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:386. [PMID: 33923571 PMCID: PMC8073568 DOI: 10.3390/medicina57040386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.
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Affiliation(s)
- Arij El Khatib
- Unité des Grands Brûlés, University of Montreal Medical Centre Sanguinet, 1051, Rue Sanguinet, Montréal, QC H2X 0C1, Canada
| | - Marc G. Jeschke
- Department of Surgery, Division of Plastic Surgery, Department of Immunology, Ross Tilley Burn Centre-Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, 2075 Bayview Avenue, Rm D704, Toronto, ON M4N 3M5, Canada;
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Nozewski J, Grzesk G, Klopocka M, Wicinski M, Nicpon-Nozewska K, Konieczny J, Wlodarczyk A. Management of Patient with Simultaneous Overt Gastrointestinal Bleeding and Myocardial Infarction with ST-Segment Elevation - Priority Endoscopy. Vasc Health Risk Manag 2021; 17:123-133. [PMID: 33833517 PMCID: PMC8020127 DOI: 10.2147/vhrm.s292253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/15/2021] [Indexed: 01/28/2023] Open
Abstract
Background The current ERC guidelines are the source of many positive changes, reduction of mortality, length of hospitalization and improvement of prognosis of STEMI patients. However, there is a small group of patients whose slight modification in guidelines would further reduce in-hospital mortality and hospitalization costs. These are patients with concomitant STEMI infarction and gastrointestinal bleeding. Methods Two separate methods of treatment were compared in patients with concomitant gastrointestinal bleeding and ST-segment elevation myocardial infarction. The first – traditional approach, in the line with the ESC guidelines, the second innovative, with priority for endoscopy. Results Despite the innovative approach, the patient with endoscopy before PCI was discharged without complication. A patient who has undergone coronary intervention and who has been started on typical antiplatelet therapy prior to gastroenterological diagnosis has died due to massive bleeding. Conclusion For ethical reasons and in connection with the cardiological guidelines of the management of ACS, a study of patients with ASC a high risk of intestinal bleeding, in which endoscopy will have priority, and only later PCI, will probably never be performed. Although, as the described case shows, despite exceeding the 90 minutes time to implement PCI (<120 minutes) in logistic terms such behavior is completely feasible.
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Affiliation(s)
- Jakub Nozewski
- Faculty of Health Sciences, Emergency Department, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Grzegorz Grzesk
- Faculty of Health Sciences, Department of Cardiology and Clinical Pharmacology, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maria Klopocka
- Faculty of Health Science, Department of Gastroenterology, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michal Wicinski
- Faculty of Medicine, Department of Pharmacology and Therapy, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Klara Nicpon-Nozewska
- Faculty of Health Sciences, Department and Clinic of Geriatrics, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Adam Wlodarczyk
- Faculty of Medicine, Department of Psychiatry, Medical University of Gdansk, Gdansk, Poland
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Dhondt L, Croubels S, De Paepe P, Goethals K, De Cock P, Devreese M. Unraveling the Contribution of Fluid Therapy to the Development of Augmented Renal Clearance in a Piglet Model. Front Pharmacol 2021; 11:607101. [PMID: 33574754 PMCID: PMC7870502 DOI: 10.3389/fphar.2020.607101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/14/2022] Open
Abstract
Augmented renal clearance (ARC) observed in the critically ill pediatric population has received an increased attention over the last years due to its major impact on the disposition and pharmacokinetics of mainly renally excreted drugs. Apart from an important inflammatory trigger, fluid administration has been suggested to contribute to the development of ARC. Therefore, the primary objective of this study was to evaluate the effect of continuous intravenous fluid administration on renal function using a conventional piglet animal model and to quantify the impact of fluid administration on the pharmacokinetics of renally excreted drugs. At baseline, twenty-four piglets (12 treatment/12 control; 7 weeks old, all ♂) received the marker drugs iohexol (64.7 mg/kg body weight (BW)) and para-aminohippuric acid (10 mg/kg BW) to quantify glomerular filtration rate and effective renal plasma flow, respectively. In addition, the hydrophilic antibiotic amikacin (7.5 mg/kg BW) was administered. Following this baseline measurement, the treatment group received fluid therapy as a constant rate infusion of 0.9% saline at 6 mL/kg/h over 36 h. After 24 h of fluid administration, the marker drugs and amikacin were administered again. When comparing both groups, a significant effect of fluid administration on the total body clearances of iohexol (p = 0.032) and amikacin (p = 0.0014) was observed. Clearances of iohexol and amikacin increased with on average 15 and 14%, although large interindividual variability was observed. This led to decreased systemic exposure to amikacin, which was manifested as decrease in area under the plasma concentration-time curve from time 0 h to infinity from 34,807 to 30,804 ng.h/mL. These results suggest that fluid therapy is a key factor involved in the development of ARC and should be taken into account when administering mainly renally excreted drugs. However, further research is necessary to confirm these results in children.
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Affiliation(s)
- Laura Dhondt
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Siska Croubels
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Klara Goethals
- Department of Nutrition, Genetics and Ethology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Pieter De Cock
- Heymans Institute of Pharmacology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
- Department of Paediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Mathias Devreese
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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Freitas FGRD, Hammond N, Li Y, Azevedo LCPD, Cavalcanti AB, Taniguchi L, Gobatto A, Japiassú AM, Bafi AT, Mazza BF, Noritomi DT, Dal-Pizzol F, Bozza F, Salluh JIF, Westphal GA, Soares M, Assunção MSCD, Lisboa T, Lobo SMA, Barbosa AR, Ventura AF, Souza AFD, Silva AF, Toledo A, Reis A, Cembranel A, Rea Neto A, Gut AL, Justo APP, Santos AP, Albuquerque ACDD, Scazufka A, Rodrigues AB, Fernandino BB, Silva BG, Vidal BS, Pinheiro BV, Pinto BVC, Feijo CAR, Abreu Filho CD, Bosso CEDCN, Moreira CEN, Ramos CHF, Tavares C, Arantes C, Grion C, Mendes CL, Kmohan C, Piras C, Castro CPP, Lins C, Beraldo D, Fontes D, Boni D, Castiglioni D, Paisani DDM, Pedroso DFF, Mattos ER, Brito Sobrinho ED, Troncoso EMV, Rodrigues Filho EM, Nogueira EEF, Ferreira EL, Pacheco ES, Jodar E, Ferreira ELA, Araujo FFD, Trevisol FS, Amorim FF, Giannini FP, Santos FPM, Buarque F, Lima FG, Costa FAAD, Sad FCDA, Aranha FG, Ganem F, Callil F, Costa Filho FF, Dall Arto FTC, Moreno G, Friedman G, Moralez GM, Silva GAD, Costa G, Cavalcanti GS, Cavalcanti GS, Betônico GN, Betônico GN, Reis H, Araujo HBN, Hortiz Júnior HA, Guimaraes HP, Urbano H, Maia I, Santiago Filho IL, Farhat Júnior J, Alvarez JR, Passos JT, Paranhos JEDR, Marques JA, Moreira Filho JG, Andrade JN, Sobrinho JODC, Bezerra JTDP, Alves JA, Ferreira J, Gomes J, Sato KM, Gerent K, Teixeira KMC, Conde KAP, Martins LF, Figueirêdo L, Rezegue L, Tcherniacovsk L, Ferraz LO, Cavalcante L, Rabelo L, Miilher L, Garcia L, Tannous L, Hajjar LA, Paciência LEM, Cruz Neto LMD, Bley MV, Sousa MF, Puga ML, Romano MLP, Nobrega M, Arbex M, Rodrigues ML, Guerreiro MO, Rocha M, Alves MAP, Alves MAP, Rosa MD, Dias MD, Martins M, Oliveira MD, Moretti MMS, Matsui M, Messender O, Santarém OLDA, Silveira PJHD, Vassallo PF, Antoniazzi P, Gottardo PC, Correia P, Ferreira P, Torres P, Silva PGMDBE, Foernges R, Gomes R, Moraes R, Nonato Filho R, Borba RL, Gomes RV, Cordioli R, Lima R, López RP, Gargioni RRDO, Rosenblat R, Souza RMD, Almeida R, Narciso RC, Marco R, Waltrick R, Biondi R, Figueiredo R, Dutra RS, Batista R, Felipe R, Franco RSDS, Houly S, Faria SS, Pinto SF, Luzzi S, Sant'ana S, Fernandes SS, Yamada S, Zajac S, Vaz SM, Bezerra SAB, Farhat TBT, Santos TM, Smith T, Silva UVA, Damasceno VB, Nobre V, Dantas VCDS, Irineu VM, Bogado V, Nedel W, Campos Filho W, Dantas W, Viana W, Oliveira Filho WD, Delgadinho WM, Finfer S, Machado FR. Resuscitation fluid practices in Brazilian intensive care units: a secondary analysis of Fluid-TRIPS. Rev Bras Ter Intensiva 2021; 33:206-218. [PMID: 34231801 PMCID: PMC8275089 DOI: 10.5935/0103-507x.20210028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022] Open
Abstract
Objective To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS. Methods This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice. Results On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only. Conclusion Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.
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Affiliation(s)
| | - Naomi Hammond
- Critical Care and Trauma Division, The George Institute for Global Health - Sydney, Austrália
| | - Yang Li
- Critical Care and Trauma Division, The George Institute for Global Health - Sydney, Austrália
| | - Luciano Cesar Pontes de Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Leandro Taniguchi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - André Gobatto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - André Miguel Japiassú
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil.,Hospital de Clínicas Mário Lioni - Rio de Janeiro (RJ), Brasil
| | - Antonio Tonete Bafi
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil.,Hospital do Rim e Hipertensão, Fundação Oswaldo Ramos - São Paulo (SP), Brasil
| | | | | | | | - Fernando Bozza
- Hospital de Clínicas Mário Lioni - Rio de Janeiro (RJ), Brasil.,Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | | | | | - Márcio Soares
- Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | | | | | | | | | | | | | | | | | - Aline Reis
- Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | | | - Alvaro Rea Neto
- Hospital Ecoville - Curitiba (PR), Brasil.,Hospital do Trabalhador - Curitiba (PR), Brasil.,Hospital Vita Batel - Curitiba (PR), Brasil
| | - Ana Lúcia Gut
- Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual "Júlio de Mesquita Filho" - Botucatu (SP), Brasil
| | | | | | | | | | | | | | | | | | - Bruno Valle Pinheiro
- Hospital Universitário, Universidade Federal de Juiz de Fora- Juiz de Fora (MG), Brasil
| | | | | | | | | | | | | | - Carmen Tavares
- Hospital Municipal Santa Isabel - João Pessoa (PA), Brasil
| | - Cidamaiá Arantes
- Hospital e Maternidade Municipal Dr. Odelmo Leão Carneiro - Uberlândia (MG), Brasil
| | - Cintia Grion
- Hospital Evangélico de Londrina - Londrina (PR), Brasil.,Universidade Estadual de Londrina - Londrina (SC), Brasil
| | | | - Claudio Kmohan
- Hospital de Caridade Astrogildo de Azevedo - Santa Maria (RS), Brasil
| | | | | | - Cyntia Lins
- Hospital do Subúrbio - Salvador (BA), Brasil
| | | | - Daniel Fontes
- Hospital Felício Rocho - Belo Horizonte (MG), Brasil
| | - Daniela Boni
- Hospital Municipal Irmã Dulce - Praia Grande (SP), Brasil
| | - Débora Castiglioni
- Hospital Universitário Júlio Müller, Universidade Federal do Mato Grosso - Cuiabá (MT), Brasil
| | | | | | | | | | | | | | | | - Eduardo Leme Ferreira
- Hospital Carlos da Silva Lacaz - Francisco Morato (SP), Brasil.,Hospital Escola, Faculdade de Medicina de Jundiaí - Jundiaí (SP), Brasil
| | - Eduardo Souza Pacheco
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil.,Hospital Sepaco - São Paulo (SP), Brasil
| | - Euzebio Jodar
- Hospital Professor Edmundo Vasconcelos - São Paulo (SP), Brasil
| | | | - Fabiana Fernandes de Araujo
- Clínica Dom Rodrigo - João Pessoa (PA), Brasil.,Complexo Hospitalar Ortotrauma de Mangabeira - Fortaleza (CE), Brasil
| | | | | | | | | | | | - Felipe Gallego Lima
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | | | | | | | - Flavio Callil
- Hospital Estadual Getúlio Vargas - Rio de Janeiro (RJ), Brasil
| | | | | | - Geovani Moreno
- Santa Casa de Misericórdia de Vitória da Conquista - Vitória da Conquista (BA), Brasil
| | - Gilberto Friedman
- Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | | | | | | | | | | | | | | | - Hélder Reis
- Hospital de Clínicas Gaspar Vianna - Belém (PA), Brasil
| | | | | | - Helio Penna Guimaraes
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Hugo Urbano
- Hospital Vila da Serra - Belo Horizonte (MG), Brasil
| | - Israel Maia
- Hospital Nereu Ramos - Florianópolis (SC), Brasil
| | | | | | - Janu Rangel Alvarez
- Santa Casa de Caridade de Don Pedrito - Dom Pedrito (RS), Brasil.,Santa Casa de Misericórdia de Santana do Livramento - Santana do Livramento (RS), Brasil
| | | | | | | | | | | | | | | | | | - Juliana Ferreira
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Jussara Gomes
- Associação Hospitalar Beneficente São Vicente de Paulo - Passo Fundo (RS), Brasil
| | - Karina Midori Sato
- Hospital do Servidor Público Municipal de São Paulo - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | - Ligia Rabelo
- Hospital Copa D'Or - Rio de Janeiro (RJ), Brasil
| | | | - Lisiane Garcia
- Hospital Universitário de Santa Maria - Santa Maria (RS), Brasil
| | - Luana Tannous
- Hospital Universitário Cajuru - Curitiba (PR), Brasil
| | - Ludhmila Abrahão Hajjar
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Instituto do Câncer do Estado de São Paulo - São Paulo (SP), Brasil
| | | | | | | | | | - Marcelo Lourencini Puga
- Hospital das Clínicas, Faculdade Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | | | - Marciano Nobrega
- Hospital Goiânia Leste - Goiânia (GO), Brasil.,Hospital Ortopédico - Goiânia (GO), Brasil.,Hospital Santa Maria - Goiânia (GO), Brasil
| | - Marcio Arbex
- Hospital Municipal Dr. Munir Rafful - Volta Redonda (RJ), Brasil.,Hospital Jardim Amália - Volta Redonda (RJ), Brasil
| | | | - Márcio Osório Guerreiro
- Hospital Universitário São Francisco de Paula, Universidade Católica de Pelotas - Pelotas (RS), Brasil
| | - Marcone Rocha
- Hospital São Joao de Deus - Divinópolis (MG), Brasil
| | | | | | | | | | - Miquéias Martins
- Hospital Geral de Vitória da Conquista - Vitória da Conquista (BA), Brasil
| | | | | | - Mirna Matsui
- Hospital Universitário, Universidade Federal da Grande Dourados - Dourados (GO), Brasil
| | | | | | | | | | - Paulo Antoniazzi
- Santa Casa de Misericórdia de Ribeirão Preto - Ribeirão Preto (SP), Brasil
| | | | - Paulo Correia
- Santa Casa de Belo Horizonte - Belo Horizonte (MG), Brasil
| | | | - Paulo Torres
- Santa Casa Maringá, Universidade Estadual Maringá - Maringá (PR), Brasil
| | | | - Rafael Foernges
- Hospital Universitário, Universidade de Santa Cruz do Sul - Santa Cruz do Sul (RS), Brasil
| | | | - Rafael Moraes
- Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | | | - Renato V Gomes
- Hospital Unimed Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | - Ricardo Lima
- Hospital Samaritano Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | | | | | | | - Roberto Almeida
- Hospital Municipal Padre Germano Lauck - Foz do Iguaçu (RS), Brasil
| | | | - Roberto Marco
- Hospital Santa Izabel - São Paulo (SP), Brasil.,Santa Casa de Misericórdia de São Paulo - São Paulo (SP), Brasil
| | | | | | | | - Rodrigo Santana Dutra
- Hospital Universitário Ciências Médicas, Fundação Educacional Lucas Machado - Belo Horizonte (MG), Brasil
| | | | - Rouge Felipe
- Instituto Nacional de Cardiologia - Rio de Janeiro (RJ), Brasil
| | | | - Sandra Houly
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | - Sergio Felix Pinto
- Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul - Campo Grande (MS), Brasil
| | - Sergio Luzzi
- Hospital do Servidor Público Estadual "Francisco Morato de Oliveira" - São Paulo (SP), Brasil
| | | | | | - Sérgio Yamada
- Hospital Universitário de Maringá, Universidade Estadual de Maringá - Maringá (PR), Brasil
| | - Sérgio Zajac
- Albert Sabin Hospital e Maternidade - Juiz de Fora (MG), Brasil
| | | | | | | | - Thiago Martins Santos
- Disciplina de Emergências Clínicas, Universidade Estadual de Campinas - Campinas (SP), Brasil
| | | | - Ulysses V A Silva
- Fundação Pio XII- Hospital de Câncer de Barretos - Barretos (SP), Brasil
| | | | - Vandack Nobre
- Hospital das Clínicas, Universidade Federal de Minas Gerais - Belo Horizonte (MG), Brasil
| | | | | | - Viviane Bogado
- Santa Casa de Angra dos Reis - Angra dos Reis (RJ), Brasil
| | - Wagner Nedel
- Grupo Hospitalar Nossa Senhora da Conceição - Porto Alegre (RS), Brasil
| | - Walther Campos Filho
- Irmandade Misericórdia Hospital Santa Casa de Monte Alto - Monte Alto (SP), Brasil
| | | | | | - Wilson de Oliveira Filho
- Hospital Unimed de Manaus - Manaus (AM), Brasil.,Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil
| | - Wilson Martins Delgadinho
- Casa de Saúde Campinas - Campinas (SP), Brasil.,Hospital e Maternidade Galileo - Valinhos (SP), Brasil
| | - Simon Finfer
- Critical Care and Trauma Division, The George Institute for Global Health - Sydney, Austrália
| | - Flavia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
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22
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Zheng Z, Ding YX, Qu YX, Cao F, Li F. A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:69. [PMID: 33553362 PMCID: PMC7859757 DOI: 10.21037/atm-20-4802] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca2+) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.
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Affiliation(s)
- Zhi Zheng
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yi-Xuan Ding
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yuan-Xu Qu
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Feng Cao
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
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23
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Meléndez-Lugo JJ, Caicedo Y, Guzmán-Rodríguez M, Serna JJ, Ordoñez J, Angamarca E, García A, Pino LF, Quintero L, Parra MW, Ordoñez CA. Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4024486. [PMID: 33795898 PMCID: PMC7968431 DOI: 10.25100/cm.v51i4.4486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the “Stop the Bleed” initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the “Stop the Bleed” initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.
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Affiliation(s)
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Instituto de Ciencias Biomédicas, Facultad de Medicina, Santiago de Chile, Chile
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Sección de Cirugía de Trauma y Emergencias, Cali, Colombia
| | - Juliana Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia
| | | | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Hospital Universitario del Valle, Sección de Cirugía de Trauma y Emergencias, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia
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24
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Al Saied G, Almutairi HM, Alharbi Y, Almohanna M, Almutairi A. Comparison Between the Impact of Vasopressors and Goal-Directed Fluid Therapy on the Management of Free Flap Reconstruction of Head and Neck and Monitoring in ICU. Cureus 2020; 12:e12108. [PMID: 33489525 PMCID: PMC7805489 DOI: 10.7759/cureus.12108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Head and neck reconstructions are often accompanied with complex long surgical procedures. Free flap tissue transfer is a standard reconstruction method that reestablishes severe tissue defects after resection due to trauma or cancer. Imbalanced fluid resuscitation can extremely harm the outcome of the flap either due to hypoperfusion or edema. Flap-related postoperative complications mainly flap failure necessitates the administration of a large amount of intravenous fluids perioperatively especially with lengthy operative time. Therefore, vasopressors may be used to preserve hemodynamic stability without excessive fluids use. Nevertheless, these vasopressors have long been disfavored as they may provoke anastomosis vasoconstriction leading to graft hypoperfusion and finally flap failure. However, according to recent guidelines, they are now well-thought to be safe. Of note, inotropes have been confirmed to increase blood flow in the anastomosis hence they can replace vasoconstrictors. Recently, goal-directed fluid therapy (GDFT) has been proven to be excellent in high-risk head and neck free tissue transfer surgery as it decreases prolonged intensive care unit (ICU) admission hospitalization and complication rate. Today, GDFT is highly suggested as one of the enhanced recoveries after surgery protocols for major head and neck free flap reconstruction surgery.
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Affiliation(s)
- Ghiath Al Saied
- Internal Medicine - Critical Care, King Fahad Medical City, Riyadh, SAU
| | - Homood M Almutairi
- Otolaryngology, Unaizah College of Medicine, Qassim University, Buraydah, SAU
| | - Yousef Alharbi
- Medicine, Unaizah College of Medicine, Qassim University, Buraydah, SAU
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25
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Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu YK. Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:693. [PMID: 33317590 PMCID: PMC7734863 DOI: 10.1186/s13054-020-03419-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022]
Abstract
Background Crystalloids and different component colloids, used for volume resuscitation, are sometimes associated with various adverse effects. Clinical trial findings for such fluid types in different patients’ conditions are conflicting. Whether the mortality benefit of balanced crystalloid than saline can be inferred from sepsis to other patient group is uncertain, and adverse effect profile is not comprehensive. This study aims to compare the survival benefits and adverse effects of seven fluid types with network meta-analysis in sepsis, surgical, trauma, and traumatic brain injury patients. Methods Searched databases (PubMed, EMBASE, and Cochrane CENTRAL) and reference lists of relevant articles occurred from inception until January 2020. Studies on critically ill adults requiring fluid resuscitation were included. Intervention studies reported on balanced crystalloid, saline, iso-oncotic albumin, hyperoncotic albumin, low molecular weight hydroxyethyl starch (L-HES), high molecular weight HES, and gelatin. Network meta-analyses were conducted using random-effects model to calculate odds ratio (OR) and mean difference. Risk of Bias tool 2.0 was used to assess bias. Confidence in Network Meta-Analysis (CINeMA) web application was used to rate confidence in synthetic evidence. Results Fifty-eight trials (n = 26,351 patients) were identified. Seven fluid types were evaluated. Among patients with sepsis and surgery, balanced crystalloids and albumin achieved better survival, fewer acute kidney injury, and smaller blood transfusion volumes than saline and L-HES. In those with sepsis, balanced crystalloids significantly reduced mortality more than saline (OR 0.84; 95% CI 0.74–0.95) and L-HES (OR 0.81; 95% CI 0.69–0.95) and reduced acute kidney injury more than L-HES (OR 0.80; 95% CI 0.65–0.99). However, they required the greatest resuscitation volume among all fluid types, especially in trauma patients. In patients with traumatic brain injury, saline and L-HES achieved lower mortality than albumin and balanced crystalloids; especially saline was significantly superior to iso-oncotic albumin (OR 0.55; 95% CI 0.35–0.87). Conclusions Our network meta-analysis found that balanced crystalloids and albumin decreased mortality more than L-HES and saline in sepsis patients; however, saline or L-HES was better than iso-oncotic albumin or balanced crystalloids in traumatic brain injury patients. Trial registration PROSPERO website, registration number: CRD42018115641).
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Affiliation(s)
- Chien-Hua Tseng
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Room 539, No. 17, Xu-Zhou Rd., Taipei, 10055, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Tzu-Tao Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,College of Science, Tunghai University, Taichung, Taiwan
| | - Ming-Chieh Shih
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Room 539, No. 17, Xu-Zhou Rd., Taipei, 10055, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Room 539, No. 17, Xu-Zhou Rd., Taipei, 10055, Taiwan. .,Department of Dentistry, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan. .,Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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26
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2020; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.,Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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27
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Edel A, Reinhart K, Schaller SJ. [Critical statement on selected recommendations of the new German S3 Sepsis Guideline]. Med Klin Intensivmed Notfmed 2020; 115:505-507. [PMID: 32910285 PMCID: PMC7481338 DOI: 10.1007/s00063-020-00720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Andreas Edel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Konrad Reinhart
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland.
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28
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Correlation between Intraoperative Fluid Administration and Outcomes of Pancreatoduodenectomy. Gastroenterol Res Pract 2020; 2020:8914367. [PMID: 32802047 PMCID: PMC7414365 DOI: 10.1155/2020/8914367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
Abstract
Background Intraoperative fluid (IOF) administration plays an important role during major abdominal surgery although increased fluid intake can adversely influence postoperative outcomes. However, the effect of the IOF rate on the outcomes of pancreatoduodenectomy (PD) is unclear. Methods 151 patients, who underwent PD at Binzhou Medical University Hospital between January 2010 and May 2017, were categorized into three groups according to IOF rates (ml/kg/hr): restricted (<10, n = 47), standard (10–15, n = 76), and liberal (>15, n = 28). Results The overall postoperative morbidity was 56.95%. The incidence of postoperative pancreatic fistula (POPF) was 11.26%. The in-hospital mortality rate was 7.28% with the most common cause being grade C POPF and secondary intra-abdominal infections. The patients in the liberal group had significantly higher incidences of POPF (25%) and respiratory complications (21.43%). The other outcome parameters such as recovery of bowel function, hospital stay, and postoperative daily drainage were similar among the groups. Multivariable analysis confirmed the IOF rate to be most strongly associated with POPF (odds ratio: 5.195, confidence interval: 1.142–23.823, P = 0.023) and respiratory complications (odds ratio: 7.302, confidence interval: 0.676–58.231, P = 0.025). Conclusions The IOF rate significantly affects the incidence of POPF and respiratory complications after PD. Careful patient-oriented fluid therapy may help to prevent these complications.
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Ting WT, Chang RW, Wang CH, Chen YS, Lee JJ. Comparison of the trometamol-balanced solution with two other crystalloid solutions for fluid resuscitation of a rat hemorrhagic model. J Vet Sci 2020; 21:e6. [PMID: 31940685 PMCID: PMC7000892 DOI: 10.4142/jvs.2020.21.e6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 09/30/2019] [Accepted: 10/21/2019] [Indexed: 12/31/2022] Open
Abstract
Currently, the optimal resuscitation fluid remains debatable. Therefore, in the present study, we designed a trometamol-balanced solution (TBS) for use as a resuscitation fluid for hemorrhagic shock. Hemorrhagic shock was induced in 18 male Wistar-Kyoto rats, which were assigned to normal saline (NS), Ringer's solution (RS), and TBS groups. During the hemorrhagic state, their hemodynamic parameters were recorded using an Abbott i-STAT analyzer with the CG4+ cartridge (for pH, pressure of carbon dioxide, pressure of oxygen, total carbon dioxide, bicarbonate, base excess, oxygen saturation, and lactate), the CG6+ cartridge (for sodium, potassium, chloride, blood glucose, blood urea nitrogen, hematocrit, and hemoglobin), and enzyme-linked immunosorbent assay kits (calcium, magnesium, creatinine, aspartate aminotransferase, alanine aminotransferase, bilirubin, and albumin). Similar trends were found for the parameters of biochemistries, electrolytes, and blood gas, and they revealed no significant changes after blood withdrawal-induced hemorrhagic shock. However, the TBS group showed more effective ability to correct metabolic acidosis than the NS and RS groups. TBS was a feasible and safe resuscitation solution in this study and may be an alternative to NS and RS for resuscitation in hemorrhagic shock patients without liver damage.
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Affiliation(s)
- Wen Ting Ting
- Department and Graduate Institute of Veterinary Medicine, School of Veterinary Medicine, National Taiwan University, Taipei 10617, Taiwan.,Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University, Taipei 10002, Taiwan.,Graduate Institute of Veterinary Clinical Sciences, School of Veterinary Medicine, National Taiwan University, Taipei 10672, Taiwan
| | - Ru Wen Chang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University, Taipei 10002, Taiwan
| | - Chih Hsien Wang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University, Taipei 10002, Taiwan
| | - Yih Sharng Chen
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University, Taipei 10002, Taiwan.
| | - Jih Jong Lee
- Department and Graduate Institute of Veterinary Medicine, School of Veterinary Medicine, National Taiwan University, Taipei 10617, Taiwan.,Graduate Institute of Veterinary Clinical Sciences, School of Veterinary Medicine, National Taiwan University, Taipei 10672, Taiwan.,Animal Cancer Treatment Center, National Taiwan University Veterinary Hospital, Taipei 10672, Taiwan.
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Abstract
Objectives To investigate the effect of albumin exposure in ICU after cardiac surgery on hospital mortality, complications, and costs. Design A retrospective, single-center cohort study with economic evaluation. Setting Cardiothoracic ICU in Australia. Patients Adult patients admitted to the ICU after cardiac surgery. Interventions None. Measurements and Main Results Comparison of outcomes and costs in ICU after cardiac surgery based on 4% human albumin exposure. During the study period, 3,656 patients underwent cardiac surgery. After exclusions, 2,594 patients were suitable for analysis. One-thousand two-hundred sixty-four (48.7%) were exposed to albumin and 19 (1.4%) of those died. The adjusted hospital mortality of albumin exposure compared with no albumin was not significant (odds ratio, 1.24; 95% CI, 0.56-2.79; p = 0.6). More patients exposed to albumin returned to the operating theater for bleeding and/or tamponade (6.1% vs 2.1%; odds ratio, 2.84; 95% CI, 1.81-4.45; p < 0.01) and received packed red cell transfusions (p < 0.001). ICU and hospital lengths of stay were prolonged in those exposed to albumin (mean difference, 18 hr; 95% CI, 10.3-25.6; p < 0.001 and 87.5 hr; 95% CI, 40.5-134.6; p < 0.001). Costs (U.S. dollar) were higher in patients exposed to albumin, compared with those with no albumin exposure (mean difference in ICU costs, $2,728; 95% CI, $1,566-3,890 and mean difference in hospital costs, $5,427; 95% CI, $3,294-7,560). Conclusions There is no increased mortality in patients who are exposed to albumin after cardiac surgery. The patients exposed to albumin had higher illness severity, suffered more complications, and incurred higher healthcare costs. A randomized controlled trial is required to determine whether albumin use is effective and safe in this setting.
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Pitocco D, Di Leo M, Tartaglione L, Rizzo EG, Caputo S, Rizzi A, Pontecorvi A. An Approach to Diabetic Ketoacidosis in an Emergency Setting. Rev Recent Clin Trials 2020; 15:278-288. [PMID: 32646361 DOI: 10.2174/1574887115666200709172402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic Ketoacidosis (DKA) is one of the most commonly encountered diabetic complication emergencies. It typically affects people with type 1 diabetes at the onset of the disease. It can also affect people with type 2 diabetes, although this is uncommon. METHODS Research and online content related to diabetes online activity is reviewed. DKA is caused by a relative or absolute deficiency of insulin and elevated levels of counter-regulatory hormones. RESULTS Goals of therapy are to correct dehydration, acidosis, and to reverse ketosis, gradually restoring blood glucose concentration to near normal. CONCLUSION It is essential to monitor potential complications of DKA and, if necessary, to treat them and any precipitating events.
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Affiliation(s)
- Dario Pitocco
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Mauro Di Leo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Linda Tartaglione
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Emanuele Gaetano Rizzo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Salvatore Caputo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Alessandro Rizzi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Alfredo Pontecorvi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
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Shahein AR, Quiros JA, Arbizu RA, Jump C, Lauzon SD, Baker SS. Impact of Clinical, Laboratory and Fluid Therapy Variables on Hospital Length of Stay for Children with Acute Pancreatitis. Pediatr Gastroenterol Hepatol Nutr 2020; 23:356-365. [PMID: 32704496 PMCID: PMC7354873 DOI: 10.5223/pghn.2020.23.4.356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/15/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE There have been many efforts to develop generalizable severity markers in children with acute pancreatitis (AP). Expert opinion panels have developed consensus guidelines on management but it is unclear if these are sufficient or valid. Our study aims to assess the effect of clinical and laboratory variables, in addition to treatment modality on hospital length of stay (LOS) as a proxy variable for severity in pediatric patients admitted with AP. METHODS We conducted a retrospective chart review of patients between ages of 0-18 years, who were admitted with AP at 2 institutions between 2013-2018, John R. Oishei Children's Hospital (Buffalo, NY, USA) and Medical University of South Carolina Children's Hospital (Charleston, SC, USA). We constructed three linear regression models to analyze the effect of clinical signs of organ dysfunction, laboratory markers and fluid intake on hospital LOS. RESULTS Ninety-two patients were included in the study. The mean age was 12 years (range, 7.6-17.4 years), 55% were females, and median LOS was 3 days. The most frequent cause of AP was idiopathic. Our study showed that elevated blood urea nitrogen (BUN) on admission (p<0.005), tachycardia that lasted for ≥48 hours (p<0.001) and need for fluid resuscitation were associated with increase LOS. Total daily fluid intake above maintenance did not have a significant effect on the primary outcome (p=0.49). CONCLUSION Elevated serum BUN on admission, persistent tachycardia and need for fluid resuscitation were associated with increase LOS in pediatric AP. Daily total fluid intake above recommended maintenance did not reduce LOS.
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Affiliation(s)
- Abdul R Shahein
- Division of Pediatric Gastroenterology and Nutrition, Children's Hospital of Arkansas, Little Rock, AR, USA
| | - J Antonio Quiros
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Ricardo A Arbizu
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Candi Jump
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Steven D Lauzon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Susan S Baker
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
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Chooi C, Cox JJ, Lumb RS, Middleton P, Chemali M, Emmett RS, Simmons SW, Cyna AM. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev 2020; 7:CD002251. [PMID: 32619039 PMCID: PMC7387232 DOI: 10.1002/14651858.cd002251.pub4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury). OBJECTIVES To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (9 August 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted data from eligible studies. We report 'Summary of findings' tables using GRADE. MAIN RESULTS We included 125 studies involving 9469 women. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review's primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit. Crystalloid versus control (no fluids) Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence). Colloid versus crystalloid Fewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.69, 95% CI 0.58 to 0.81; 2009 women; 27 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women; very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.98, 95% CI 0.54 to 1.78, 5 studies, 413 women; very low-quality evidence), nausea and/or vomiting (average RR 0.89, 95% CI 0.66 to 1.19, 14 studies, 1058 women, I² = 29%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 10 studies, 730 babies; very low-quality evidence). Ephedrine versus phenylephrine There were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence). Ondansetron versus control Ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence). Lower limb compression versus control Lower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42, 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence). Walking versus lying There was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence). Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections. External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration. AUTHORS' CONCLUSIONS While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.
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Affiliation(s)
- Cheryl Chooi
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Julia J Cox
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Richard S Lumb
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Richard S Emmett
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Scott W Simmons
- Department of Anaesthesia, Mercy Hospital for Women, Heidelberg, Australia
| | - Allan M Cyna
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
- University of Sydney, Sydney, Australia
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Is Fresh Frozen Plasma Still Necessary for Management of Acute Traumatic Coagulopathy? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00397-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
PURPOSE OF REVIEW Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders. RECENT FINDINGS There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.
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Affiliation(s)
| | - Paul Feuerstadt
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA. .,Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, CT, USA.
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Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:429-450. [PMID: 32082905 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Ramesh GH, Uma JC, Farhath S. Fluid resuscitation in trauma: what are the best strategies and fluids? Int J Emerg Med 2019; 12:38. [PMID: 31801458 PMCID: PMC6894336 DOI: 10.1186/s12245-019-0253-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 10/29/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Traumatic injuries pose a global health problem and account for about 10% global burden of disease. Among injured patients, the major cause of potentially preventable death is uncontrolled post-traumatic hemorrhage. MAIN BODY This review discusses the role of prehospital trauma care in low-resource/remote settings, goals, principles and evolving strategies of fluid resuscitation, ideal resuscitation fluid, and post-resuscitation fluid management. Management of fluid resuscitation in few special groups is also discussed. CONCLUSIONS Prehospital trauma care systems reduce mortality in low-resource/remote settings. Delayed resuscitation seems a better option when transport time to definitive care is shorter whereas goal-directed resuscitation with low-volume crystalloid seems a better option if transport time is longer. Few general recommendations regarding the choice of fluid are provided. Adhering to evidence-based clinical practice guidelines and local modifications based on patient population, available resources, and expertise will improve patient outcomes.
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Affiliation(s)
- G H Ramesh
- Emergency Department BMC & RI. Victoria Hospital, City Market, Bengaluru, Karnataka, 560002, India
| | - J C Uma
- K.C.G Hospital 89, 5th Cross Rd, Behind Police Station, Malleshwaram, Bengaluru, Karnataka, 560003, India
| | - Sheerin Farhath
- Columbia Asia Hospital Yeshwanthpur 26/4, Brigade Gateway Malleshwaram West Beside Metro Cash and Carry West, Yeswanthpur, Bengaluru, Karnataka, 560055, India.
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Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171:805-822. [PMID: 31634917 PMCID: PMC7233308 DOI: 10.7326/m19-1795] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
DESCRIPTION This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. METHODS An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. RECOMMENDATIONS Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
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Affiliation(s)
- Alan N Barkun
- McGill University, Montreal, Quebec, Canada (A.N.B.)
| | - Majid Almadi
- McGill University, Montreal, Quebec, Canada, and King Saud University, Riyadh, Saudi Arabia (M.A.)
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, the Netherlands (E.J.K.)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut (L.L.)
| | - Joseph Sung
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Frances Tse
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | | | | | - Xavier Calvet
- Hospital Parc Taulí de Sabadell, University of Barcelona, Sabadell, Spain, and CiberEHD (Instituto de Salud Carlos III), Madrid, Spain (X.C.)
| | - Francis K L Chan
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - James Douketis
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (R.E.)
| | - Ian M Gralnek
- Technion-Israel Institute of Technology, Emek Medical Center, Afula, Israel (I.M.G.)
| | | | - Dennis Jensen
- University of California, Los Angeles, Los Angeles, California (D.J.)
| | - James Lau
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Romaric Loffroy
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| | | | | | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (N.R.)
| | - John R Saltzman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.R.S.)
| | - John K Marshall
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Marc Bardou
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
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Korang SK, Safi S, Feinberg J, Gluud C, Perner A, Jakobsen JC. Higher versus lower blood pressure targets in adults with shock. Hippokratia 2019. [DOI: 10.1002/14651858.cd013470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Simonetti RG, Perricone G, Nikolova D, Bjelakovic G, Gluud C. Plasma expanders for people with cirrhosis and large ascites treated with abdominal paracentesis. Cochrane Database Syst Rev 2019; 6:CD004039. [PMID: 31251387 PMCID: PMC6598734 DOI: 10.1002/14651858.cd004039.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious effect on haemodynamic balance, and increase morbidity and mortality. Albumin is considered the standard product against which no plasma expansion or other plasma expanders, e.g. other colloids (polygeline , dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared. However, the benefits and harms of these plasma expanders are not fully clear. OBJECTIVES To assess the benefits and harms of any plasma volume expanders such as albumin, other colloids (polygeline, dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol versus no plasma volume expander or versus another plasma volume expander for paracentesis in people with cirrhosis and large ascites. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CNKI, VIP, Wanfang, Science Citation Index Expanded, and Conference Proceedings Citation Index until January 2019. Furthermore, we searched FDA, EMA, WHO (last search January 2019), www.clinicaltrials.gov/, and www.controlled-trials.com/ for ongoing trials. SELECTION CRITERIA Randomised clinical trials, no matter their design or year of publication, publication status, and language, assessing the use of any type of plasma expander versus placebo, no intervention, or a different plasma expander in connection with paracentesis for ascites in people with cirrhosis. We considered quasi-randomised, retrieved with the searches for randomised clinical trials only, for reports on harms. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We calculated the risk ratio (RR) or mean difference (MD) using the fixed-effect model and the random-effects model meta-analyses, based on the intention-to-treat principle, whenever possible. If the fixed-effect and random-effects models showed different results, then we made our conclusions based on the analysis with the highest P value (the more conservative result). We assessed risks of bias of the individual trials using predefined bias risk domains. We assessed the certainty of the evidence at an outcome level, using GRADE, and constructed 'Summary of Findings' tables for seven of our review outcomes. MAIN RESULTS We identified 27 randomised clinical trials for inclusion in this review (24 published as full-text articles and 3 as abstracts). Five of the trials, with 271 participants, assessed plasma expanders (albumin in four trials and ascitic fluid in one trial) versus no plasma expander. The remaining 22 trials, with 1321 participants, assessed one type of plasma expander, i.e. dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus another type of plasma expander, i.e. albumin in 20 of these trials and polygeline in one trial. Twenty-five trials provided data for quantitative meta-analysis. According to the Child-Pugh classification, most participants were at an intermediate to advanced stage of liver disease in the absence of hepatocellular carcinoma, recent gastrointestinal bleeding, infections, and hepatic encephalopathy. All trials were assessed as at overall high risk of bias. Ten trials seemed not to have been funded by industry; twelve trials were considered unclear about funding; and five trials were considered funded by industry or a for-profit institution.We found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality (RR 0.52, 95% CI 0.06 to 4.83; 248 participants; 4 trials; very low certainty); renal impairment (RR 0.32, 95% CI 0.02 to 5.88; 181 participants; 4 trials; very low certainty); other liver-related complications (RR 1.61, 95% CI 0.79 to 3.27; 248 participants; 4 trials; very low certainty); and non-serious adverse events (RR 1.04, 95% CI 0.32 to 3.40; 158 participants; 3 trials; very low certainty). Two of the trials stated that no serious adverse events occurred while the remaining trials did not report on this outcome. No trial reported data on health-related quality of life.We found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality (RR 1.03, 95% CI 0.82 to 1.30; 1014 participants; 14 trials; very low certainty); serious adverse events (RR 0.89, 95% CI 0.10 to 8.30; 118 participants; 2 trials; very low certainty); renal impairment (RR 1.17, 95% CI 0.71 to 1.91; 1107 participants; 17 trials; very low certainty); other liver-related complications (RR 1.10, 95% CI 0.82 to 1.48; 1083 participants; 16 trials; very low certainty); and non-serious adverse events (RR 1.37, 95% CI 0.66 to 2.85; 977 participants; 14 trials; very low certainty). We found no data on heath-related quality of life and refractory ascites. AUTHORS' CONCLUSIONS Our systematic review and meta-analysis did not find any benefits or harms of plasma expanders versus no plasma expander or of one plasma expander such as polygeline, dextrans, hydroxyethyl starch, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus albumin on primary or secondary outcomes. The data originated from few, small, mostly short-term trials at high risks of systematic errors (bias) and high risks of random errors (play of chance). GRADE assessments concluded that the evidence was of very low certainty. Therefore, we can neither demonstrate or discard any benefit of plasma expansion versus no plasma expansion, and differences between one plasma expander versus another plasma expander.Larger trials at low risks of bias are needed to assess the role of plasma expanders in connection with paracentesis. Such trials should be conducted according to the SPIRIT guidelines and reported according to the CONSORT guidelines.
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Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato‐Biliary GroupBlegdamsvej 9, 7811CopenhagenDenmark2100
| | - Giovanni Perricone
- Azienda Socio‐Sanitaria Territoriale Grande Ospedale Metropolitano NiguardaS.C. Epatologia e GastroenterologiaPiazza Ospedale Maggiore, 3MilanItaly20162
- UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free HospitalLiver Failure GroupLondonUK
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Goran Bjelakovic
- Medical Faculty, University of NisDepartment of Internal MedicineZorana Djindjica 81NisSerbia18000
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Liu T, Lin SW, Lin S, Yang L, Ji H, Zou J, Xie R. Exploration of high-risk factors for pulmonary embolism in patients undergoing postoperative anti-thrombotic therapy among gynecologic oncology surgery: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:143. [PMID: 31157264 DOI: 10.21037/atm.2019.03.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The aim of this study was to find the high-risk factors of patients undergoing postoperative anti-thrombotic therapy that had a pulmonary embolism (PE). Methods In this retrospective analysis, a total of 35 patients with gynecologic oncological surgery were included from April 3, 2013, to January 12, 2018. Variable characteristic selection (Boruta's method), binary logistic regression (Fifth's method), and elastic network analysis were used to establish models and screen the high-risk factors. The decision curve analysis (DCA) was used to discriminate differences on these models as well. Results Three models were established, and the clinical efficiency of these three models was similar. Within the risk range of 0.1-0.3, the elastic network model was shown to have a good net benefit rate. The preoperative cholesterol levels were selected in all three models. The high-risk factors that were selected in both models were operative time, preoperative fibrinogen level, crystal rehydration on the day of surgery in the ward, a preoperative low-density lipoprotein (LDL) level, deep venous catheters, and presence of colloids. Other factors included crystal fluid intake during surgery, age, and chemotherapy before surgery. Conclusions Positive anti-thrombotic therapy may be required among the patients with increased risk and further research might be needed to verify high-risk factors.
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Affiliation(s)
- Tongyu Liu
- Department of Gynecology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Shao-Wei Lin
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou 350004, China
| | - Su Lin
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou 350004, China
| | - Lin Yang
- Department of Gynecology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Haizhou Ji
- Department of Gynecology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Jianping Zou
- Department of Gynecology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Rong Xie
- Department of Gynecology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
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Gyawali B, Ramakrishna K, Dhamoon AS. Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Med 2019; 7:2050312119835043. [PMID: 30915218 PMCID: PMC6429642 DOI: 10.1177/2050312119835043] [Citation(s) in RCA: 211] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.
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Affiliation(s)
- Bishal Gyawali
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Karan Ramakrishna
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Amit S Dhamoon
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
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Fluid Management and Transfusion. Int Anesthesiol Clin 2019; 55:78-95. [PMID: 28598882 DOI: 10.1097/aia.0000000000000154] [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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Aoki T, Hirata Y, Yamada A, Koike K. Initial management for acute lower gastrointestinal bleeding. World J Gastroenterol 2019; 25:69-84. [PMID: 30643359 PMCID: PMC6328962 DOI: 10.3748/wjg.v25.i1.69] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/17/2018] [Accepted: 12/01/2018] [Indexed: 02/06/2023] Open
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Yoshihiro Hirata
- Division of Advanced Genome Medicine, the Institute of Medical Science, the University of Tokyo, Tokyo 108-8639, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
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Abstract
Background Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia. Main text Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions. Conclusions The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma). Electronic supplementary material The online version of this article (10.1186/s12871-018-0669-3) contains supplementary material, which is available to authorized users.
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Udeh CI, You J, Wanek MR, Dalton J, Udeh BL, Demirjian S, Rahman N, Hata JS. Acute kidney injury in postoperative shock: is hyperoncotic albumin administration an unrecognized resuscitation risk factor? Perioper Med (Lond) 2018; 7:29. [PMID: 30564306 PMCID: PMC6293561 DOI: 10.1186/s13741-018-0110-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 11/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of hyperoncotic albumin (HA) for shock resuscitation is controversial given concerns about its cost, effectiveness, and potential for nephrotoxicity. We evaluated the association between early exposure to hyperoncotic albumin (within the first 48 h of onset of shock) and acute organ dysfunction in post-surgical patients with shock. METHODS This retrospective, cohort study included 11,512 perioperative patients with shock from 2009 to 2012. Shock was defined as requirement for vasopressors to maintain adequate mean arterial pressure and/or elevated lactate (> 2.2 mmol/L). Subsets of 3600 were selected after propensity score and exact matching on demographics, comorbidities, and treatment variables (> 30). There was a preponderance of cardiac surgery patients. Proportional odds logistic regression, multivariable logistic regression or Cox proportional hazard regression models measured association between hyperoncotic albumin and acute kidney injury (AKI), hepatic injury, ICU days, and mortality. RESULTS Hyperoncotic albumin-exposed patients showed greater risk of acute kidney injury compared to controls (OR 1.10, 95% CI 1.04, 1.17. P = 0.002), after adjusting for imbalanced co-variables. Within matched patients, 20.3%, 2.9%, and 4.4% of HA patients experienced KDIGO stages 1-3 AKI, versus 19.6%, 2.5%, and 3.0% of controls. There was no difference in hepatic injury (OR 1.16; 98.3% CI 0.85, 1.58); ICU days, (HR 1.05; 98.3% CI 1.00, 1.11); or mortality, (OR 0.88; 98.3% CI 0.64, 1.20). CONCLUSIONS Early exposure to hyperoncotic albumin in postoperative shock appeared to be associated with acute kidney injury. There did not appear to be any association with hepatic injury, mortality, or ICU days. The clinical and economic implications of this finding warrant further investigation.
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Affiliation(s)
- Chiedozie I. Udeh
- Center for Critical Medicine, Anesthesiology Institute, 9500 Euclid Avenue, (J4-331), Cleveland, OH 44195 USA
| | - Jing You
- Department of Special Line Product Development, Progressive Insurance, 300 N. Commons Blvd, Cleveland, OH 44143 USA
| | - Matthew R. Wanek
- Department of Inpatient Pharmacy, Cleveland Clinic Pharm D, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Jarrod Dalton
- Department of Quantitative Health Sciences, Lemer Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Belinda L. Udeh
- Department of Quantitative Health Sciences, Lemer Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
- Quality and Patient Safety Institute, NI-CORE, Neurological Institute, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Sevag Demirjian
- Department of Nephrology, Glickman Urology and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic, P.O. Box 112412, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - J. Steven Hata
- Center for Critical Medicine, Anesthesiology Institute, 9500 Euclid Avenue, (J4-331), Cleveland, OH 44195 USA
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Keddissi JI, Youness HA, Jones KR, Kinasewitz GT. Fluid management in Acute Respiratory Distress Syndrome: A narrative review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 55:1-8. [PMID: 31297439 PMCID: PMC6591787 DOI: 10.29390/cjrt-2018-016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute Respiratory Distress Syndrome remains a major source of morbidity and mortality in the modern intensive care unit (ICU). Major advances in the understanding and management of this condition were made in the last two decades. The use of low tidal ventilation is a well-established therapy. Conservative fluid management is now another cornerstone of management. However, much remains to be understood in this arena. Assessing volume status in these patients may be challenging and the tools available to do so are far from perfect. Several dynamic measures including pulse pressures variation are used. Ultrasound of the lungs and the vascular system may also have a role. In addition, the type of fluid to administer when needed is still open to debate. Finally, supportive measures in these patients, early during their ICU stay and later after discharge continue to be crucial for survival and adequate recovery.
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Affiliation(s)
- Jean I Keddissi
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Houssein A Youness
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kellie R Jones
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Gary T Kinasewitz
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Jin X, Bighamian R, Hahn JO. Development and In Silico Evaluation of a Model-Based Closed-Loop Fluid Resuscitation Control Algorithm. IEEE Trans Biomed Eng 2018; 66:1905-1914. [PMID: 30452347 DOI: 10.1109/tbme.2018.2880927] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To develop and evaluate in silico a model-based closed-loop fluid resuscitation control algorithm via blood volume feedback. METHODS Model-based adaptive control algorithm for fluid resuscitation was developed by leveraging a low-order lumped-parameter blood volume dynamics model, and then in silico evaluated based on a detailed mechanistic model of circulatory physiology. The algorithm operates in two steps: (1) the blood volume dynamics model is individualized based on the patient's fractional blood volume response to an initial fluid bolus via system identification; and (2) an adaptive control law built on the individualized blood volume dynamics model regulates the blood volume of the patient. RESULTS The algorithm was able to track the blood volume set point as well as accurately estimate and monitor the patient's absolute blood volume level. The algorithm significantly outperformed a population-based proportional-integral-derivative control. CONCLUSION Model-based development of closed-loop fluid resuscitation control algorithm may enable regulation of blood volume and monitoring of absolute blood volume level. SIGNIFICANCE Model-based closed-loop fluid resuscitation algorithm may offer opportunities for standardized and patient-tailored therapy and reduction of clinician workload.
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