Fluid Therapy in Sepsis. In: Reinhart K, Eyrich K, Sprung C, editors. Sepsis. Berlin: Springer Berlin Heidelberg; 1994. pp. 266-73. [DOI: 10.1007/978-3-642-85036-3_21]

Audit of preoperative fluid resuscitation in perforation peritonitis patients using Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity

Context:

Debate continues regarding fluid (crystalloid vs. colloid) of choice for resuscitation. Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) may be used to compare the benefits of preoperative fluid resuscitation with crystalloids and colloids in peritonitis patients.

Aims:

The aim of this study is to compare crystalloid and colloid for preoperative resuscitation using morbidity, mortality, length of hospital stay (LOS), and time taken to resuscitate as the outcome parameters.

Settings and Design:

This was a prospective randomized clinical trial.

Subjects and Methods:

One hundred and seven peritonitis patients were prospectively randomized to fluid resuscitation by crystalloid (Group A) and colloid (Group B) solutions. Physiological score component of POSSUM was recorded before and after fluid resuscitation; operative score component was recorded at discharge/death. These scores were then used to calculate the predicted morbidity and mortality before and after the fluid resuscitation.

Statistical Analysis Used:

Effect on morbidity and mortality were compared by repeated measure analysis of variance, and its significance was tested by Tukey's test. LOS and time taken to resuscitate were compared using unpaired t-test. Significance was taken at 5%.

Results:

Fluid resuscitation improved mean predicted morbidity by 0.095 and 0.137 in Group A and Group B, respectively. Similarly, fluid resuscitation improved predicted mortality by 0.145 and 0.185 in Group A and Group B, respectively. These changes were statistically significant. Improvement in morbidity and mortality appeared greater in Group B. No difference was found in the two groups for LOS and time to resuscitate.

Conclusions:

Preoperative fluid resuscitation using either crystalloid or colloidal solutions decreases morbidity as well as mortality in peritonitis patients.

Volume replacement strategies on intensive care units: results from a postal survey

OBJECTIVE

To assess volume replacement strategies on intensive care units (ICUs) in Germany.

DESIGN

A postal survey questionnaire of 18 questions was sent to 451 ICUs in Germany. The questionnaire was sent to general, surgical, anesthesiology, neurosurgery, cardiac surgery, and medical ICUs of hospital with more than 200 beds.

RESULTS

286 questionnaires (64%) were returned and analysed. Hydroxyethylstarch (HES) solution is the solution most often used for volume replacement (total: 193 ICUs, exclusively HES: 93 ICUs), crystalloids are next (crystalloids exclusively: 61 ICUs), and human albumin is used rarely as a first choice. Clinical experience is a very important argument for administering volume. Diagnostic tools, e.g. measurement of central venous pressure or pulmonary capillary wedge pressure, also play an important role. Albumin/total protein and colloid osmotic pressure (COP) are measured often on ICUs (albumin measured routinely: 173 ICUs; COP measured routinely: 33 ICUs). Critical values for albumin/total protein are defined in most ICUs. Reduced plasma levels of albumin/total protein was the indication most often cited for administering human albumin. Only 149 ICUs (52%) have a financial budget for their unit. Costs still do not play a major role in the choice of volume replacement on 30 ICUs (10%).

CONCLUSIONS

The kind of volume therapy differs widely among the different ICUs. This questionnaire supported the supposition that no standards exist for volume therapy in intensive care patients. New results concerning the abuse of albumin in the critically ill have not yet influenced strategies of volume replacement.

Influence of different volume therapies on platelet function in the critically ill

OBJECTIVE

Both albumin and synthetic colloids such as hydroxyethyl starch (HES) solution are used to optimize hemodynamics in the critically ill. The influence of different long-term infusion regimes on platelet function was studied.

DESIGN

Prospective, randomized study.

SETTING

Clinical investigation on a university hospital surgical intensive care unit.

PATIENTS

Twenty-eight consecutive trauma patients (injury severity score > 15 points) and 28 consecutive nontraumatized surgical patients with sepsis.

INTERVENTIONS

The patients received either 20% human albumin (HA trauma, n = 14; HA sepsis, n = 14) or 10% low-molecular-weight HES solution HES 200/0.5 (HES trauma, n = 14; HES sepsis; n = 14) for 5 days to maintain central venous pressure and/or pulmonary capillary wedge pressure between 12 and 16 mmHg.

MEASUREMENTS AND RESULTS

Platelet function was assessed by aggregometry (= turbidimetric technique) using adenosine diphosphate 2.0 mumol/l, collagen 4 microliters/ml, and epinephrine 25 mumol/l as inductors. Arterial blood was sampled on the day of admission or the day of diagnosis of sepsis (= baseline value) and over the next 5 days. Standard coagulation parameters (antithrombin III, fibrinogen, partial thromboplastin time) were also measured. Total use of HES by the 5th day totalled 4870 +/- 990 ml in the trauma and 3260 +/- 790 ml in the sepsis patients (HA trauma: 1850 +/- 380 ml; HA sepsis: 1790 +/- 400 ml). Maximum platelet aggregation decreased significantly during the first 2-3 days after baseline in all groups. At the end of the investigation period, platelet aggregation variables had recovered and reached (or even exceeded) baseline values. Within the entire investigation period, the course of platelet aggregation variables did not differ significantly between HA and HES-treated patients irrespective of whether they were trauma or sepsis patients.

CONCLUSIONS

Alterations in hemostasis may occur for several reasons in the critically ill. Human albumin is the preferred first-line volume therapy in patients at risk for coagulation disorders. With respect to platelet function, volume replacement with (lower-priced) low-molecular-weight HES solutions can be recommended in this situation without any risk.