Colloids versus crystalloids for fluid resuscitation in critically ill people

Fluid management strategies in critically ill patients with ARDS: a narrative review

Hypervolemia is associated with worse outcomes in critically ill patients with acute respiratory distress syndrome (ARDS), with early positive fluid balance linked to longer intensive care unit (ICU) stays, prolonged ventilatory support, and increased mortality risk due to cardiopulmonary complications, lung edema, and extrapulmonary organ dysfunction. However, a restrictive fluid management strategy is associated with hypoperfusion and distal organ dysfunction, including acute renal failure and cognitive impairment. Indeed, fluid administration in patients with ARDS represents a challenge, as it must take into account the underlying condition, such as sepsis or acute brain injury (ABI), where optimal fluid management is a major determinant of disease outcome. In such cases, the approach to fluid administration should be individualized based on hemodynamic and clinical parameters according to the course of the disease. The strategy of "salvage, optimization, stabilization, and de-escalation" can guide fluid administration in the initial therapeutic approach, whereas negative fluid balance with the use of diuretics or renal replacement therapy (RRT) should be the goal once hemodynamic stabilization has been achieved.

Stewart's theory and acid-base changes induced by crystalloid infusion in humans: a randomized physiological trial

BACKGROUND

Stewart's acid-base theory states that, under isocapnic conditions, crystalloid infusion affects plasma pH due to changes in strong ion difference and total weak acid concentration: a comprehensive study also assessing renal response and hemodilution effects has not been conducted in humans. We aimed to evaluate Stewart's approach during crystalloid infusion in humans.

METHODS

In this randomized trial, patients undergoing surgery with minimal blood losses were randomized to receive to normal saline (chloride content 154 mEq/L, strong ion difference 0 mEq/L), lactated Ringer's (chloride content 112 mEq/L, strong ion difference 29 mEq/L) or Crystalsol (chloride content 98 mEq/L, strong ion difference 50 mEq/L): patients received 10 ml/kg immediately after intubation, and 20 ml/kg after 2 h. Plasma/urinary acid-base and electrolytes were measured before study start and then at prespecified timepoints. The primary endpoint was pH one hour after the second fluid bolus: secondary outcomes included urinary/plasmatic electrolyte concentrations and strong ion difference during the study.

RESULTS

Forty-five patients were enrolled (15 in each group). The extent of hemodilution achieved with the first (median [Interquartile range]: saline 9% [6-15], Ringer's 7% [4-9], Crystalsol 8% [5-12]) and the second fluid bolus (saline 13% [5-17], Ringer's 12% [9-15], Crystalsol 15% [10-20]) was not different between groups (p = 0.39 and p = 0.19, respectively). Patients in saline group received more chloride (449 mEq [383-495]) vs. Ringer's (358 mEq [297-419]) and Crystalsol groups (318 mEq [240-366]) (p = 0.001). One hour after the second bolus, pH was lower in saline group (7.34 [7.32-7.36]) vs. Ringer's (7.40 [7.35-7.43) and Crystalsol groups (7.42 [7.38-7.44]) (both p < 0.01), since plasma chloride increased significantly over time in saline group but not in Ringer's and Crystalsol groups. Overall chloride urinary excretion was not different between study groups (saline 36 mEq [28-64], Ringer's 42 mEq [29-68], Crystalsol 44 mEq [27-56], p = 0.60) but, at the end of experiments, urinary chloride concentration was higher and diuresis was lower in saline group vs. Ringer's and Crystalsol groups (p = 0.01, p = 0.04, respectively).

CONCLUSIONS

Consistent with Stewart's approach, crystalloid solutions with high chloride content lower pH due to reduced strong ion difference, progressive hemodilutional acidosis and limited renal response to chloride load.

TRIAL REGISTRATION

Registered on clinicaltrials.gov (NCT03507062) on April, 24th 2018.

Osteoarthritis is a risk factor for renal function injury based on the National Health and Nutrition Examination Survey and Mendelian Randomized study

This study aims to investigate the association and causality between osteoarthritis (OA) and chronic kidney disease (CKD) using data from the National Health and Nutrition Examination Survey (NHANES) and Mendelian Randomization (MR) analysis. Participants with OA, urinary albumin, urinary creatinine, urinary albumin-to-creatinine ratio (UACR), blood creatinine, and estimated glomerular filtration rate (eGFR) were selected from NHANES. CKD was calculated using the CKD-EPI equation, and logistic regression assessed by the OA-CKD association. A two-sample MR analysis was conducted using Genome-wide association studies (GWAS) data for OA, hip OA (HOA), knee OA (KOA), acute renal failure (ARF), chronic renal failure (CRF), cystatin C, serum creatinine (eGFRcrea), and microalbuminuria. The inverse variance weighted (IVW) method was used, with heterogeneity, sensitivity, and pleiotropy assessments. The cross-sectional analysis showed a significant positive association between OA and CKD [unadjusted OR: 2.398 (95% CI: 2.176-2.643), p < 0.001], which persisted after adjustment for demographic factors, socioeconomic status, lifestyle factors, and medical history [adjusted OR: 1.161 (95% CI: 1.029-1.310), p = 0.015]. The MR analysis revealed no significant causal relationship between overall OA and renal function markers but found a significant genetic association between HOA and cystatin C [IVW p = 0.0014, OR = 1.02, 95% CI: 1.01-1.03], and between KOA and cystatin C [IVW p < 0.0001, OR = 1.06, 95% CI: 1.04-1.08]. Our study indicates that HOA and KOA are risk factors for renal function injury, providing new insights for clinical OA management.

Essential Pharmaceutical Drugs in the Filler Emergency Kit

INTRODUCTION

The rise in clinical procedures utilizing dermal fillers necessitates preparedness for potential emergencies. Effective management of complications arising from filler use, including vascular occlusions and allergic reactions, hinges on the availability of the appropriate pharmacological supplies.

METHODS

A two-tiered search in PubMed and Google Scholar was conducted to identify essential drugs for dermal filler emergencies. An initial 10-year review used keywords "Dermal Fillers," "vascular occlusion," and "hyaluronidase," followed by a targeted search on "Resuscitation guidelines," "anaphylaxis management," "allergy fillers," and "lidocaine." This article outlines the critical drug inventory for emergency kits to manage filler-related complications effectively.

RESULTS

An ORA classification system (Obligatory, Recommended, Advisable) is introduced to categorize essential drugs according to urgency and clinical necessity. The required drugs are grouped based on their application in cases of vascular occlusion without ocular involvement, vascular occlusion with ocular involvement, anaphylactic reactions, cardiopulmonary resuscitation and hemodynamic disorders, delayed reactions, and aseptic, oxygen, and topical treatments. Additionally, the importance of meticulous drug inventory management-including tracking of stock entry, exit, and expiration dates-is emphasized to reduce the risk of shortages.

CONCLUSION

Ensuring that filler emergency kit is well stocked with vital pharmacological supplies is imperative for effective emergency management during filler procedures. Adopting systematic inventory practices and utilizing the ORA classification can enhance preparedness and patient safety.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of Early Administration of Albumin on Mortality Among Severe COVID-19 Patients, China

Purpose

Hypoalbuminemia is commonly observed in patients with severe Coronavirus Disease 2019 (COVID-19) and is independently associated with adverse outcomes. However, the efficacy of albumin administration on the clinical prognosis of these patients remains uncertain.

Patients and Methods

This multicenter retrospective study enrolled 458 patients with severe COVID-19 in four medical centers from December 1, 2022, to June 1, 2024. Clinical features and laboratory variables were collected through electronic medical records. The cohorts were divided into two groups: albumin administration and non-albumin administration. Propensity score matching (PSM) was used for minimizing confounding effect. Statistical analyses were conducted to assess the relationship between early albumin administration and 28-day mortality.

Results

Four hundred and fifty-eight severe COVID-19 cases were included in the study, of which 167 (36.5%) received early albumin administration, while 291 (63.5%) did not. Among these patients, 140 experienced in-hospital mortality and 318 survived. Compared to survivors, non-survivors exhibited significantly lower serum albumin levels (29.1g/L vs.33.8g/L, p < 0.05). In comparison to patients with admission albumin levels ≥30 g/L, those with albumin levels <30 g/L had a significantly higher in-hospital mortality (48.4% vs 21.1%, p < 0.001). Prior to PSM, the albumin administration group demonstrated significantly higher 28-day and in-hospital cumulative survival rates compared to the non-albumin group (both p < 0.001). However, no significant differences were observed between the two groups following PSM (p = 0.21 and p = 0.41, respectively).

Conclusion

Hypoalbuminemia was correlated with adverse outcomes in severe COVID-19 patients. However, early albumin administration did not reduce 28-day mortality and in-hospital mortality in these patients, and more relative RCTs were required for validation.

Nonlinear Association Between Geriatric Nutritional Risk Index and Cardiovascular Disease in the Elderly Based on the NHANES Database

There is growing evidence that body nutritional status influences the development of cardiovascular disease, particularly in the elderly population. The Geriatric Nutritional Risk Index (GNRI), as a tool for assessing the nutritional status and nutritional risk of elderly individuals, is applied in clinical practice. This study aimed to elucidate the relationship between GNRI and cardiovascular disease in the elderly and to assess the impact of nutritional status on cardiovascular disease.This study is a cross-sectional study based on the National Health and Nutrition Examination Survey (NHANES) database. The data for this investigation were obtained from the NHANES database from 2007 to 2018, which included 10,277 individuals aged 60 years and older. The relationship between GNRI and cardiovascular disease in the elderly was investigated using weighted multivariable logistic regression models, and smooth fitting curves were drawn to explore their association. In addition, subgroup analyses were used to explore population differences.In this study, after adjusting for all confounding variables, the odds ratio and 95% confidence intervals (CI) of the model were 0.98 (0.96, 1.00), with no statistically significant association. Smooth fitting curves showed a nonlinear correlation between GNRI and cardiovascular disease. We found an inflection point (GNRI = 139.55). Moreover, GNRI was negatively associated with cardiovascular disease in the elderly before the inflection point and not statistically significant after the inflection point.In this large cross-sectional study, we found a nonlinear correlation between GNRI and cardiovascular disease in the general elderly population in the United States.

Up-and-down determination of prophylactic norepinephrine boluses combined with crystalloid co-load for preventing post-spinal anesthesia hypotension during cesarean section

BACKGROUND

The use of a fluid co-load has been shown to enhance hemodynamic stability and diminish the occurrence of hypotension after spinal anesthesia when paired with prophylactic norepinephrine. This research aimed to identify the effective dosages (ED90 and ED50) of prophylactic norepinephrine boluses, in conjunction with a crystalloid co-load, for the prevention of hypotension after spinal anesthesia in cesarean delivery patients.

METHODS

Patients were administered crystalloid co-loads at a dosage of 10 mL/kg, in addition to preventive norepinephrine dosages direct following spinal anesthesia administration. The dosages of norepinephrine were established employing the up-and-down sequential allocation technique, starting with 8 µg and progressively rising by 1 µg increments. The primary objective was to detect the effective dosage (ED90 and ED50) of norepinephrine necessary to avoid hypotension following spinal anesthesia.

RESULTS

The ED90 for a single norepinephrine bolus, in combination with a crystalloid co-load, was calculated to be 5.35 µg (95% CI: 4.75 to 7.13). The ED50 was determined to be 4.05 µg (95% CI: 3.68 to 4.46) using the up-and-down method and 3.926 µg (95% CI: 3.362 to 4.422) through the probit regression model.

CONCLUSION

A prophylactic norepinephrine bolus of 5.35 µg, administered with a crystalloid co-load, effectively prevents hypotension following the spinal anesthesia in cesarean delivery patients.

Preferences for albumin use in adult intensive care unit patients with shock: An international survey

INTRODUCTION

Use of albumin is suggested for some patients with shock, but preferences for its use may vary among intensive care unit (ICU) physicians.

METHODS

We conducted an international online survey of ICU physicians with 20 questions about their use of albumin and their opinion towards a randomised trial among adults with shock comparing the use versus no use of albumin.

RESULTS

A total of 1248 respondents participated, with a mean response rate of 37%, ranging from 18% to 75% across 21 countries. Respondents mainly worked in mixed ICUs and 92% were specialists in intensive care medicine. The reported use of albumin in general shock varied as 18% reported 'almost never', 22% 'rarely', 34% 'occasionally', 22% 'frequently' and 4% 'almost always' using albumin. In septic shock, 19% reported 'almost never', 22% 'rarely', 29% 'occasionally', 22% 'frequently' and 7% 'almost always' using albumin. Physicians' preferences were more consistent for haemorrhagic- and cardiogenic shock, with more than 45% reporting 'almost never' using albumin. While the reported use of albumin for other purposes than resuscitation was infrequent (40%-85% reported 'almost never' for five other indications), the most frequent other indications were low serum albumin levels and improvement of the efficacy of diuretics. Most respondents (93%) would randomise adult ICU patients with shock to a trial of albumin versus no albumin.

CONCLUSIONS

In this international survey, the reported preferences for the use of albumin in adult ICU patients with shock varied considerably among surveyed ICU physicians. The support for a future randomised trial was high.

Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN)

Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients.

Understanding, assessing and treating immune, endothelial and haemostasis dysfunctions in bacterial sepsis

The interplay between the immune system, coagulation, and endothelium is critical in regulating the host response to infection. However, in sepsis and other critical illnesses, a dysregulated immune response can lead to excessive alterations in these mechanisms, resulting in coagulopathy, endothelial dysfunction, and multi-organ dysfunction. This review aims to provide a comprehensive analysis of the pathophysiological mechanisms that govern the complex interplay between immune dysfunction, endothelial dysfunction, and coagulation in sepsis. It emphasises clinical significance, evaluation methods, and potential therapeutic interventions. Understanding these mechanisms is essential for developing effective treatments that can modulate the immune response, mitigate thrombosis, restore endothelial function, and ultimately improve patient survival.

Early identification and diagnosis, pathophysiology, and treatment of sepsis-related acute lung injury: a narrative review

Background and Objective

Sepsis is a life-threatening organ dysfunction, and the most common and vulnerable organ is the lungs, with sepsis-related acute respiratory distress syndrome (ARDS) increasing mortality. In recent years, an increasing number of studies have improved our understanding of sepsis-related ARDS in terms of epidemiology, risk factors, pathophysiology, prognosis, and other aspects, as well as our ability to prevent, detect, and treat sepsis-related ARDS. However, sepsis-related lung injury remains an important issue and clinical burden. Therefore, a literature review was conducted on sepsis-related lung injury in order to further guide clinical practice in reducing the acute and chronic consequences of this condition.

Methods

This study conducted a search of the MEDLINE and PubMed databases, among others for literature published from 1991 to 2023 using the following keywords: definition of sepsis, acute lung injury, sepsis-related acute lung injury, epidemiology, risk factors, early diagnosis of sepsis-related acute lung injury, sepsis, ARDS, pathology and physiology, inflammatory imbalance caused by sepsis, congenital immune response, and treatment.

Key Content and Findings

This review explored the risk factors of sepsis, sepsis-related ARDS, early screening and diagnosis, pathophysiology, and treatment and found that in view of the high mortality rate of ARDS associated with sepsis. In response to the high mortality rate of sepsis-related ARDS, some progress has been made, such as rapid identification of sepsis and effective antibiotic treatment, early fluid resuscitation, lung-protective ventilation, etc.

Conclusions

Sepsis remains a common and challenging critical illness to cure. In response to the high mortality rate of sepsis-related ARDS, progress has been made in rapid sepsis identification, effective antibiotic treatment, early fluid resuscitation, and lung-protective ventilation. However, further research is needed regarding long-term effects such as lung recruitment, prone ventilation, and the application of neuromuscular blocking agents and extracorporeal membrane oxygenation.

Assessment of Albumin Usage Patterns and Appropriateness in a Comprehensive Cancer Centre: A retrospective study in Jordan

Objectives

Albumin is commonly used for various indications; however, there is conflicting data regarding its appropriate use in different clinical cases. This study aimed to determine the pattern and appropriateness of albumin use among cancer patients at the King Hussein Cancer Center in Jordan.

Methods

A retrospective analysis was conducted on adult cancer patients who were prescribed albumin between January 2019 and July 2020 in both outpatient and inpatient settings. Data collected included demographics, prescribing services, indications and dosing regimens. A literature review was performed using PubMed to assess the appropriateness of albumin indications and dosing regimens against current guidelines, drug information resources and the package insert.

Results

Albumin was prescribed to 1,361 patients during the study period. Each patient received an average of 74.4 ± 89 g of albumin for an average of 2.6 ± 1.8 days. Albumin use was deemed appropriate in 69% of the patients. The critical care service accounted for the highest albumin consumption, with 37% of prescriptions for septic shock. Inappropriate use of albumin was most prevalent in the medical solid tumour services (40.8% of prescriptions), primarily for edema (28%).

Conclusion

To the best of the author's knowledge, this study is the first to evaluate albumin use in a large cohort of oncology patients. Approximately one-third of the albumin prescriptions were considered inappropriate. Continuous education on appropriate usage and regular evaluations of guideline adherence are essential to ensure proper utilisation of albumin in cancer care.

Use of colloids and crystalloids for perioperative clinical infusion management in cardiac surgery patients and postoperative outcomes: a meta-analysis

BACKGROUND

The optimal fluid management strategy for patients undergoing cardiac surgery was controversial regarding fluid volume and intraoperative fluid types. This study aimed to assess the correlation between colloids and crystalloids used for perioperative fluid therapy in cardiac surgery patients and postoperative prognosis.

METHODS

The Ovid MEDLINE(R) ALL, Embase, and Cochrane Central Register of Controlled Trials databases were searched for eligible studies on fluid management strategies using colloids and crystalloids for cardiac surgery patients published before August 25th, 2023.

RESULTS

Ten randomized controlled trials met the eligibility criteria. Compared to the use of crystalloids, the use of colloids, including hydroxyethyl starch (HES), albumin, and gelatine, did not show any differences in mortality, transfusion, acute kidney injury, and atrial fibrillation rates, postoperative blood loss, the length of hospital stay, or the length of intensive care unit (ICU) stay. The results of this meta-analysis showed that the crystalloid group had significantly reduced postoperative chest tube output compared to the colloid group. In the subgroup analysis, the amount of fresh frozen plasma (FFP) infused was significantly lower when using fluid management in the ICU and when using isotonic crystalloids compared to the colloids. In addition, when using fluid management in the ICU, patients in the colloid group had a significant increase in urine volume 24 h after surgery. However, other related factors, including the type of crystalloid solution, type of colloidal solution, and timing of liquid management, did not affect most outcomes.

CONCLUSION

Both colloids and crystalloids could be used as alternatives for perioperative fluid management after cardiac surgery. The use of crystalloids significantly reduced the postoperative chest tube output, and the need for FFP infusion decreased significantly with the use of isotonic crystalloids or fluid management during the ICU stay. ICU patients in the colloid group had higher urine output 24 h after surgery. In addition, although the infusion method was not related to most outcomes, the rates of red blood cell and FFP transfusion and postoperative blood loss in the crystalloid group seemed to be lower, which needed to be further studied in high-quality and large-sample RCTs.

TRIAL REGISTRATION

PROSPERO, CRD42023415234.

The Effect of Colloids versus Crystalloids for Goal-Directed Fluid Therapy on Prognosis in Patients Undergoing Noncardiac Surgery: A Meta-Analysis of Randomized Controlled Trials

Background

Goal-directed fluid therapy (GDFT) contributes to improvements in intraoperative fluid infusion based on objective parameters and has been widely recommended in clinical practice. In addition, increasing evidence reveals that GDFT can improve the prognosis of surgical patients. However, considering the individual characteristics of colloids and crystalloids in clinical use, it is uncertain as to which type of fluids administered is associated with better outcomes in the condition of GDFT.

Objectives

To evaluate the effect of colloids versus crystalloids under GDFT on prognosis in patients undergoing noncardiac surgery. Data Sources. Randomized controlled trials (RCTs) from PubMed, EMBASE, Ovid MEDLINE, CNKI, Cochrane library, and reference lists of relevant articles.

Methods

Two investigators independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was a composite of postoperative complications. The secondary outcomes were (1) mortality at the follow-up duration; (2) postoperative complications of several organ systems, including cardiac, pulmonary, digestive, urinary, nervous system, and postoperative infection events; and (3) hospital and ICU length of stay. Heterogeneity was assessed by the I 2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data.

Results

Of 332 articles retrieved, 15 RCTs (involving 2,956 patients undergoing noncardiac surgery) were included in the final analysis. When the data were pooled, patients in the colloids and crystalloids group revealed no difference in postoperative composite complications (OR = 0.84, 95% CI = 0.51-1.38, P=0.49) under GDFT. Regarding the secondary outcomes, patients in the colloids group were associated with fewer digestive system complications (OR = 0.64, 95% CI = 0.41-0.98, P=0.04). However, no difference was found in mortality (OR = 1.37, 95% CI = 0.72-2.58, P=0.34), complications of the cardiac system (OR = 1.49, 95% CI = 0.66-3.37, P=0.34), pulmonary system (OR = 0.89, 95% CI = 0.62-1.28, P=0.53), urinary system (OR = 1.05, 95% CI = 0.61-1.80, P=0.87), nervous system (OR = 1.04, 95% CI = 0.55-1.98, P=0.90), postoperative infection events (OR = 0.89, 95% CI = 0.75-1.07, P=0.22), length of hospital stay (difference in mean = -0.71, 95% CI = -1.49-0.07, P=0.07), and ICU stay (difference in mean = -0.01, 95% CI = -0.20-0.18, P=0.95) between patients receiving GDFT with colloids or crystalloids.

Conclusion

There is no evidence of a benefit in using colloids over crystalloids under GDFT in patients undergoing noncardiac surgery, despite its use resulting in lower digestive system complications.

European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids

PURPOSE

This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal.

METHODS

This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.

RESULTS

For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence).

CONCLUSIONS

This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.

Cardiac Surgery-Associated Acute Kidney Injury

AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.

Prophylactic norepinephrine combined with 6% hydroxyethyl starch (130/0.4) co-load infusion for preventing postspinal anesthesia hypotension during cesarean section: a randomized, controlled, dose-finding trial

PURPOSE

Colloid and/or co-load may be more effective than crystalloid for preventing postspinal anesthesia hypotension. We tested five different prophylactic norepinephrine dosages combined with colloid co-load infusion in patients receiving cesarean section and spinal anesthesia.

METHODS

Patients were randomly allocated to receive different prophylactic norepinephrine dosages (0 [NE 0 group], 0.025 [NE 25 group], 0.05 [NE 50 group], 0.075 [NE 75 group], or 0.1 [NE 100 group] µg/kg/min) combined with 500 mL 6% hydroxyethyl starch (130/0.4) immediately following spinal anesthesia (n = 35 per group). The primary endpoint was the incidence of postspinal anesthesia hypotension (systolic blood pressure [SBP] < 80% of baseline). Secondary endpoints included severe hypotension, bradycardia, nausea or vomiting, hypertension, SBP stability control versus baseline, the 50% (effective dose, ED50) and 90% (ED90) dose effective for preventing postspinal anesthesia hypotension, Apgar scores, and umbilical cord blood gases.

RESULTS

The incidence of postspinal anesthesia hypotension was 48.6%, 31.3%, 17.1%, 14.3%, and 5.7% in the respective groups. As the prophylactic norepinephrine dosage increased, the incidence of postspinal anesthesia hypotension declined (p < 0.001), and SBP remained stable relative to baseline (median performance error [MDPE], p < 0.001; median absolute performance error [MDAPE], p = 0.001). The ED50 and ED90 values were -0.006 (95% CI -0.046-0.013) and 0.081 (95% CI 0.063-0.119) µg/kg/min. Other endpoints were comparable across the groups.

CONCLUSION

An initial prophylactic norepinephrine dosage of 0.05 µg/kg/min combined with 500 mL 6% hydroxyethyl starch (130/0.4) co-load infusion was optimal for preventing postspinal anesthesia hypotension during cesarean section.

TRIAL REGISTRATION

NCT05133817, registration date: 12 Nov, 2021.

Incidence of acute kidney injury and its associated risk factors in patients undergoing elective oesophagectomy surgeries at a tertiary care cancer institute - A pilot prospective observational study

Background and Aims

Acute kidney injury (AKI) is a significant postoperative complication. Multiple perioperative factors are implicated in the causation of AKI in the postoperative period in patients with oesophageal cancer. The study aimed to find out the incidence, causes and effects of AKI following oesophagectomy surgery.

Methods

A prospective observational study was conducted in consecutive adult patients undergoing elective oesophagectomy at a tertiary cancer care hospital. Patients with preoperative chronic renal insufficiency (serum creatinine >1.5 mg/dl), AKI in the past and a history of renal replacement therapy were excluded. Serum creatinine values were measured on postoperative days 1, 3, 5, the day of discharge or day 15 and on the day of first follow-up or day 28, following oesophagectomy surgery. The incidence of AKI was measured using the 'Kidney Disease Improving Global Outcome' (KDIGO) criteria.

Results

The incidence of AKI was 14.7% [95% confidence interval (CI) 9.9%, 20.7%] (i.e., 27/183) in patients who underwent elective oesophagectomy. AKI was associated with prolonged hospital stay [median- 13 days (interquartile range {IQR} 11-21.5) versus 9 days (IQR 8-12), P < 0.001] and increased in-hospital mortality (14.8% versus 1.3%, P 0.004, odds ratio = 13.2, 95% CI 2.3, 77.3). After multivariate analysis, age, anastomotic leak and use of vasopressors in the postoperative period were independent predictors of AKI.

Conclusion

The incidence of AKI was 14.7% after elective oesophagectomy. AKI was associated with prolonged hospital stay and in-hospital mortality. Higher age, anastomotic leak and use of vasopressors in the postoperative period were independent predictors of AKI.

Tactics of infusion therapy in patients with acute destructive pancreatitis: a narrative review

INTRODUCTION: Infusion therapy is the main method of correcting pathological changes that occur during the phase of “aseptic” inflammation in acute pancreatitis. OBJECTIVE: Summarize current data on infusion therapy regimens in patients with acute destructive pancreatitis, the advisability of using various infusion solutions and options for monitoring the effectiveness of therapy. MATERIALS AND METHODS: The study was carried out in accordance with international reporting requirements for reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The search was carried out in the following Internet search engines Pubmed and Cochrane Controlled Clinical Trials Register. To select articles, a literature reference search method was also used. The search strategy did not include restrictions on language, article type, or date. RESULTS: The analysis of literature data revealed two approaches to infusion therapy. The initial interest in “aggressive (4 liters per day or more)” infusion therapy regimens in the first 24 hours of the disease has now been replaced by a trend towards less “aggressive” regimens due to the publication of works on the high incidence of various complications (progression of organ dysfunction, local complications). When considering the qualitative composition of infusion therapy, preference should certainly be given to crystalloids. Basic monitoring of infusion therapy should include non-invasive methods: heart rate, blood pressure, diuresis rate. CONCLUSIONS: The analysis demonstrated different approaches to the tactics of infusion therapy in this category of patients. further research into the effectiveness and safety of infusion therapy, taking into account the varying severity of acute pancreatitis, the possibility of the influence of the qualitative composition of the infusion on the course of this disease and the formation of recommendations for initial and maintenance infusion therapy based on the principles of personalized medicine.

February 6th, Kahramanmaraş earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review

This compilation covers emergency medical management lessons from the February 6th Kahramanmaraş earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.

A Comprehensive Review of Chloride Management in Critically Ill Patients

Chloride, often overshadowed in electrolyte management, emerges as a crucial player in the physiological intricacies of critically ill patients. This comprehensive review explores the multifaceted aspects of chloride, ranging from its significance in cellular homeostasis to the consequences of dysregulation in critically ill patients. The pathophysiology of hyperchloremia and hypochloremia is dissected, highlighting their intricate impact on acid-base balance, renal function, and cardiovascular stability. Clinical assessment strategies, including laboratory measurements and integration with other electrolytes, lay the foundation for targeted interventions. Consequences of dysregulated chloride levels underscore the need for meticulous management, leading to an exploration of emerging therapies and interventions. Fluid resuscitation protocols, the choice between crystalloids and colloids, the role of balanced solutions, and individualized patient approaches comprise the core strategies in chloride management. Practical considerations, such as monitoring and surveillance, overcoming implementation challenges, and embracing a multidisciplinary approach, are pivotal in translating theoretical knowledge into effective clinical practice. As we envision the future, potential impacts on critical care guidelines prompt reflections on integrating novel therapies, individualized approaches, and continuous monitoring practices. In conclusion, this review synthesizes current knowledge, addresses practical considerations, and envisions future directions in chloride management for critically ill patients. By embracing a holistic understanding, clinicians can navigate the complexities of chloride balance, optimize patient outcomes, and contribute to the evolving landscape of critical care medicine.

Reviving the Critically Ill: Exploring Effective Fluid Resuscitation Approaches for Diverse Hypovolemic Shock Cases-A Systematic Review and Meta-Analysis

Objective

The present study was performed to investigate the efficacy of different resuscitation fluids in critically ill patients presenting any type of hypovolemic shock.

Methods

We comprehensively searched PubMed, Web of Science, ScienceDirect, Cochrane Library, and Google Scholar for randomized trials published in English from January 1990 to August 2023. The risk of bias and methodological quality assessment was performed using Cochrane's risk of bias tool embedded within the Review Manager software (RevMan 5.4.1). Moreover, this software was used to perform all the statistical analyses in the present study. During these analyses, the random effects model and 95% confidence interval was employed. The overall effect sizes for continuous and dichotomous data were calculated using the Mean Difference (MD) and Risk ratio (RR), respectively.

Results

Our initial database search resulted in 4768 articles, of which only 16 were reviewed and analyzed. A subgroup analysis of data from 4 of these studies showed that hydroxyethyl starches (HES), gelatins and albumins had no significant mortality benefit compared to crystalloids (RR: 0.94; 95% CI: 0.75-1.17; P=0.58, RR: 0.71; 95% 0.46-1.08; P=0.11 and RR: 1.05; 95% CI: 0.77-1.43; P=0.77, respectively). Similarly, a subgroup analysis of data from 9 studies showed that hypertonic saline plus dextran (HSD) had no significant mortality benefit over normal saline (RR: 0.84; 95% CI: 0.62-1.13; P=0.24) or Lactated ringer's solution (RR: 1.03; 95% CI: 0.75-1.42; P=0.87). In addition, we found that hypertonic saline had a similar effect on the overall mortality as isotonic crystalloids (RR: 0.92; 95% CI: 0.68-1.25; P=0.60). Also, our analysis shows that modified fluid gelatins had a similar mortality effect as HES ((RR: 1.02; 95% CI: 0.52-2.02; P=0.95).

Conclusion

Colloids, whether individually or in hypertonic crystalloids (HSD), had no mortality benefit over crystalloids in adult patients with hypovolemic shock.

A Systematic Bibliometric Analysis of High-Impact Articles in Critical Care Nephrology

INTRODUCTION

Critical care nephrology is a subspecialty that merges critical care and nephrology in response to shared pathobiology, clinical care, and technological innovations. To date, there has been no description of the highest impact articles. Accordingly, we systematically identified high impact articles in critical care nephrology.

METHODS

This was a bibliometric analysis. The search was developed by a research librarian. Web of Science was searched for articles published between January 1, 2000 and December 31, 2020. Articles required a minimum of 30 citations, publication in English language, and reporting of primary (or secondary) original data. Articles were screened by two reviewers for eligibility and further adjudicated by three experts. The "Top 100" articles were hierarchically ranked by adjudication, citations in the 2 years following publication and journal impact factor (IF). For each article, we extracted detailed bibliometric data. Risk of bias was assessed for randomized trials by the Cochrane Risk of Bias tool. Analyses were descriptive.

RESULTS

The search yielded 2,805 articles. Following initial screening, 307 articles were selected for full review and adjudication. The Top 100 articles were published across 20 journals (median [IQR] IF 10.6 [8.9-56.3]), 38% were published in the 5 years ending in 2020 and 62% were open access. The agreement between adjudicators was excellent (intraclass correlation, 0.96; 95% CI, 0.84-0.99). Of the Top 100, 44% were randomized trials, 35% were observational, 14% were systematic reviews, 6% were nonrandomized interventional studies and one article was a consensus document. The risk of bias among randomized trials was low. Common subgroup themes were RRT (42%), AKI (30%), fluids/resuscitation (14%), pediatrics (10%), interventions (8%), and perioperative care (6%). The citations for the Top 100 articles were 175 (95-393) and 9 were cited >1,000 times.

CONCLUSION

Critical care nephrology has matured as an important subspecialty of critical care and nephrology. These high impact papers have focused largely on original studies, mostly clinical trials, within a few core themes. This list can be leveraged for curricula development, to stimulate research, and for quality assurance.

Pediatric perioperative fluid management

The purpose of perioperative fluid management in children is to maintain adequate volume status, electrolyte level, and endocrine system homeostasis during the perioperative period. Although hypotonic solutions containing glucose have traditionally been used as pediatric maintenance fluids, recent studies have shown that isotonic balanced crystalloid solutions lower the risk of hyponatremia and metabolic acidosis perioperatively. Isotonic balanced solutions have been found to exhibit safer and more physiologically appropriate characteristics for perioperative fluid maintenance and replacement. Additionally, adding 1-2.5% glucose to the maintenance fluid can help prevent children from developing hypoglycemia as well as lipid mobilization, ketosis, and hyperglycemia. The fasting time should be as short as possible without compromising safety; recent guidelines have recommended that the duration of clear fluid fasting be reduced to 1 h. The ongoing loss of fluid and blood as well as the free water retention induced by antidiuretic hormone secretion are unique characteristics of postoperative fluid management that must be considered. Reducing the infusion rate of the isotonic balanced solution may be necessary to avoid dilutional hyponatremia during the postoperative period. In summary, perioperative fluid management in pediatric patients requires careful attention because of the limited reserve capacity in this population. Isotonic balanced solutions appear to be the safest and most beneficial choice for most pediatric patients, considering their physiology and safety concerns.

Association of Hypoalbuminemia With Clinical Outcomes in Patients Admitted With Acute Heart Failure

Albumin is a protein produced by the liver essential for maintaining blood volume and regulating fluid balance. Hypoalbuminemia is characterized by low levels of albumin in the blood. It is also a marker of malnutrition-inflammatory syndrome. Several studies have demonstrated its prognostic role in patients with chronic heart failure; however, data regarding hypoalbuminemia in acute heart failure admissions are scarce. This study aims to analyze the relationship between hypoalbuminemia and heart failure. We used a retrospective cohort study surveying data from the 2016-2018 combined National Inpatient Sample (NIS) database. Adult hospitalizations for heart failure patients were identified using the ICD-10 codes, stratified into cohorts with and without hypoalbuminemia. Primary outcomes were (1) in-patient mortality, (2) length of stay, and total hospital charge. We also reclassified the HF admissions with hypoalbuminemia to those with systolic or diastolic heart failure to compare any differences in mortality and other in-patient complications. Multivariate linear and logistic regression were used to adjust for confounders and to analyze the outcomes. There were 1,365,529 adult hospitalizations for Congestive Heart Failure (CHF), and among them 1,205,990 (88 %) had secondary diagnoses of hypoalbuminemia. Patients with comorbid hypoalbuminemia were, on average, 8 years older (P < 0.001), predominantly white race, and males (P-value <0.001). HF hospitalizations with hypoalbuminemia had double in-hospital mortality than those without (4.8% vs 2.7%, P < 0.001). However, there was no difference in mortality between patients with Systolic heart failure and Diastolic heart failure with concomitant low albumin levels (from 4.9 % vs 4.7%, P 0.13). We found that patients admitted with HF and concomitant Hypoalbuminemia (HA) had nearly twice the odds of in-patient mortality than those with normal albumin levels. The Length of Stay (LOS) was higher between comparison groups. THC remained statistically indifferent in patients regardless of albumin levels but was greater in hypoalbuminemic patients with Systolic heart failure than Diastolic heart failure ones.

Comparison of crystalloid and colloid co-load combined with norepinephrine prophylaxis on post-spinal anesthesia hypotension during cesarean delivery: a randomized sequential allocation dose-finding study

Background

Fluid loading is an essential component of treatment for reducing the incidence of post-spinal anesthesia hypotension and is necessary to maintain intravascular volume, perfuse tissues, and control spinal anesthesia hypotension after sympathetic blockade. We performed a randomized sequential allocation dose-finding study to compare the effects of 10 mL/kg crystalloid and 6% hydroxyethyl starch (130/0.4) co-load on the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery.

Methods

Eighty patients were randomly allocated to receive either a 10 mL/kg crystalloid (Crystalloid Group, n = 40) or 6% hydroxyethyl starch (130/0.4) (Colloid Group, n = 40) co-load combined with prophylactic norepinephrine infusion during spinal anesthesia for cesarean delivery. The first patient received an initial prophylactic norepinephrine infusion rate of 0.025 μg/kg/min. Subsequent patients received a 0.005 μg/kg/min gradient dose of prophylactic norepinephrine. This dose was administered as a gradient based on its effectiveness for preventing post-spinal anesthesia hypotension (defined as SBP < 80% of baseline value) and determined by the up-and-down sequential allocation methodology. The primary study outcome was the ED90 of prophylactic norepinephrine infusion. Secondary outcomes included the incidence of post-spinal anesthesia hypotension, bradycardia, hypertension, Apgar scores, and umbilical artery blood gas values were also measured.

Results

The ED90 values of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery were 0.063 μg (95% CI: 0.050 to 0.064) and 0.062 μg (95% CI: 0.045 to 0.064) using isotonic regression analysis, and 0.068 μg (95% CI: 0.056 to 0.353) and 0.060 μg (95% CI: 0.050 to 3.590) using probit regression analysis in the Crystalloid Group and Colloid Group, respectively. The secondary outcomes were comparable between the two groups.

Conclusion

The administration of a 10 mL/kg 6% hydroxyethyl starch (130/0.4) does not provide additional benefits compared to crystalloid co-load in reducing the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery.

Fluids in the ICU: which is the right one?

The administration of fluids is one of the most common interventions in the intensive care unit. The effects and side effects of intravenous fluids depend on the amount administered and their specific composition. Intravenous fluid solutions are either considered crystalloids (for example 0.9% saline, lactated Ringer's solution) or colloids (artificial colloids such as gelatins, and albumin). This narrative review summarizes the physiological principles of fluid therapy and reviews the most important studies on crystalloids, artificial colloids and albumin in the context of critically ill patients.

Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews

BACKGROUND

Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT.

OBJECTIVES

To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery.

METHODS

In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality.

MAIN RESULTS

We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL.

AUTHORS' CONCLUSIONS

Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.

Albumin infusion may decrease the mortality of hypoalbuminemia patients with severe acute pancreatitis: a retrospective cohort study

BACKGROUND

At present, the relationship between severe acute pancreatitis (SAP) and albumin infusion is not clear. We aimed to identify the impact of serum albumin on the prognosis of SAP and the association between albumin infusions and mortality for hypoalbuminemia patients.

METHODS

This was a retrospective cohort study that analyzed 1000 patients with SAP who were admitted to the First Affiliated Hospital of Nanchang University between January 2010 and December 2021 using data from a prospectively maintained database. Multivariate logistic regression analysis was conducted to reveal the relationship between serum albumin within 1 week after admission and poor prognosis of SAP. Propensity score matching (PSM) analysis was adopted to evaluate the effect of albumin infusion for hypoalbuminemia patients with SAP.

RESULTS

The prevalence of hypoalbuminemia (≤ 30 g/L) was 56.9% within 1 week after admission. Multivariate logistic regression identified that age (OR: 1.02; 95% CI: 1.00-1.04; P = 0.012), serum urea (OR: 1.08; 95% CI: 1.04-1.12; P < 0.001), serum calcium (OR: 0.27; 95% CI: 0.14-0.50; P < 0.001), lowest albumin level within 1 week after admission (OR: 0.93; 95% CI: 0.89-0.97; P = 0.002), and APACHE II score ≥ 15 (OR: 1.73; 95% CI: 1.19-2.51; P = 0.004) were independently associated with mortality. The PSM analysis demonstrated that mortality (OR: 0.52, 95% CI: 0.29-0.92, P = 0.023) was less common in albumin-infused than non-albumin-infused hypoalbuminemia patients. In subgroup analyses, doses > 100 g within 1 week after admission for hypoalbuminemia patients with albumin infusions was associated with lower mortality than doses ≤ 100 g (OR: 0.51, 95% CI: 0.28-0.90, P = 0.020).

CONCLUSIONS

Hypoalbuminemia in early-stage SAP is significantly related to poor prognosis. However, albumin infusions could significantly decrease mortality in hypoalbuminemia patients with SAP. Additionally, infusing sufficient albumin within a week after admission may decrease mortality in hypoalbuminemia patients.

Septic shock in obstetrics: guidelines of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”

The article reflects the main provisions of the clinical guidelines on septic shock in obstetrics, approved by the All-Russian public organization “Federation of Anesthesiologists-Resuscitators” in 2022. The relevance of the problem is associated with high mortality and morbidity rates from sepsis and septic shock in obstetrics. The main issues of etiology, pathogenesis, clinical picture, methods of laboratory and instrumental diagnostics, features of using the qSOFA, SOFA, MOEWS, SOS, MEWC, IMEWS scales for sepsis verification are consistently presented. The article presents the starting intensive therapy (the first 6–12 hours) of the treatment of septic shock in obstetrics, taking into account the characteristics of the pregnant woman's body. The strategy of prescribing vasopressors (norepinephrine, phenylephrine, epinephrine), inotropic drugs (dobutamine) is described, antibiotics and optimal antibiotic therapy regimens, features of infusion and adjuvant therapy are presented. The issues of surgical treatment of the focus of infection and indications for hysterectomy, as well as the organization of medical care and rehabilitation of patients with sepsis and septic shock were discussed. The basic principles of prevention of sepsis and septic shock in obstetrics are described. The criteria for the quality of medical care for patients with septic shock and the algorithms of doctor's actions in the diagnosis and intensive care of patients with septic shock in obstetrics are presented.

Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project

BACKGROUND

To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study.

METHODS

Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction.

RESULTS

Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay.

CONCLUSIONS

Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01753050.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Advances in Shock Management and Fluid Resuscitation in Children

Shock in children is associated with significant mortality and morbidity, particularly in resource-limited settings. The principles of management include early recognition, fluid resuscitation, appropriate inotropes, antibiotic therapy in sepsis, supportive therapy for organ dysfunction, and regular hemodynamic monitoring. During the past decade, each step has undergone several changes and evolved as evidence that has been translated into recommendations and practice. There is a paradigm shift from protocolized-based care to personalized management, from liberal strategies to restrictive strategies in terms of fluids, blood transfusion, ventilation, and antibiotics, and from clinical monitoring to multimodal monitoring using bedside technologies. However, uncertainties are still prevailing in terms of the volume of fluids, use of steroids, and use of extracorporeal and newer therapies while managing shock. These changes have been summarized along with evidence in this article with the aim of adopting an evidence-based approach while managing children with shock.

Impact of Goal-Directed Fluid Therapy on Postoperative Outcomes in Colorectal Surgery: An Evidence-Based Review

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.

Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup

Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research.

Study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-ll (HAS FLAIR-II) trial

Background: Fluid bolus therapy with 20% albumin may shorten the duration of vasopressor therapy in patients after cardiac surgery. Objective: To describe the study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-II (HAS FLAIR-II) trial. Design, setting, participants and intervention: HAS FLAIR-II is a phase 2b, multicentre, parallel group, openlabel, randomised controlled trial that will be conducted at six Australian intensive care units. Patients requiring fluid bolus therapy after cardiac surgery will be randomly assigned in a 1:1 ratio to the intervention of fluid bolus therapy with 20% albumin or a comparator of fluid bolus therapy with a crystalloid solution. Main outcome measures: The primary outcome measure is the cumulative duration of vasopressor therapy. Secondary outcomes include vasopressor use, service utilisation, and mortality. All analyses will be conducted on an intention-to-treat basis. Results and conclusion: The study protocol and statistical analysis plan will guide the conduct and analysis of the HAS FLAIR-II trial, such that analytical and reporting biases are minimised. Trial registration: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN No. 12620000137998).

Diagnosis, severity stratification and management of adult acute pancreatitis-current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

Complex Permittivity of Ex-Vivo Human, Bovine and Porcine Brain Tissues in the Microwave Frequency Range

Accurate knowledge about the dielectric properties of biological tissues in the microwave frequency range may lead to advancement of biomedical applications based on microwave technology. However, the published data are very scarce, especially for human brain tissues. The aim of this work was to measure and report the complex permittivity of brain white matter, grey matter and cerebellum. Complex permittivity was measured on human, bovine and porcine brain tissues in the microwave frequency range from 0.5 to 18 GHz using an open-ended coaxial probe. The results present a valuable addition to the available data on the brain tissue complex permittivity. Some noticeable variations between the results lead to several conclusions. Complex permittivity variation within the same tissue type of the individual species was comparable to interspecies variation. The difference was prominent between human brains obtained from autopsies, while bovine brains obtained from healthy animals showed very similar complex permittivity. We hypothesize that the difference might have been caused by the basic pathologies of the patients, where the associated therapies could have affected the brain water content. We also examined the effect of excised tissue degradation on its complex permittivity over the course of three days, and the results suggest the gradual dehydration of the samples.

Biomarkers of Coagulation and Inflammation in Dogs after Randomized Administration of 6% Hydroxyethyl Starch 130/0.4 or Hartmann's Solution

Synthetic colloid fluids containing hydroxyethyl starch (HES) have been associated with impairment of coagulation in dogs. It is unknown if HES causes coagulation impairment in dogs with naturally occurring critical illness. This study used banked plasma samples from a blinded, randomized clinical trial comparing HES and balanced isotonic crystalloid for bolus fluid therapy in 39 critically ill dogs. Blood was collected prior to fluid administration and 6, 12, and 24 h thereafter. Coagulation biomarkers measured at each time point included prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen concentration, and the activities of coagulation factors V, VII, VIII, IX, and X, von Willebrand factor antigen, antithrombin, and protein C. Given the links between coagulation and inflammation, cytokine concentrations were also measured, including interleukins 6, 8, 10, and 18, keratinocyte-derived chemokine, and monocyte chemoattractant protein-1. Data were analyzed with linear mixed effects models. No significant treatment-by-time interactions were found for any biomarker, indicating that the pattern of change over time was not modified by treatment. Examining the main effect of time showed significant changes in several coagulation biomarkers and keratinocyte-derived chemokines. This study could not detect evidence of coagulation impairment with HES.

ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy

Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI.

HOW TO CITE THIS ARTICLE

Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.

Human albumin solution utilization patterns prior and during COVID-19 pandemic in United Arab Emirates: Time to develop and implement national guidelines on prescription and utilization

The human albumin solution (HAS) has limited but important indications in clinical practices. However, the inappropriate use of HAS can be costly. Thus, it is imperative to establish a practical protocol to use albumin products and rationalize its usage. The aim of this study was to identify HAS utilization patterns in a multi-specialty private hospital in Dubai, United Arab Emirates (UAE), before and during the COVID-19 pandemic. In addition, the objective was to demonstrate the importance of reconsidering the prescribing strategies for HAS administration. All data on 20% HAS administration in Mediclinic Welcare Hospital (MWEL) were retrieved between January 2019 and May 2021, including the total quantities administered and data on primary diagnosis. A total of 579 patient admissions with various diagnoses were included in this study. Our data suggested that the percentage of clinically indicated 20% HAS administrations decreased from 13.0% in the pre-COVID-19 phase to 1.5% in the COVID-19 phase (p<0.001). An increase in the administration of 20% HAS not backed by agreed clinical evidence followed the increase in new number of COVID-19 cases in the UAE. Our study suggests a large proportion of administered HAS, that drastically increased during COVID-19 with lack of evidence of its benefit. This study can be helpful to refine the institutional guidelines of HAS use, and frequent audits and interactive educational interventions are recommended to tackle this issue. In turn, the refinement of HAS administration guidelines could help to reduce the unjustified cost of inappropriate HAS use.

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

Albumin use for fluid resuscitation in cardiac surgical patients: a survey of Canadian perioperative care providers

PURPOSE

To evaluate the perceptions and practices of Canadian cardiovascular anesthesiologists and intensivists towards intravenous albumin as a resuscitation fluid in patients undergoing cardiac surgery.

METHODS

We conducted a cross-sectional survey of cardiac anesthesiologists and intensivists involved in the care of cardiac surgical patients. The 22-item survey included seven open-ended questions and assessed practice patterns and attitudes towards albumin. Descriptive statistics were analyzed using counts and proportions. Qualitative data were analyzed to identify themes describing albumin use patterns in Canada.

RESULTS

A total of 133 respondents from seven provinces participated, with 83 (62%) using albumin perioperatively. The majority of respondents (77%) felt a low fluid balance in cardiac surgical patients was important, and that supplementing crystalloids with albumin was helpful for this objective (67%). There was poor agreement among survey respondents regarding the role of albumin for faster vasopressor weaning or intensive care discharge, and ≥ 90% did not feel albumin reduced mortality, renal injury, or coagulopathy. Nevertheless, cardiac surgical patients were identified as a distinct population where albumin may help to minimize fluid balance. There was an acknowledged paucity of formal evidence supporting possible benefits. Fewer than 10% of respondents could identify institutional or national guidelines for albumin use. A lack of evidence supporting albumin use in cardiac surgical patients, especially those at highest risk of complications, was a frequently identified concern.

CONCLUSIONS

The majority of Canadian anesthesiologists and intensivists (62%) use albumin in cardiac surgical patients. There is clinical equipoise regarding its utility, and an acknowledged need for higher quality evidence to guide practice.

Hydroxyethyl Starch Improves the Prognosis of Rats with Traumatic Shock via Activation of the ERK Signaling Pathway in Lymphocytes

OBJECTIVE

Severe traumatic shock is one of the leading causes of death in young adults. A large number of studies have shown that effective volumetry resuscitation on the basis of controlled injury can not only increase the success rate of early resuscitation but also reduce systemic inflammatory response and improve the cure rate of severe traumatic shock. The study explored the effects of hydroxyethyl starch (HES) on the survival rate, lymphocyte function and proliferation of rats with traumatic shock, and the potential mechanisms.

METHODS

Traumatic shock was constructed in rats as experimental model, and liquid resuscitation was performed using HES and lactated Ringer's (LR). 24-h mortality was recorded, and lymphocytes were isolated. The expressions of signaling pathway factors was detected by qPCR and Western blot. ELISA was performed to determine the expression of interleukin 6 (IL-6) and tumor necrosis factor-α (TNF-α) in cell supernatant.

RESULTS

HES for fluid resuscitation augmented the survival of traumatic shock rats, upregulated the expressions of MEK and ERK1/2, and downregulated the expressions of IL-6 and TNF-α. However, inhibition of ERK signaling pathway reversed the effect of HES on the immune improvement and the 24-h survival rate of the traumatic shock rats (P < 0.05).

CONCLUSION

HES could exert the anti-inflammatory effects on lymphocytes by mediating the phosphorylation of proteins of the ERK signaling pathway. HSE demonstrated a high efficacy in effectively treating traumatic shock, thus could be used in clinical practice.

Early Combination of Albumin With Crystalloid Administration Might Reduce Mortality in Patients With Cardiogenic Shock: An Over 10-Year Intensive Care Survey

BACKGROUND

In updated international guidelines, combined albumin resuscitation is recommended for septic shock patients who receive large volumes of crystalloids, but minimal data exist on albumin use and the optimal timing in those with cardiogenic shock (CS). The objective of this study was to evaluate the relationship between resuscitation with a combination of albumin within 24 h and 30-day mortality in CS patients.

METHODS

We screened patients with CS from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Multivariable Cox proportional hazards models and propensity score matching (PSM) were employed to explore associations between combined albumin resuscitation within 24 h and 30-day mortality in CS. Models adjusted for CS considered potential confounders. E-value analysis suggested for unmeasured confounding.

RESULTS

We categorized 1,332 and 254 patients into crystalloid-only and early albumin combination groups, respectively. Patients who received the albumin combination had decreased 30-day and 60-day mortality (21.7 vs. 32.4% and 25.2 vs. 34.2%, respectively, P < 0.001), and the results were robust after PSM (21.3 vs. 44.7% and 24.9 vs. 47.0%, respectively, P < 0.001) and following E-value. Stratified analysis showed that only ≥ 60 years old patients benefited from administration early albumin. In the early albumin combination group, the hazard ratios (HRs) of different adjusted covariates remained significant (HRs of 0.45-0.64, P < 0.05). Subgroup analysis showed that resuscitation with combination albumin was significantly associated with reduced 30-day mortality in patients with maximum sequential organ failure assessment score≥10, with acute myocardial infarction, without an Impella or intra-aortic balloon pump, and with or without furosemide and mechanical ventilation (HRs of 0.49, 0.58, 0.65, 0.40, 0.65 and 0.48, respectively; P < 0.001).

CONCLUSION

This study found, compared with those given crystalloid-only, resuscitation with combination albumin within 24 h is associated with lower 30-day mortality of CS patients aged≥60. The results should be conducted to further assess in randomized controlled trials.

Effect of a 3% gelatin solution on urinary KIM-1 levels in patients after thyroidectomy: a preliminary randomized controlled trial

Optimal fluid therapy significantly affects the maintenance of proper tissue perfusion and, consequently, kidney function. An adverse effect of colloids on kidney function is related to the incidence of postoperative kidney failure. The study aimed to assess the effect of a 3% gelatin solution on kidney function based on the urinary kidney injury molecule-1 (uKIM-1) level. This study used a parallel design and enrolled 64 adult patients with a mean age of 52.5 ± 13.1 years, all of whom underwent a thyroidectomy procedure under general anesthesia. Patients were randomly assigned to three comparison groups, each receiving a different dose of 3% gelatin solution during the thyroidectomy procedure. The patients from study groups A (n = 21) and B (n = 21) received a 3% gelatin solution at a dose of 30 ml/kg and 15 ml/kg body weight, respectively, during the first hour of the procedure. The patients from the control group C (n = 22) received an isotonic multi-electrolyte solution. Serum creatinine levels were determined, and urine samples were collected to determine levels of uKIM-1 before, 2 h, and 24 h after surgery. The patients' demographic data, type and volume of fluid and hemodynamic status during the surgery were collected from relevant anesthesia protocols and were included in the study data. There were no statistically significant changes between groups in hemodynamic parameters such as systolic and diastolic blood pressure, heart rate, and oxygen saturation values. A statistically significant increase in uKIM-1 level was noted in patients receiving the 3% gelatin solution regardless of the dose. A statistically significant difference in uKIM-1 level was observed between groups A, B, and C measured 24 h after surgery, with the highest uKIM-1 level in group A. Measurement of uKIM-1 level could be an early and sensitive biomarker of kidney injury. Kidney toxicity of a 3% gelatin solution, evaluated based on the level of uKIM-1 in urine, correlates with transfused fluid volume. This study was retrospectively registered in the ISRCTN clinical trials registry (ISRCTN73266049, 08/04/2021: https://www.isrctn.com/ISRCTN73266049 ).