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Hoen L, Pfeffer D, Schmidt JR, Kraft J, Hildebrand J, Kalkhof S. Hydration Status of Geriatric Patients Is Associated with Changes in Plasma Proteome, Especially in Proteins Involved in Coagulation. Nutrients 2023; 15:3789. [PMID: 37686821 PMCID: PMC10490147 DOI: 10.3390/nu15173789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 09/10/2023] Open
Abstract
Due to multifactorial reasons, such as decreased thirst and decreased total body water, elderly patients are vulnerable to dehydration. The study aims to investigate whether moderate dehydration or hyperhydration affects the blood proteome. Blood samples, medication, and bioelectrical impedance analysis (BIA) details were collected from 131 geriatric patients (77 women and 54 men aged 81.1 ± 7.2 years). Based on an evaluation by Bioelectrical Impedance Vector Analyses (BIVAs) of this cohort, for each hydration status (dehydrated, hyperhydrated, and control), five appropriate blood plasma samples for both males and females were analyzed by liquid chromatography-mass spectrometry (LC-MS). Overall, 262 proteins for female patients and 293 proteins for male patients could be quantified. A total of 38 proteins had significantly different abundance, showing that hydration status does indeed affect the plasma proteome. Protein enrichment analysis of the affected proteins revealed "Wound Healing" and "Keratinization" as the two main biological processes being dysregulated. Proteins involved in clot formation are especially affected by hydration status.
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Affiliation(s)
- Laura Hoen
- Institute for Bioanalysis, Coburg University of Applied Sciences and Arts, Friedrich-Streib-Str. 2, 96450 Coburg, Germany
| | - Daniel Pfeffer
- Institute for Bioanalysis, Coburg University of Applied Sciences and Arts, Friedrich-Streib-Str. 2, 96450 Coburg, Germany
- Division of Geriatrics, Klinikum Coburg GmbH, 96450 Coburg, Germany
| | - Johannes R. Schmidt
- Proteomics Unit, Department of Preclinical Development and Validation, Fraunhofer Institute for Cell Therapy and Immunology—IZI, Perlickstr. 1, 04103 Leipzig, Germany
| | - Johannes Kraft
- Division of Geriatrics, Klinikum Coburg GmbH, 96450 Coburg, Germany
| | - Janosch Hildebrand
- Institute for Bioanalysis, Coburg University of Applied Sciences and Arts, Friedrich-Streib-Str. 2, 96450 Coburg, Germany
| | - Stefan Kalkhof
- Institute for Bioanalysis, Coburg University of Applied Sciences and Arts, Friedrich-Streib-Str. 2, 96450 Coburg, Germany
- Proteomics Unit, Department of Preclinical Development and Validation, Fraunhofer Institute for Cell Therapy and Immunology—IZI, Perlickstr. 1, 04103 Leipzig, Germany
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Zhou FL, Wang LH, Dai CQ, Shentu GJ, Xu GH. Risk Factors and Outcomes for Preoperative Asymptomatic Pulmonary Embolism in Patients Aged 60 Years and Over with Hip Fracture. Orthop Surg 2021; 13:958-965. [PMID: 33818010 PMCID: PMC8126953 DOI: 10.1111/os.12983] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the risk factors for, and outcomes of, preoperative asymptomatic pulmonary embolism (PE) in patients ≥60 years old following delayed operation for hip fracture. Methods From March 2017 to December 2018, 90 patients aged ≥60 years with hip fracture who suffered a delay in surgery were recruited to this prospective study following admission to our hospital. Computed tomography pulmonary angiography (CTPA) was used to detect preoperative asymptomatic PE and calculated its incidence. Time from injury to admission, baseline characteristics, medical comorbidities, and blood biomarker levels were evaluated as potential risk factors. Logistic regression analysis was used to identify risk factors. Mortality and major bleeding events were recorded and compared between individuals with PE and without. Data were analyzed by t‐test, Mann–Whitney U test, χ2 test, Fisher's exact test, and logistic regression analysis. Results The incidence of preoperative asymptomatic PE was 18.9% (17/90 patients). In the univariate analysis, the risk factors for preoperative asymptomatic PE were male sex, hypertension, cerebrovascular accident, smoking, plasma D‐dimer level, potassium level, urea level, creatinine level, and cysteine level. Multivariate logistic regression analysis showed that the risk of preoperative asymptomatic PE was higher in patients with hypertension (odds ratio [OR] = 10.048; 95% confidence interval [CI], 1.118–90.333), cerebrovascular accident (OR = 20.135; 95% CI, 1.875–216.164), smoking (OR = 48.741; 95% CI, 4.155–571.788), high plasma D‐dimer levels (OR = 1.200; 95% CI, 1.062–157.300), and high plasma potassium levels (OR = 12.928; 95% CI, 1.062–157.300). All patients were followed up for 21.0 months (range, 2 to 36 months). Mortality within the first year postoperatively was higher in patients with PE (29.41% vs 9.59%, P = 0.046). Conclusions In view of the high incidence of preoperative asymptomatic PE and the inferior prognosis in individuals with PE, routine CTPA examination for preoperative asymptomatic PE could be useful for patients aged ≥60 years with hip fracture for whom surgery is delayed.
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Affiliation(s)
- Fang-Lun Zhou
- Department of Arthrology, Dongyang People's Hospital, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang, China
| | - Li-Hong Wang
- Department of Arthrology, Dongyang People's Hospital, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang, China
| | - Cheng-Qian Dai
- Department of Arthrology, Dongyang People's Hospital, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang, China
| | - Guo-Jian Shentu
- Department of Arthrology, Dongyang People's Hospital, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang, China
| | - Guo-Hong Xu
- Department of Arthrology, Dongyang People's Hospital, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang, China
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3
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Ma J, Qin J, Hu J, Shang M, Zhou Y, Liang N, Zhang Y, Zhu Y. Incidence and Hematological Biomarkers Associated With Preoperative Deep Venous Thrombosis Following Foot Fractures. Foot Ankle Int 2020; 41:1563-1570. [PMID: 32806946 DOI: 10.1177/1071100720943844] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study was designed to investigate the incidence and hematological biomarker levels that are associated with deep venous thrombosis (DVT) following closed foot fractures (except calcaneal fractures). METHODS A retrospective analysis of data on patients presenting with closed foot fractures (excluding the calcaneus) between October 2014 and December 2018 was conducted. Duplex ultrasonography was used to screen preoperative DVT of bilateral lower extremities. Data on demographics, comorbidities, types of fracture, and laboratory biomarkers at admission were collected. Univariate analyses and multivariate logistic regression analyses were carried out to determine the independent risk factors associated with DVT. RESULTS A total of 537 patients were included, among whom 28 patients had preoperative DVTs, indicating a crude incidence rate of 5.2%. In isolated closed foot fractures, DVT occurred in 12 (2.9%) out of 410 patients, while in patients with concurrent fracture in other locations, 16 (12.6%) out of 127 patients developed DVT. The average interval between fracture occurrence and diagnosis of DVT was 4.2 days (median, 2 days), ranging from 0 to 17 days. Twenty-four patients (85.7%) developed DVT in the injured extremity, 3 (10.7%) in the uninjured extremity, and 1 (3.5%) in bilateral extremities. Seven risk factors were identified to be associated with DVT, including alcohol consumption, concomitant other fractures, platelet distribution width (PDW) <12%, high-density lipoprotein cholesterol (HDL-C) <1.1mmol/L, serum alkaline phosphatase (ALP) >100 U/L, serum sodium concentration (Na+) <135 mmol/L, and D-dimer >0.5 mg/L. CONCLUSION Being aware of the prevalence of DVT in closed foot fractures can help physicians to carry out the overall assessment, risk stratification, and individual prevention programs. LEVEL OF EVIDENCE Level III, a prospective cohort study.
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Affiliation(s)
- Jiangtao Ma
- Hebei Orthopedic Clinical Research Center, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Jin Qin
- Hebei Orthopedic Clinical Research Center, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Jinglve Hu
- Hebei Orthopedic Clinical Research Center, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Meishuang Shang
- Hebei Orthopedic Clinical Research Center, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Yali Zhou
- Hebei Orthopedic Clinical Research Center, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Ningxi Liang
- Hebei Orthopedic Clinical Research Center, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Chinese Academy of Engineering, Beijing, People's Republic of China
| | - Yanbin Zhu
- Department of Orthopaedic Surgery, the 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
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Lin TL, Dhillon NK, Conde G, Toscano S, Margulies DR, Barmparas G, Ley EJ. Early positive fluid balance is predictive for venous thromboembolism in critically ill surgical patients. Am J Surg 2020; 222:220-226. [PMID: 32900497 DOI: 10.1016/j.amjsurg.2020.08.032] [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: 04/05/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Positive fluid balance (FB) in the intensive care unit (ICU) may be a marker for increased venous thromboembolism (VTE) risk. We hypothesized that an early positive fluid balance (FB) would be associated with increased VTE occurrence. METHODS A single-center retrospective review of surgical ICU patients was conducted from May 2011 to December 2014. Patients with a VTE were compared to those who did not develop a VTE (NVTE). RESULTS There were 619 patients analyzed with 77 (12.4%) diagnosed with a VTE; these patients had longer ventilator days (12.3 vs. 5.0 days, p < 0.01) and ICU stays (10.3 vs. 6.4 days, p < 0.01), and were more likely to have a net FB ≥ 4L over the first three days (62% vs. 44%, p < 0.01). A FB ≥ 4L over the first three ICU days was an independent predictor of VTE (AOR 1.74, p = 0.04). CONCLUSION Patients with an early positive FB are more likely to develop a VTE.
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Affiliation(s)
- Ting-Lung Lin
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States; Departments of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Geena Conde
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Samantha Toscano
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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Hikasa Y, Suzuki S, Mihara Y, Tanabe S, Shirakawa Y, Fujiwara T, Morimatsu H. Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study. J Anesth 2020; 34:404-412. [PMID: 32232660 DOI: 10.1007/s00540-020-02766-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/21/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE. METHODS This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications. RESULTS In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001). CONCLUSIONS In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.
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Affiliation(s)
- Yukiko Hikasa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Satoshi Suzuki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuko Mihara
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery Transplant and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Shirakawa
- Department of Gastroenterological Surgery Transplant and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery Transplant and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Bampoe S, Odor PM, Dushianthan A, Bennett‐Guerrero E, Cro S, Gan TJ, Grocott MPW, James MFM, Mythen MG, O'Malley CMN, Roche AM, Rowan K, Burdett E. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures. Cochrane Database Syst Rev 2017; 9:CD004089. [PMID: 28933805 PMCID: PMC6483610 DOI: 10.1002/14651858.cd004089.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Perioperative fluid strategies influence clinical outcomes following major surgery. Many intravenous fluid preparations are based on simple solutions, such as normal saline, that feature an electrolyte composition that differs from that of physiological plasma. Buffered fluids have a theoretical advantage of containing a substrate that acts to maintain the body's acid-base status - typically a bicarbonate or a bicarbonate precursor such as maleate, gluconate, lactate, or acetate. Buffered fluids also provide additional electrolytes, including potassium, magnesium, and calcium, more closely matching the electrolyte balance of plasma. The putative benefits of buffered fluids have been compared with those of non-buffered fluids in the context of clinical studies conducted during the perioperative period. This review was published in 2012, and was updated in 2017. OBJECTIVES To review effects of perioperative intravenous administration of buffered versus non-buffered fluids for plasma volume expansion or maintenance, or both, on clinical outcomes in adults undergoing all types of surgery. SEARCH METHODS We electronically searched the Clinicaltrials.gov major trials registry, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 6) in the Cochrane Library, MEDLINE (1966 to June 2016), Embase (1980 to June 2016), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to June 2016). We handsearched conference abstracts and, when possible, contacted leaders in the field. We reran the search in May 2017. We added one potential new study of interest to the list of 'Studies awaiting classification' and will incorporate this trial into formal review findings when we prepare the review update. SELECTION CRITERIA Only randomized controlled trials that compared buffered versus non-buffered intravenous fluids for surgical patients were eligible for inclusion. We excluded other forms of comparison such as crystalloids versus colloids and colloids versus different colloids. DATA COLLECTION AND ANALYSIS Two review authors screened references for eligibility, extracted data, and assessed risks of bias. We resolved disagreements by discussion and consensus, in collaboration with a third review author. We contacted trial authors to request additional information when appropriate. We presented pooled estimates for dichotomous outcomes as odds ratios (ORs) and for continuous outcomes as mean differences (MDs), with 95% confidence intervals (CIs). We analysed data via Review Manager 5.3 using fixed-effect models, and when heterogeneity was high (I² > 40%), we used random-effects models. MAIN RESULTS This review includes, in total, 19 publications of 18 randomized controlled trials with a total of 1096 participants. We incorporated five of those 19 studies (330 participants) after the June 2016 update. Outcome measures in the included studies were thematically similar, covering perioperative electrolyte status, renal function, and acid-base status; however, we found significant clinical and statistical heterogeneity among the included studies. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Trial authors variably reported outcome data at disparate time points and with heterogeneous patient groups. Consequently, many outcome measures are reported in small group sizes, reducing overall confidence in effect size, despite relatively low inherent bias in the included studies. Several studies reported orphan outcome measures. We did not include in the results of this review one large, ongoing study of saline versus Ringer's solution.We found insufficient evidence on effects of fluid therapies on mortality and postoperative organ dysfunction (defined as renal insufficiency leading to renal replacement therapy); confidence intervals were wide and included both clinically relevant benefit and harm: mortality (Peto OR 1.85, 95% CI 0.37 to 9.33; I² = 0%; 3 trials, 6 deaths, 276 participants; low-quality evidence); renal insufficiency (OR 0.82, 95% CI 0.34 to 1.98; I² = 0%; 4 trials, 22 events, 276 participants; low-quality evidence).We noted several metabolic differences, including a difference in postoperative pH measured at end of surgery of 0.05 units - lower in the non-buffered fluid group (12 studies with a total of 720 participants; 95% CI 0.04 to 0.07; I² = 61%). However, this difference was not maintained on postoperative day one. We rated the quality of evidence for this outcome as moderate. We observed a higher postoperative serum chloride level immediately after operation, with use of non-buffered fluids reported in 10 studies with a total of 530 participants (MD 6.77 mmol/L, 95% CI 3.38 to 10.17), and this difference persisted until day one postoperatively (five studies with a total of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). We rated the quality of evidence for this outcome as moderate. AUTHORS' CONCLUSIONS Current evidence is insufficient to show effects of perioperative administration of buffered versus non-buffered crystalloid fluids on mortality and organ system function in adult patients following surgery. Benefits of buffered fluid were measurable in biochemical terms, particularly a significant reduction in postoperative hyperchloraemia and metabolic acidosis. Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Larger studies are needed to assess these relevant clinical outcomes.
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Affiliation(s)
- Sohail Bampoe
- University College LondonCentre for Anaesthesia and Perioperative MedicineLondonUKNW1 2BU
| | - Peter M Odor
- University College LondonDepartment Anaesthesia and Critical Care235 Euston Rd, FitzroviaLondonUKNW1 2BU
| | - Ahilanandan Dushianthan
- University Hospital Southampton NHS Foundation TrustGeneral Intensive Care UnitTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Elliott Bennett‐Guerrero
- Stony Brook MedicineDepartment of AnesthesiologyHealth Science Tower, Level 4 (Rm 060)Stony BrookNYUSA
| | - Suzie Cro
- Medical Research Council Clinical Trials Unit222 Euston RoadLondonUKNW1 2DA
| | - Tong J Gan
- Stony Brook MedicineDepartment of AnesthesiologyHealth Science Tower, Level 4 (Rm 060)Stony BrookNYUSA
| | - Michael PW Grocott
- Faculty of Medicine, University of SouthamptonCritical Care Group, Clinical and Experimental SciencesTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Michael FM James
- University of Cape TownDepartment of AnaesthesiaAnzio RoadObservatory 7925Cape TownWestern CapeSouth Africa7925
| | - Michael G Mythen
- University College LondonDepartment Anaesthesia and Critical Care235 Euston Rd, FitzroviaLondonUKNW1 2BU
| | | | - Anthony M Roche
- University of WashingtonDepartment of Anesthesiology and Pain MedicineBox 359724SeattleWAUSA98104
| | - Kathy Rowan
- Intensive Care National Audit & Research CentreNapier House24 High HolbornLondonUKWC1V 6AZ
| | - Edward Burdett
- UCL Centre for AnaesthesiaDepartment of Anaesthesia3rd floor PodiumUniversity College Hospital, 235 Euston RoadLondonUKNW1 2BU
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Moderate plasma dilution using artificial plasma expanders shifts the haemostatic balance to hypercoagulation. Sci Rep 2017; 7:843. [PMID: 28405015 PMCID: PMC5429808 DOI: 10.1038/s41598-017-00927-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 03/21/2017] [Indexed: 11/08/2022] Open
Abstract
Artificial plasma expanders (PEs) are widely used in modern transfusion medicine. PEs do not contain components of the coagulation system, so their infusion in large volumes causes haemodilution and affects haemostasis. However, the existing information on this effect is contradictory. We studied the effect of the very process of plasma dilution on coagulation and tested the hypothesis that moderate dilution with a PE should accelerate clotting owing to a decrease in concentration of coagulation inhibitors. The standard clotting times, a thrombin generation test, and the spatial rate of clot growth (test of thrombodynamics) were used to assess donor plasma diluted in vitro with various PEs. The pH value and Ca+2 concentration were maintained strictly constant in all samples. The effect of thrombin inhibitors on dilution-induced hypercoagulation was also examined. It was shown that coagulation was enhanced in plasma diluted up to 2.0-2.5-fold with any PE. This enhancement was due to the dilution of coagulation inhibitors in plasma. Their addition to plasma or PE could partially prevent the hypercoagulation shift.
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Abstract
The reduction in oxygen-carrying capacity during hemodilution is well tolerated by most patients. However, hemodilution not only decreases O2 transport capacity, but also may influence blood coagulation. Advanced hemodilution with crystalloids does not compromise blood coagulation and, with moderate hemodilution, even augmented blood coagulation may develop. In contrast, blood coagulation is compromised during hemodilution with colloids. The effect of human serum albumin and gelatin is relatively modest, but significantly more than during equivalent hemodilution with crystalloids. Dextran and hydroxyethyl starch compromise blood coagulation more. This results from reduction of factor VIII, a decrease in plasmatic coagulation, and an impairment of platelet function. For hydroxyethyl starch, molecular size and degree of substitution are crucial for the effect on blood coagulation, with hydroxyethyl starch (200,000/0.5) having the least effect. Furthermore, accelerated fibrin formation is observed during hemodilution with Dextran, hydroxyethyl starch, and gelatin with an altered fibrin structure. In vitro clot lysis is also increased with all colloids, but there are no reports on augmented in vivo fibrin degradation products. Besides the effect on intraoperative blood coagulation, the hemodynamic effectiveness, duration thereof, effect on microcirculation and edema formation, and, in particular, the effect on the hypercoagulable state in the postoperative period need to be considered in the choice of the replacement fluid during hemodilution and intraoperative blood loss.
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Affiliation(s)
- Gabi A. Egli
- Institute of Anesthesiology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Donat R. Spahn
- Institute of Anesthesiology, University Hospital, University of Zurich, Zurich, Switzerland
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El-Sharkawy AM, Sahota O, Lobo DN. Acute and chronic effects of hydration status on health. Nutr Rev 2015; 73 Suppl 2:97-109. [DOI: 10.1093/nutrit/nuv038] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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10
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Burdett E, Dushianthan A, Bennett-Guerrero E, Cro S, Gan TJ, Grocott MPW, James MFM, Mythen MG, O'Malley CMN, Roche AM, Rowan K. Perioperative buffered versus non-buffered fluid administration for surgery in adults. Cochrane Database Syst Rev 2012; 12:CD004089. [PMID: 23235602 DOI: 10.1002/14651858.cd004089.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Perioperative fluid therapy influences clinical outcomes following major surgery. Fluid preparations may be based on a simple non-buffered salt solution, such as normal saline, or may be modified with bicarbonate or bicarbonate precursor buffers, such as maleate, gluconate, lactate or acetate, to better reflect the human physiological state. These latter fluids have theoretical advantages over normal saline in preventing hyperchloraemic acidosis. A number of clinical studies have now compared fluid preparations with and without a buffer to achieve a balanced electrolyte solution for perioperative fluid resuscitation. OBJECTIVES To review the safety and efficacy of perioperative administration of buffered versus non-buffered fluids for plasma volume expansion or maintenance in adult patients undergoing surgery. SEARCH METHODS We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 4), MEDLINE (1966 to May 2011), EMBASE (1980 to May 2011), and CINAHL (1982 to May 2011). We handsearched conference abstracts and where possible, contacted leaders in the field. SELECTION CRITERIA We only included randomized trials of buffered versus non-buffered intravenous fluids for perioperative fluid resuscitation. The trials with other forms of comparisons such as crystalloids versus colloids and colloids versus different colloids were excluded. We also excluded trials using hypertonic fluids and dextrose-based fluids. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the methodological quality of clinical trials. We resolved any disagreements by discussion. We contacted the trial authors to provide additional information where appropriate. We presented pooled estimates of the dichotomous outcomes as odds ratios (OR) and on continuous outcomes as mean differences, with 95% confidence intervals (CI). We analysed data on Review Manager 5.1 using fixed-effect models, and when heterogeneity was high (I² > 40%) random-effect models were used. MAIN RESULTS We identified 14 publications reporting 13 trials or comparisons with a total of 706 participants. For many of the outcomes reported, there was significant clinical and statistical heterogeneity. The primary outcome of mortality at any time was reported in only three studies with a total of 267 patients. The mortality rate was 2.9% for the buffered fluids group and 1.5% for the non-buffered fluids group but this difference was not statistically significant. The Peto OR was 1.85 (95% CI 0.37 to 9.33, P = 0.45, I(2)= 0%). Organ dysfunction was only presented for renal impairment. There was no difference in renal insufficiency leading to renal replacement therapy between the buffered and non-buffered groups (OR 0.61, 95% CI 0.23 to 1.63, P = 0.32, I(2) = 0%). Markers of organ system failure as assessed by urine output, creatinine and its variables (for renal function), PaC0(2) (respiratory function) and postoperative nausea and vomiting (gastro-intestinal function) showed a statistically significant difference only in PaC0(2) levels. The mean difference was 1.18 with lower PaC0(2) levels in the non-buffered fluid group (95% CI 0.09 to 2.28, P = 0.03, I(2) = 0%) compared to the buffered fluid group.There was no difference in intraoperative blood loss nor the volumes of intraoperative red cell or fresh frozen plasma transfused between groups. There was an increase in platelet transfusion in the non-buffered group which was statistically significant after analysing the transformed data (log transformation because the data were highly skewed).A number of metabolic differences were noted. There was a difference in postoperative pH of 0.06 units, lower in the non-buffered fluid group (95% CI 0.04 to 0.08, P < 0.00001, I(2) = 74%). However, this difference was not maintained on postoperative day one. The non-buffered fluid group also had significantly greater base deficit, serum sodium and chloride levels.There was no difference demonstrated in length of hospital stay and no data were reported on cost or quality of life. AUTHORS' CONCLUSIONS The administration of buffered fluids to adult patients during surgery is equally safe and effective as the administration of non-buffered saline-based fluids. The use of buffered fluids is associated with less metabolic derangement, in particular hyperchloraemia and metabolic acidosis. Larger studies are needed to assess robust outcomes such as mortality.
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Affiliation(s)
- Edward Burdett
- Department of Anaesthesia, UCL Centre for Anaesthesia, London, UK.
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Topçu I, Civi M, Oztürk T, Keleş GT, Coban S, Yentür EA, Okçu G. Evaluation of hemostatic changes using n thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery. Braz J Med Biol Res 2012; 45:869-74. [PMID: 22666779 PMCID: PMC3854317 DOI: 10.1590/s0100-879x2012007500095] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 05/21/2012] [Indexed: 11/27/2022] Open
Abstract
The effects of Ringer lactate, 6% hydroxyethyl starch (130/0.4) or 4% succinylated gelatin solutions on perioperative coagulability were measured by thromboelastography (TEG). Seventy-five patients (ASA I-III) who were to undergo major orthopedic procedures performed under epidural anesthesia were included in the study. Patients were randomly divided into three groups of 25 each for the administration of maintenance fluids: group RL (Ringer lactate), group HES (6% hydroxyethyl starch 130/0.4), and group JEL (4% gelofusine solution). Blood samples were obtained during the perioperative period before epidural anesthesia (t1, baseline), at the end of the surgery (t2), and 24 h after the operation (t3). TEG data, reaction time (R), coagulation time (K), angle value (α), and maximum amplitude (MA) were recorded. TEG parameters changed from normal values in all patients. In group RL, R and K times decreased compared to perioperative values while the α angle and MA increased (P < 0.05). In group HES, R and K times increased, however, the α angle and MA decreased (P < 0.05). In group JEL, R time increased (P < 0.05), but K time, α angle and MA did not change significantly. In the present study, RL, 6% HES (130/0.4) and 4% JEL solutions caused changes in the coagulation system of all patients as measured by TEG, but these changes remained within normal limits.
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Affiliation(s)
- I Topçu
- Department of Anesthesiology and Reanimation, Celal Bayar University, Manisa, Turkey.
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Morin JF, Mistry B, Langlois Y, Ma F, Chamoun P, Holcroft C. Fluid Overload after Coronary Artery Bypass Grafting Surgery Increases the Incidence of Post-Operative Complications. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/wjcs.2011.12004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Llewellyn RL, James MFM. The effect of low molecular weight heparin (enoxaparin) on enhanced coagulation induced by crystalloid haemodilution. Anaesthesia 2010; 65:1013-6. [PMID: 20731638 DOI: 10.1111/j.1365-2044.2010.06475.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to establish whether a low molecular weight heparin (enoxaparin) attenuated or abolished the enhanced coagulation induced by crystalloid fluid therapy. Twenty young, healthy male volunteers were injected subcutaneously with either enoxaparin 40 mg or saline on two separate occasions one week apart, in a randomised, blinded study. Twelve hours later, a blood sample was taken for thrombelastography analysis and haematocrit. Saline 14 ml.kg⁻¹ was then infused over thirty minutes and thrombelastography and haematocrit measurements repeated. There was a significant post-dilutional difference in the alpha angle (p = 0.002) and k-time (p = 0.001) between the two groups. There was a trend towards reduced shortening of r-time in the enoxaparin group compared to the saline control (p = 0.18). The findings suggest that enoxaparin diminished acceleration of clot formation due to haemodilution.
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Affiliation(s)
- R L Llewellyn
- Department of Anaesthesiology, University of Cape Town Medical School, South Africa.
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Abstract
Adequate restoration of intravascular volume remains an important therapeutic maneuver in managing the surgical patient. Definition of the ideal volume replacement strategy still remains one of the burning problems. Firstly, the choice between colloid and crystalloid solutions continues to generate controversy. Secondly, the highly controversial crystalloid/colloid dispute has been enlarged to a colloid/colloid debate because of the increasing number of colloids that are available. And lastly, whether high or low volume replacement strategies are favorable for the surgical patient is an another issue for the anesthesiologists. Volume replacement has been hitherto often based on art, dogma and personal beliefs. It was the aim of this overview to present the different solutions and to facilitate the strategies for above three main issues in the field of intraoperative fluid therapy.
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Affiliation(s)
- Jaemin Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Affiliation(s)
- François Lette
- Executive and International Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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Viuff D, Lauritzen B, Pusateri AE, Andersen S, Rojkjaer R, Johansson PI. Effect of haemodilution, acidosis, and hypothermia on the activity of recombinant factor VIIa (NovoSeven). Br J Anaesth 2008; 101:324-31. [PMID: 18565966 PMCID: PMC2517151 DOI: 10.1093/bja/aen175] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background A range of plasma volume expanders is used clinically, often in settings where haemostasis may already be impaired. The haemostatic agent, recombinant activated factor VII (rFVIIa, NovoSeven®), may be used to improve haemostasis but potential interactions with different volume expanders are poorly understood. Methods Clot formation was measured by thromboelastography (TEG) using blood from healthy volunteers. In vitro effects of rFVIIa with haemodilution, acidosis, and hypothermia were examined. Conditions were induced by dilution with NaCl (0.9%), lactated Ringer's solution, albumin 5%, or hydroxyethyl starch (HES) solutions [MW (molecular weight) 130–670 kDa]; by adjusting pH to 6.8 with 1 M HEPES (N-2-hydroxyethylpiperazine-N′-2-ethanesulphonic acid) buffer; or by reducing temperature to 32°C. We also studied the effect of low vs high MW HES (MW 200 vs 600 kDa) and rFVIIa on in vivo bleeding time (BT) in rabbits. Results Haemodilution progressively altered TEG parameters. rFVIIa improved TEG parameters in the presence of acidosis, hypothermia or 20% haemodilution (P<0.05). At 40% haemodilution, the rFVIIa effect was diminished particularly with high MW HES. In vivo, rFVIIa shortened the BT (P<0.05) with low but not high MW HES. Conclusions Efficacy of rFVIIa was affected by the degree of haemodilution and type of volume expander, but not by acidosis or hypothermia.
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Affiliation(s)
- D Viuff
- Hemostasis Pharmacology, Novo Nordisk A/S, Novo Nordisk Park, 2760 Måløv, Denmark.
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Rehak J, Rehak M. Branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities. Curr Eye Res 2008; 33:111-31. [PMID: 18293182 PMCID: PMC2430176 DOI: 10.1080/02713680701851902] [Citation(s) in RCA: 282] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Accepted: 12/08/2007] [Indexed: 01/04/2023]
Abstract
In branch retinal vein occlusion (BRVO), abnormal arteriovenous crossing with vein compression, degenerative changes of the vessel wall and abnormal hematological factors constitute the primary mechanism of vessel occlusion. In general, BRVO has a good prognosis: 50-60% of eyes are reported to have a final visual acuity (VA) of 20/40 or better even without treatment. One important prognostic factor for final VA appears to be the initial VA. Grid laser photocoagulation is an established treatment for macular edema in a particular group of patients with BRVO, while promising results for this condition are shown by intravitreal application of steroids or new vascular endothelial growth factor inhibitors. Vitrectomy with or without arteriovenous sheathotomy combined with removal of the internal limiting membrane may improve vision in eyes with macular edema which are unresponsive to or ineligible for laser treatment.
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Affiliation(s)
- Jiri Rehak
- Department of Ophthalmology, University Hospital, Palacky University, Olomouc, Czech Republic.
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Holte K, Kristensen BB, Valentiner L, Foss NB, Husted H, Kehlet H. Liberal Versus Restrictive Fluid Management in Knee Arthroplasty: A Randomized, Double-Blind Study. Anesth Analg 2007; 105:465-74. [PMID: 17646507 DOI: 10.1213/01.ane.0000263268.08222.19] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are few data describing the relationship between amount of perioperative fluid and organ function. In this study we investigated the effects of two levels of intravascular fluid administration ("liberal" versus "restrictive") in knee arthroplasty on physiological recovery as the primary outcome variable. METHODS In a double-blind study, 48 ASA I-III patients undergoing fast-track elective knee arthroplasty were randomized to restrictive or liberal perioperative intravascular fluid administration. Patients received a fixed rate infusion of Ringer's lactate solution with a standardized volume of colloid. All other aspects of perioperative management (including anesthesia, preoperative fluid status, and postoperative management) were standardized. Primary outcome variables included pulmonary function (spirometry), exercise capacity ("timed up and go" test), coagulation (Thrombelastograph), postoperative hypoxemia (nocturnal pulse oximetry), postoperative ileus (defecation), and subjective patient recovery (visual analog scales). Hospital stay and complications were also noted. RESULTS Fluid guidelines were followed strictly in all patients. Liberal (median 4250 mL, range 3150-5200 mL) compared with restrictive (median 1740 mL, range 1100-2165 mL) intravascular fluid administration led to improved pulmonary function 6 h postoperatively, significant hypercoagulability 24-48 h postoperatively, and reduced incidence of vomiting. There were no overall differences in the other assessed perioperative physiological recovery variables (postoperative hypoxemia, exercise capacity or subjective patient recovery variables). No difference was found in hospital stay (median 4 days in both groups, not significant). CONCLUSION A liberal compared to a restrictive intravascular fluid regimen may lead to significant hypercoagulability and a reduction in vomiting, but without differences in other recovery variables or hospital stay after fast-track knee arthroplasty.
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Affiliation(s)
- Kathrine Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark.
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Ruttmann TG, Montoya-Pelaez LF, James MFM. The Coagulation Changes Induced by Rapid In Vivo Crystalloid Infusion Are Attenuated When Magnesium Is Kept at the Upper Limit of Normal. Anesth Analg 2007; 104:1475-80, table of contents. [PMID: 17513645 DOI: 10.1213/01.ane.0000261256.88414.e4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rapid crystalloid infusion enhances coagulation, regardless of electrolytes, pH or osmolality, an effect thought to be related to deep vein thrombosis and other clot formations. Altered serum magnesium may play a role in the balance of coagulation. In this in vivo study we investigated the coagulation response to rapid hemodilution when serum magnesium is maintained or partially increased. METHODS Twenty-five healthy volunteers were investigated on three occasions, randomly receiving normal saline, Balsol (magnesium 1.5 g/L), and Balsol plus additional magnesium (magnesium 3.0 g/L). Investigators were blinded to the solution's identity. Baseline blood samples were taken measuring hematocrit, serum magnesium, and thrombelastography (TEG), whereafter 14 mL/kg (20% blood volume) was infused over 30 min, followed by a second blood sample. All results were compared to their own baseline values using ANOVA with LSD post hoc significance testing. RESULTS All groups had a similar postdilutional hematocrit decrease, with significant magnesium reduction in the saline group (0.81 +/- 0.07 to 0.74 +/- 0.07 (approximately -8.6%) (P < 0.003)), no change in the Balsol group and significant increase in the Balsol + magnesium group (0.84 +/- 0.07 to 0.99 +/- 0.06 (approximately 17.9%) (P < 0.001)). Postdilutional TEG results reflected no significant change from control in the Balsol + magnesium group. Both of the other two groups had statistically significant increased clot formation (reaction time to onset of clotting and clotting time shortened; alpha-angle increased). CONCLUSIONS Rapid hemodilution-induced coagulation may be partially due to decreased magnesium, and the effect is attenuated by maintaining magnesium at the upper limit of normal. Crystalloid resuscitation fluids should possibly contain higher magnesium levels, around 3 mmol/L.
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Affiliation(s)
- Thomas G Ruttmann
- Department of Anaesthesiology, University of Cape Town Medical School, Cape Town, Republic of South Africa.
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Ruttmann TG, Lemmens HJM, Malott KA, Brock-Utne JG. The haemodilution enhanced onset of coagulation as measured by the thrombelastogram is transient. Eur J Anaesthesiol 2006; 23:574-9. [PMID: 16507197 DOI: 10.1017/s0265021506000238] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Crystalloid haemodilution has been widely found to enhance coagulation onset, but the duration of this effect has never been documented. METHODS Twelve healthy, consenting volunteers had a rapid infusion of 14 mL kg-1 of normal (0.9%) saline. Blood samples were taken, prior to (control), and immediately after (30 min) the rapid saline infusion was completed (30 min). They were then repeated at regular intervals up to 120 min. Haematocrit/platelet counts were taken to determine the degree of dilution and thrombelastograms, with and without platelet antagonists (ReoPro, Abciximab), were measured in all samples. Antithrombin levels were selectively measured. RESULTS The haematocrit and platelet count showed a rapid dilutional decrease at 30 min (mean of -12.2% and -14.4%, respectively), with values returning towards baseline within 15 min after finishing the infusion. There was a significantly faster onset of coagulation (decrease in r-time) in the post-infusion sample (30 min) compared to control (P<0.05), again returning towards normal as the dilution effect was reversed. Similar thrombelastograms findings were evident in the plasma factor only group (platelets inhibited by ReoPro). Antithrombin levels changed in keeping with the haemodilution effect (P<0.0001). There was a linear relationship between antithrombin and thrombelastograms r-time (P=0.012). CONCLUSION The faster onset of coagulation brought on by haemodilution return towards normal as the dilutional effect is reversed. This effect is mediated through plasma clotting factors. Of interest is the significant inverse correlation of the onset of coagulation increasing as the antithrombin levels decreased with dilution.
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Affiliation(s)
- T G Ruttmann
- Stanford University, Department of Anesthesiology, CA, USA.
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Holte K, Kehlet H. Fluid Therapy and Surgical Outcomes in Elective Surgery: A Need for Reassessment in Fast-Track Surgery. J Am Coll Surg 2006; 202:971-89. [PMID: 16735213 DOI: 10.1016/j.jamcollsurg.2006.01.003] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Revised: 01/06/2006] [Accepted: 01/16/2006] [Indexed: 11/18/2022]
Affiliation(s)
- Kathrine Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
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Abstract
The clinical case presented in this article illustrates how many of the more recent advances in the management of critically ill patients apply to current clinical practice. Simple cost-effective general measures (eg, optimal sterile precautions during procedures; hand washing; early goal-directed resuscitation with appropriate fluids, inotropes, and antibiotics; and surgical source control of infected foci) still should form the basis of clinical practice, however. There has been renewed interest in blood transfusion therapy and its associated risks. Lower tidal volume ventilation now is practiced almost universally in patients with ARDS, and several new selective pulmonary vasodilators have extended the armamentarium when taking care of these patients. High-frequency oscillatory ventilation and ECMO remain challenging options in patients with refractory hypoxemia. Appropriate patient selection is important when corticosteroid therapy is considered. Tight blood glucose control and monitoring improve outcome and should be part of ICU care of septic patients. The role of the PAC is controversial. Other techniques to measure cardiac output, hemodynamics, and perfusion are available and should be considered. Sedation and analgesia form an integral part of critical care. Because of its immediate and long-term risks, neuromuscular blockade should be used sparingly and only when all other options have been exhausted. Ongoing education regarding sedation protocols and the effect of sedation on outcome is needed among physicians and nurses caring for these patients.
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Affiliation(s)
- Charl J De Wet
- Department of Anesthesiology and Division of Cardiothoracic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St. Louis, MO 63110, USA
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Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238:641-8. [PMID: 14578723 PMCID: PMC1356139 DOI: 10.1097/01.sla.0000094387.50865.23] [Citation(s) in RCA: 1062] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. SUMMARY BACKGROUND DATA Current fluid administration in major surgery causes a weight increase of 3-6 kg. Complications after colorectal surgery are reported in up to 68% of patients. Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown. METHODS We did a randomized observer-blinded multicenter trial. After informed consent was obtained, 172 patients were allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects. RESULTS The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, P = 0.013) and per-protocol (30% versus 56%, P = 0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, P = 0.007) and tissue-healing complications (16% versus 31%, P = 0.04) were significantly reduced. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P = 0.12). No harmful adverse effects were observed. CONCLUSION The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection.
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Affiliation(s)
- Birgitte Brandstrup
- Clinical Unit of Preventive Medicine and Health Promotion, H:S Bispebjerg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark.
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Boldt J. New Light on Intravascular Volume Replacement Regimens: What Did We Learn from the Past Three Years? Anesth Analg 2003; 97:1595-1604. [PMID: 14633526 DOI: 10.1213/01.ane.0000089961.15975.78] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Definition of the "ideal" intravascular fluid volume replacement strategy still remains a critical problem. This article analyzes studies on volume replacement by using a MEDLINE search of the past 3 years (from January 1, 2000, to December 12, 2002). Forty original studies in humans with a total of 2454 subjects were identified. Five studies were performed in volunteers (n = 113); the other 35 studies (n = 2341) were performed in a variety of patients (e.g., cardiac surgery, trauma patients, children, and intensive care unit patients). The influence of different volume replacement regimens on coagulation was one of the major topics of interest (16 studies with 1183 subjects), and other studies focused on metabolic state, alterations in macro- and microcirculation, volume distribution, and organ function (e.g., kidney function and splanchnic perfusion). Among all synthetic colloids, hydroxyethyl starch (HES) was the solution most often studied. Two new HES preparations have been approved (Hextend), a balanced hetastarch solution, and a new third-generation HES [130/0.4]). Only two studies used albumin, and no superiority of albumin was found over less expensive synthetic colloids. In almost all studies, the outcome either was no end-point or was not reported. Volume replacement has often been hitherto based on dogma and personal beliefs. Future well performed studies in this area will hopefully help to shed new light on the ideal volume replacement strategy. IMPLICATIONS By using a MEDLINE search covering the last 3 yr, the present knowledge on volume replacement regimens was analyzed. Forty studies in humans were identified. New hydroxyethyl starch preparations have shed light on this topic, whereas no additional data supporting the use of albumin have been presented.
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Affiliation(s)
- Joachim Boldt
- Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany
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Abstract
Fluid resuscitation is an essential part of managing patients with major trauma, as well as in the perioperative setting. Common misconceptions exist regarding the role of fluid therapy in maintaining, enhancing or inhibiting normal coagulation and haemostasis. This review provides an overview of the basic coagulation processes, as well as the influence of intravenous crystalloid and colloid preparations on haemostasis and coagulation. The use of point-of-care devices is encouraged as a feasible way of monitoring these effects in the acute setting.
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Affiliation(s)
- Anthony M Roche
- Department of Anesthesiology, Duke University Medical Center, Durham, USA,
| | - Michael FM James
- Department of Anaesthesia, University of Cape Town, Cape Town, South Africa
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Ruttmann TG, Roche AM, Gasson J, James MFM. The effects of a one unit blood donation on auto-haemodilution and coagulation. Anaesth Intensive Care 2003; 31:40-3. [PMID: 12635393 DOI: 10.1177/0310057x0303100107] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The effect of haemodilution on coagulation has been extensively investigated. We investigated auto-haemodilution following a 10% blood loss (480 ml) and its effect on coagulation. Ten healthy, unstarved volunteers were enrolled. One unit of blood was taken from each volunteer. Concurrently blood was taken from the opposite arm prior to and immediately after the blood donation, and at 1, 2, 4 and 6 hours. It was tested for thrombelastography, haematocrit and endorphins. There was a significant decrease in r-time from the control sample to the sample taken immediately post blood donation. This value returned to baseline at 1 hour post donation and did not change again. There were no other significant changes in thromboelastographic parameters. Fractional plasma noradrenaline changes were significantly raised at 1 hour post donation (P = 0.048), returning to baseline by 2 hours post donation. The haematocrit showed a rapid (approximately 4%) fall during donation followed by a slow, but progressive decrease over six hours, falling by a mean of 8.3% from pre-donation values. A state of relative hypercoagulability is found immediately after a rapid 10% loss in circulating blood volume. This may be related to the rapid immediate haemodilution. It is unlikely that the sympathetic response to blood loss plays a role. However, after the initial drop, slow restoration of circulating blood volume by autodilution takes six to eight hours, and is not associated with enhanced coagulation. Of interest is that a 10% blood loss in a healthy person does not require volume replacement.
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Affiliation(s)
- T G Ruttmann
- Western Province Blood Transfusion Service, Pinelands, Cape Town, South Africa
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Boldt J. New Light on Volume Therapy in the Critically Ill? Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Innerhofer P, Fries D, Klingler A, Streif W. In vivo effect of haemodilution with saline on coagulation. Br J Anaesth 2002; 89:934; author reply 934-6. [PMID: 12453943 DOI: 10.1093/bja/aef574] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ekseth K, Abildgaard L, Vegfors M, Berg-Johnsen J, Engdahl O. The in vitro effects of crystalloids and colloids on coagulation. Anaesthesia 2002; 57:1102-8. [PMID: 12428635 DOI: 10.1046/j.1365-2044.2002.02782_1.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Classically haemodilution is regarded as causing coagulopathy. However, haemodilution with saline seems to cause a hypercoagulable state both in vivo and in vitro. The aim of the present study was to measure the effect of mild to severe haemodilution using thrombelastography. Blood samples were taken in 12 healthy volunteers and divided into seven aliquots. One aliquot was undiluted and acted as control. The other six were diluted with normal saline, Ringer Acetate, 4% albumin, Dextran 70, 6% and 10% hydroxyethylstarch to 10%, 20%, 40%, 50% and 60% dilution. The dilution was checked by measuring the haemoglobin concentration. Each aliquot was placed in a temperature-controlled thrombelastography channel. Increased coagulation activity, as measured by thrombelastography changes, was detected at low and medium levels of dilution with all the tested solutions. At more than 40% dilution, coagulation returned to normal while in the case of dextran and hydroxyethylstarch coagulopathy developed. For crystalloids and albumin,dilution had to exceed 50% before coagulation was impaired. If these findings can be reproduced in vivo, they may have implications for transfusion practice and prophylaxis against thrombosis.
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Affiliation(s)
- K Ekseth
- Department of Neurosurgery, The National Hospital, Oslo, Norway.
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Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002; 89:622-32. [PMID: 12393365 DOI: 10.1093/bja/aef220] [Citation(s) in RCA: 408] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- K Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark
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Ruttmann TG, James MFM, Finlayson J. Effects on coagulation of intravenous crystalloid or colloid in patients undergoing peripheral vascular surgery. Br J Anaesth 2002; 89:226-30. [PMID: 12378657 DOI: 10.1093/bja/aef179] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study investigated whether haemodilution-enhanced coagulation can be demonstrated under regional anaesthesia, whether this occurs before surgery, and whether the fluid used influences the effect. METHODS Patients were randomly allocated to receive either crystalloid or colloid intravenous fluid. An epidural was administered. Samples of venous blood were taken before fluid administration, after completion of the epidural and initial fluid load, during surgery before heparin, and after 24 h. Thrombelastograph analysis was performed, and full blood count, international normalised ratio, activated partial thromboplastin time, D-dimers and thrombin-antithrombin complex were measured. RESULTS In the crystalloid group, enhanced coagulation compared with baseline was demonstrated after initial fluid load (mean (SD) r-time 10.1 (4.9) min; P < 0.033; k-time 3.5 (1.7) min; P < 0.01; alpha-angle 54.9 (13.9) degrees; P < 0.01) and before heparin administration (r-time 8.8 (3.9) min; P < 0.01; alpha-angle 54.9 (12.6) degrees; P < 0.02). There was no enhancement of coagulation in the colloid group. There were no changes from baseline after 24 h. CONCLUSIONS This study confirms that the enhanced perioperative coagulation mechanism is related to dilution, rather than surgery, and is triggered by rapid crystalloid haemodilution. Consideration should be given to the use of colloid rather than crystalloid solutions for rapid fluid loading in vasculopathic patients undergoing surgery.
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Affiliation(s)
- T G Ruttmann
- Department of Anaesthesia, University of Cape Town, Medical School, Observatory, Cape 7925, South Africa
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Martin G, Bennett-Guerrero E, Wakeling H, Mythen MG, el-Moalem H, Robertson K, Kucmeroski D, Gan TJ. A prospective, randomized comparison of thromboelastographic coagulation profile in patients receiving lactated Ringer's solution, 6% hetastarch in a balanced-saline vehicle, or 6% hetastarch in saline during major surgery. J Cardiothorac Vasc Anesth 2002; 16:441-6. [PMID: 12154422 DOI: 10.1053/jcan.2002.125146] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the effects of lactated Ringer's solution (LR), 6% hetastarch in a balanced-saline vehicle (HS-BS), and 6% hetastarch in normal saline (HS-NS) on coagulation using thromboelastography. DESIGN Prospective, randomized double-blinded evaluation of previously published clinical trial. SETTING Tertiary-care medical center. PARTICIPANTS Patients undergoing elective noncardiac surgery with an anticipated blood loss >500 mL. A total of 90 patients were enrolled with 30 patients in each group. INTERVENTIONS Patients received a standardized anesthetic. LR, HS-BS, and HS-NS were administered intraoperatively based on a fluid administration algorithm. Hemodynamic targets included maintenance of arterial blood pressure, heart rate, and urine output within a predefined range. MEASUREMENTS AND MAIN RESULTS Thromboelastography variables for r time, k time, maximum amplitude, and alpha angle (mean +/- SD) were recorded at induction of anesthesia, at the end of surgery, and 24 hours postoperatively. Patients in the LR group showed a state of hypercoagulation at the end of surgery with reductions (p < 0.005) in r time (-3.8 +/- 6.7 mm) and k time (-1.7 +/- 2.5 mm). This state of hypercoagulation continued into the postoperative period. Patients in the HS-NS group showed a state of hypocoagulation with increases (p < 0.05) in r time (+6.2 +/- 8.5 mm) and k time (+1.7 +/- 3.9 mm) and a reduction in maximum amplitude (-8.0 +/- 9.8 mm) at the end of surgery. This state of hypocoagulation was reduced in the postoperative period. Patients in the HS-BS group showed no significant changes in coagulation status at end of surgery, with the smallest changes in r time (-0.3 +/- 4.1 mm), k time (+0.1 +/- 3.1 mm), maximum amplitude (-5.4 +/- 12.3 mm), and alpha angle (0.3 +/- 12.5 degrees ). CONCLUSION LR-treated patients exhibited a hypercoagulative profile that persisted into the postoperative period. HS-BS administration was associated with a lesser change in the coagulation profile compared with HS-NS, which was associated with a hypocoagulative state.
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Affiliation(s)
- G Martin
- Department of Anesthesiology, and Division of Biometry, Duke University Medical Center, Durham, NC 27710, USA
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Boldt J, Haisch G, Suttner S, Kumle B, Schellhase F. Are lactated Ringer's solution and normal saline solution equal with regard to coagulation? Anesth Analg 2002; 94:378-84, table of contents. [PMID: 11812703 DOI: 10.1097/00000539-200202000-00028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Crystalloids represent an attractive strategy to alleviate intravascular volume deficits. Crystalloid hemodilution was associated with hypercoagulability in in vitro and in vivo studies. The influence of different crystalloids on coagulation in the surgical patient is not well studied. In a prospective, randomized study in patients undergoing major abdominal surgery, we used either lactated Ringer's solution (RL) (n = 21) or 0.9% saline solution (SS) (n = 21) exclusively for intravascular volume replacement over 48 h to maintain central venous pressure between 8 and 12 mm Hg. Activated thrombelastography (TEG) using different activators (intrinsic TEG, extrinsic TEG, heparinase TEG, aprotinin TEG) was used to measure coagulation time, clot formation time, and maximum clot firmness. Measurements were performed after induction of anesthesia (T0), immediately after surgery (T1), 5 h after surgery (T2), and on the morning of the first (T3) and second (T4) postoperative days. RL 18,750 +/- 1890 mL and 17,990 +/- 1790 mL of SS were infused during the study period. Acidosis was seen only in the SS-treated group. Blood loss was not different between the groups. Fibrinogen and antithrombin III decreased similarly at T1 and T2 in both groups, most likely because of hemodilution. Differences in TEG data from normal baseline were seen only immediately after surgery and 5 h thereafter, indicating mild hypercoagulability in the intrinsic TEG (RL, from 147 +/- 130 s to 130 +/- 11 s; SS, from 146 +/- 12 s to 131 +/- 12 s). There were no differences in coagulation between RL- and SS-treated patients. We conclude that in major abdominal surgery intravascular volume replacement with crystalloids resulted in only moderate and abbreviated changes in coagulation. No differences in activated TEG and blood loss were seen between an RL- and an SS-based intravascular volume replacement regimen. IMPLICATIONS In 42 patients undergoing major abdominal surgery, either lactated Ringer's solution or 0.9% saline solution were exclusively used for volume therapy for 48 h. Activated thrombelastography revealed some mild hypercoagulability after surgery. No differences in coagulation were seen between the two intravascular volume replacement strategies.
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Affiliation(s)
- Joachim Boldt
- Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.
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Wilson D, Cooke EA, McNally MA, Wilson HK, Yeates A, Mollan RA. Changes in coagulability as measured by thrombelastography following surgery for proximal femoral fracture. Injury 2001; 32:765-70. [PMID: 11754883 DOI: 10.1016/s0020-1383(01)00139-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The effect of surgery for femoral neck fracture on whole blood coagulation and the relationship of altered coagulation to deep venous thrombosis were investigated in 250 patients. Whole blood coagulation was measured using thrombelastography preoperatively, in the early postoperative period and at 6-week review. Significant hypercoagulability was demonstrated after surgery and persisted to 6-week review. A significant correlation between hypercoagulability and the development of deep venous thrombosis is demonstrated. Hypercoagulability is shown to be a major factor in thrombosis formation following proximal femoral neck fracture surgery.
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Affiliation(s)
- D Wilson
- Department of Orthopaedic Surgery, Musgrave Park Hospital, Stockman's Lane, BT97JB, Belfast, UK.
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Ruttmann TG, Jamest MF, Lombard EH. Haemodilution-induced enhancement of coagulation is attenuated in vitro by restoring antithrombin III to pre-dilution concentrations. Anaesth Intensive Care 2001; 29:489-93. [PMID: 11669429 DOI: 10.1177/0310057x0102900507] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Moderate haemodilution enhances coagulability in vitro and in vivo as measured by thrombelastography (TEG). The mechanism has never been established. We have conducted an in vitro study to determine whether the effect can be moderated or prevented when the reduction in antithrombin III caused by dilution is prevented by supplementation. Blood from 20 volunteers was divided into four samples. One sample was not diluted and served as control (C). Another was diluted (by 20%) with saline (S). The third was diluted by 20% with saline plus two units of antithrombin (AT III) (SA). The fourth remained undiluted, with two units of added AT III (CA). Coagulation was measured in all four samples using the TEG. In a separate laboratory study, the levels of AT III were measured in control samples and compared with levels after 20% dilution, and 20% dilution with two units of AT III added to the diluent. Enhanced coagulation was demonstrated in saline-diluted samples (S) by shortening of r- and k-times, and increased alpha angle. In the SA samples, r-time shortening was prevented; k-time shortening and alpha-angle increase persisted, but to a reduced degree (difference from saline-only dilution P<0.051). There were no differences between samples C and CA. A predictable drop of AT III (24.2%) occurred with saline dilution, while AT III levels in the AT III/Saline group were similar to the undiluted control. Haemodilution-induced coagulation enhancement is attenuated, but not prevented, if AT III levels are maintained in the normal range. This is in keeping with the established concept of an antithrombin threshold preventing positive coagulation feedback into the intrinsic pathway.
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Affiliation(s)
- T G Ruttmann
- Department of Anaesthesia and Haematology, University of Cape Town, South Africa
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Abstract
There is no standard or official recipe for the tumescent anesthetic solutions. The actual concentrations of lidocaine and epinephrine should depend on the areas to be treated and clinical situation. This article discusses the safe usage of tumescent solutions and the proper procedures and precautions to take when mixing these solutions.
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Jamnicki M, Zollinger A, Seifert B, Popovic D, Pasch T, Spahn DR. Compromised blood coagulation: an in vitro comparison of hydroxyethyl starch 130/0.4 and hydroxyethyl starch 200/0.5 using thrombelastography. Anesth Analg 1998; 87:989-93. [PMID: 9806670 DOI: 10.1097/00000539-199811000-00002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We compared the effects of progressive in vitro hemodilution (30% and 60%) on blood coagulation in 80 patients receiving one of two different 6% hydroxyethyl starch (HES) solutions using thrombelastography (TEG). The newly developed solution has a mean molecular weight of 130 kD and a degree of substitution, defined as the average number of hydroxyethyl groups per glucose moiety, of 0.4 (HES 130/0.4); the conventional solution has a mean molecular weight of 200 kD and a degree of substitution of 0.5 (HES 200/0.5). Both HES solutions significantly compromised blood coagulation, as seen by an increase in reaction time and coagulation time and a decrease in angle alpha, maximal amplitude, and coagulation index (all P < 0.05). There was no difference between HES 130/0.4 and HES 200/0.5 diluted blood (P > 0.05 for all TEG variables). When analyzing the intrinsic HES effect by taking hemodilution with 0.9% saline into account, progressive hemodilution with both HES solutions resulted in an increasing clot lysis (P < 0.05 after 60 min). Again, there was no difference between HES 130/0.4 and HES 200/0.5 diluted blood. We conclude that HES 130/ 0.4 and HES 200/0.5 compromise blood coagulation to the same degree. IMPLICATIONS Progressive in vitro hemodilution using hydroxyethyl starch (HES) compromises blood coagulation. We observed similar effects of a new HES solution with a mean molecular weight of 130 kD and a degree of substitution of 0.4 (HES 130/0.4), compared with the conventional HES 200/0.5.
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Affiliation(s)
- M Jamnicki
- Institute of Anesthesiology, University Hospital, Zurich, Switzerland
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Tobias MD, Wambold D, Pilla MA, Greer F. Differential effects of serial hemodilution with hydroxyethyl starch, albumin, and 0.9% saline on whole blood coagulation. J Clin Anesth 1998; 10:366-71. [PMID: 9702614 DOI: 10.1016/s0952-8180(98)00034-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVES To determine by thrombelastography assessed coagulation, the effects of progressive hemodilution with three intravascular volume expanders. DESIGN Prospective, controlled, whole blood, volumetric ex vivo hemodilution study. SETTING University of Pennsylvania Medical Center Operating Rooms. PATIENTS 60 ASA physical status I and II patients; phlebotomy prior to administration of IV fluids or medications. INTERVENTIONS Analysis of whole blood clotting determined by six thrombelastographic channels for control and five volumetric hemodilutions (11%, 25%, 33%, 50%, and 75%) with 0.9% saline, 5% albumin, and 6% hydroxyethyl starch (n = 20 for each diluent group). MEASUREMENTS AND MAIN RESULTS Thrombelastographic parameters R (minutes), angle alpha (degree), MA (mm), and lysis (%) were measured and compared to the sample control for each dilution of the same specimen. There was no significant difference between control groups in any thrombelastographic variable (R, angle alpha, MA, or lysis). No changes were seen in any variable from any diluent at 11% hemodilution. Seventy-five percent hemodilution caused significantly hypocoagulable changes from control for all thrombelastographic parameters for all three diluents. Thrombelastographic indices differed significantly from controls at intermediate hemodilutions. Both colloids caused decreases in measured angle alpha and MA at lower hemodilution than did 0.9% saline. Albumin 5% caused significant hypocoagulable changes from control values at lower hemodilution than did either 0.9% saline or 6% hydroxyethyl starch for all thrombelastographic parameters. Saline 0.9% increased angle alpha significantly at 50% hemodilution. Abnormal lysis did not occur at any dilution. Differing ex vivo effects of three different intravascular fluids thrombelastography assessed coagulation are found. CONCLUSION No differences were found after 11% hemodilution with any volume expanders. Hemodilution with up to 50% saline maintained thrombelastographic indices. Albumin produced early and profound hypocoagulable effects. Significant hypocoagulability occurred for all three diluents at 75% hemodilution. The study supports the use of albumin in patients at risk for thrombosis, and saline in patients with a need for normal hemostasis.
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Affiliation(s)
- M D Tobias
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia 19102, USA
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Jamnicki M, Zollinger A, Seifert B, Popovic D, Pasch T, Spahn DR. The effect of potato starch derived and corn starch derived hydroxyethyl starch on in vitro blood coagulation. Anaesthesia 1998; 53:638-44. [PMID: 9771171 DOI: 10.1046/j.1365-2044.1998.489-az0565.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We have compared the effects of progressive in vitro haemodilution (30% and 60%) with potato starch derived hydroxyethyl starch and corn starch derived hydroxyethyl starch on blood coagulation in 80 patients using thrombelastography. Both solutions significantly compromised blood coagulation as evidenced by an increase in coagulation time and decrease in angle alpha, maximum amplitude and coagulation index (p < 0.05). Blood coagulation was more compromised during haemodilution with potato starch derived hydroxyethyl starch as compared with corn starch derived hydroxyethyl starch (p < 0.05). When taking the effect of haemodilution with 0.9% saline into account, haemodilution with both hydroxyethyl starch solutions also augmented clot lysis (p < 0.05), with potato starch derived hydroxyethyl starch having a greater effect than corn starch derived hydroxyethyl starch (p < 0.05). We conclude that potato starch derived hydroxyethyl starch compromises in vitro blood coagulation more than corn starch derived hydroxyethyl starch.
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Affiliation(s)
- M Jamnicki
- Institute of Anaesthesiology, University Hospital, Zurich, Switzerland
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Chen HC, Wiek J, Gupta A, Luckie A, Kohner EM. Effect of isovolaemic haemodilution on visual outcome in branch retinal vein occlusion. Br J Ophthalmol 1998; 82:162-7. [PMID: 9613383 PMCID: PMC1722474 DOI: 10.1136/bjo.82.2.162] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To assess the efficacy of isovolaemic haemodilution therapy (IHT) in the treatment of patients with branch retinal vein occlusion (BRVO). METHODS Patients presenting with BRVO between 1 July 1991 and 31 August 1993 were eligible for inclusion and randomised into treatment and control groups. Patients randomised to receive IHT were treated for 6 weeks with venesection and volume replacement using hydroxyethylstarch, a plasma expander. The target haematocrit was 35%. Follow up was for 1 year. RESULTS The baseline visual acuity of the two groups was similar at 0.74 and 0.75 logMAR units (Snellen 6/36), for the IHT and control groups, respectively. At 6 weeks, visual acuity in the IHT group had improved by 0.20 logMAR units (2 lines on the Bailey-Lovie chart) (p = 0.0001). Vision was unchanged in the control group. At 1 year, the IHT group exhibited an improvement of 0.43 logMAR units. By comparison, the improvement in the control group at 1 year was significantly less at 0.17 logMAR units (p = 0.03). The final visual acuity in the IHT and control groups was 0.30 (Snellen 6/12) and 0.60 (Snellen 6/24) logMAR units, respectively. CONCLUSIONS The results support the theory that IHT has a positive effect on the visual outcome in patients with BRVO.
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Affiliation(s)
- H C Chen
- Royal Postgraduate Medical School, Hammersmith Hospital, London
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AN AUTHOR'S REPLY TO A REVIEW. Plast Reconstr Surg 1997. [DOI: 10.1097/00006534-199704000-00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
To provide an overview of current knowledge, this article reviews experimental and clinical data from investigations examining effects of regional anesthesia on perioperative morbidity in specific physiologic systems. The issues of morbidity and mortality following general and regional anesthesia are addressed, as are the development of perioperative thromboembolism and blood loss, which are known to be increased during general anesthesia. Finally, the effects of regional anesthesia on the vascular system, the perioperative stress response, and the pulmonary function are discussed.
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Affiliation(s)
- P G Atanassoff
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510-8051, USA
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Abd Rabbo S. Early oral hydration: a novel regimen for management after elective cesarean section. JOURNAL OF OBSTETRICS AND GYNAECOLOGY (TOKYO, JAPAN) 1995; 21:563-7. [PMID: 8640466 DOI: 10.1111/j.1447-0756.1995.tb00913.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To compare early oral hydration versus the conventional intravenous fluid replacement after elective cesarean section. METHODS Two hundred women performed elective cesarean section were selected and randomized to: Regimen I (n = 100): early oral hydration (sips of fruit juices sweetened with honey once the women felt thirst immediately after the operation, then solid food 24 hours later, the amounts of juice or food were determined by the patient herself, i.e. she would regulate her physiological needs) versus regimen II (n = 100): conventional intravenous hydration (2-3 L of dextrose saline/24 hours and solid food thereafter). Biochemical, metabolic values, postoperative nausea and vomiting, propulsive bowel movements, tolerance of solid food, hospital stay and successful continuation of breast feeding were compared in both groups. RESULTS The two regimens were equally effective in maintaining fluid balance and normal plasma and urinary electrolytes without any observed differences in biochemical or metabolic values. The return of bowel sounds, first occurrence of flatus and tolerance of solid food were achieved in regimen I at time periods significantly shorter than those attained with regimen II (p < 0.0001). The incidence of nausea and vomiting, ileus and deep vein thrombosis was higher in regimen II than in regimen I but the difference is statistically insignificant (p > 0.05). Patients in regimen II were hospitalized for significantly longer times than those on regimen I (p < 0.0001). Successful continuation of breast feeding was significantly more in regimen I than in regimen II (p < 0.01). CONCLUSION Early oral hydration after elective cesarean section effectively maintained fluid balance and it was associated with rapid return of propulsive bowel movements, successful breast feeding, less side effects and shorter hospital stay than the conventional intravenous hydration. So, it should be used in most cases after elective cesarean section.
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Affiliation(s)
- S Abd Rabbo
- Department of Obstetrics and Gynecology, Shatby Maternity University Hospital, Alexandria University, Egypt
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Coleridge Smith PD, Hasty JH, Scurr JH. Deep vein thrombosis: effect of graduated compression stockings on distension of the deep veins of the calf. Br J Surg 1991; 78:724-6. [PMID: 2070243 DOI: 10.1002/bjs.1800780628] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The mechanisms by which graduated compression stockings prevent deep vein thrombosis are not completely understood. Recent work has suggested that venous distension plays a role in initiating the process. Our previous work has shown that the deep veins of the lower limb distend in patients undergoing surgical procedures. We have investigated 40 patients receiving surgical treatment on the abdomen or neck. A medial gastrocnemius vein was studied using ultrasound imaging during the operations. In half the patients a graduated compression anti-embolism stocking was applied to the limb under study at the start of the operation, immediately after initial measurements of vein diameter. The median vein diameter in both groups was the same at the start of the operative procedures (control, 2.6 mm, interquartile range 2.1-3.3 mm; stocking, 2.6 mm, interquartile range 2.1-3.7 mm). After application of a stocking the median diameter in this group fell to 1.6 mm (interquartile range 1.3-2.8 mm) and then decreased slightly at the end of the operation. In the control group the vein diameter increased to 2.9 mm (interquartile range 2.3-4.0 mm) during the operative procedure.
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Affiliation(s)
- P D Coleridge Smith
- Department of Surgery, University College, Middlesex School of Medicine, Middlesex Hospital, London, UK
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Abstract
The mechanisms underlying the development of postoperative deep vein thrombosis remain to be fully elucidated. Previous studies have suggested that peroperative venous distension may be a factor associated with venous thromboembolism. In this study we have obtained high resolution ultrasound images of gastrocnemius and posterior tibial veins in 62 patients undergoing a range of general surgical procedures. From these we determined the changes in vein diameter occurring during the operative procedures, in response to induction of anaesthesia, and after completion of surgery. Veins showed no evidence of dilatation in response to the induction of anaesthesia, but by the end of the operative procedure showed distension of 22-28 per cent. Distension was most prominent in the gastrocnemius veins, and lesser distension was observed in the posterior tibial veins. In a series of patients who received an infusion of 1 litre of saline in addition to basal requirements, distension was 57 per cent compared with 22 per cent in the corresponding control group. Intraoperative venous distension is associated with factors that lead to deep vein thrombosis and may be involved in the mechanisms which result in the commencement of deep vein thrombosis.
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Affiliation(s)
- P D Coleridge-Smith
- Department of Surgery, University College and Middlesex School of Medicine, UK
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Abstract
Traditionally, blood rheology tests have been used in diagnosis and monitoring of infection, rheumatic diseases and malignancy, and are still of clinical value in these conditions. In the last twenty years, clinical and epidemiological studies have shown that the haematological determinants of blood flow resistance (haematocrit, fibrinogen, white cell count and altered red and white cell rigidity) are also associated with nutritional, metabolic, endocrine and vascular disorders. Decreased red cell deformability may contribute to reduced red cell survival and anaemia in burns, malaria, liver disease and kidney failure. In trauma and inflammatory disease, overt hyperviscosity is usually prevented by vasodilatation and reduction in the haematocrit. However, low-flow states may arise systemically from haemoconcentration (contracted plasma volume, Chapter 3) in severe burns, inappropriate red cell transfusion, or dehydration due to illness; systemically in circulatory shock; and locally in venous thrombosis or arterial disease. In such circumstances, the intrinsic flow resistance of blood may perpetuate flow disturbance, ischaemia and thrombosis. Conversely, optimal levels of haematocrit, fibrinogen and white cell count may be lower than normal in low-flow states. Haemodilution by colloid infusion is beneficial in burns, shock, major surgery, prevention of postoperative venous thrombosis, chronic stable claudication and possibly in acute stroke and retinal vein thrombosis. Plasma exchange may be beneficial in severe Raynaud's phenomenon. Defibrination with ancrod is effective in prevention and treatment of venous thrombosis but its role in arterial disease is unproven. The benefits of streptokinase therapy in venous thrombo-embolism and acute myocardial infarction may be partly rheological, due to fibrinogen depletion. Drugs with rheological effects may be beneficial in intermittent claudication.
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