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Vlasov H, Wilkman E, Petäjä L, Suojaranta R, Hiippala S, Tolonen H, Jormalainen M, Raivio P, Juvonen T, Pesonen E. Comparison of 4% Albumin and Ringer's Acetate on Hemodynamics in On-pump Cardiac Surgery: An Exploratory Analysis of a Randomized Clinical Trial. J Cardiothorac Vasc Anesth 2024; 38:2269-2277. [PMID: 39098542 DOI: 10.1053/j.jvca.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES Compare hemodynamics between 4% albumin and Ringer's acetate. DESIGN Exploratory analysis of the double-blind randomized ALBumin In Cardiac Surgery trial. SETTING Single-center study in Helsinki University Hospital. PARTICIPANTS We included 1,386 on-pump cardiac surgical patients. INTERVENTION We used 4% albumin or Ringer's acetate administration for cardiopulmonary bypass priming, volume replacement intraoperatively and 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS Hypotension (time-weighted average mean arterial pressure of <65 mmHg) and hyperlactatemia (time-weighted average blood lactate of >2 mmol/L) incidences were compared between trial groups in the operating room (OR), and early (0-6 hours) and late (6-24 hours) postoperatively. Associations of hypotension and hyperlactatemia with the ALBumin In Cardiac Surgery primary outcome (≥1 major adverse event [MAE]) were studied. In these time intervals, hypotension occurred in 118, 48, and 17 patients, and hyperlactatemia in 313, 131, and 83 patients. Hypotension and hyperlactatemia associated with MAE occurrence. Hypotension did not differ between the groups (albumin vs Ringer's: OR, 8.8% vs 8.5%; early postoperatively, 2.7% vs 4.2%; late postoperatively, 1.2% vs 1.3%; all p > 0.05). In the albumin group, hyperlactatemia was less frequent late postoperatively (2.9% vs 9.1%; p < 0.001), but not earlier (OR, 22.4% vs 23.6%; early postoperatively, 7.9% vs 11.0%; both p > 0.025 after Bonferroni-Holm correction). CONCLUSIONS In on-pump cardiac surgery, hypotension and hyperlactatemia are associated with the occurrence of ≥1 MAE. Compared with Ringer's acetate, albumin did not decrease hypotension and decreased hyperlactatemia only late postoperatively. Albumin's modest hemodynamic effect is concordant with the finding of no difference in MAEs between albumin and Ringer's acetate in the ALBumin In Cardiac Surgery trial.
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Affiliation(s)
- Hanna Vlasov
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Erika Wilkman
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Petäjä
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raili Suojaranta
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Seppo Hiippala
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Tolonen
- HUS Pharmacy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Jormalainen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Peter Raivio
- HUS Pharmacy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tatu Juvonen
- HUS Pharmacy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eero Pesonen
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Chen SD, Ma YT, Wei HX, Ou XR, Liu JY, Tian YL, Zhang C, Xu YJ, Kong Y. Use of colloids and crystalloids for perioperative clinical infusion management in cardiac surgery patients and postoperative outcomes: a meta-analysis. Perioper Med (Lond) 2024; 13:83. [PMID: 39049111 PMCID: PMC11267693 DOI: 10.1186/s13741-024-00445-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 07/22/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND The optimal fluid management strategy for patients undergoing cardiac surgery was controversial regarding fluid volume and intraoperative fluid types. This study aimed to assess the correlation between colloids and crystalloids used for perioperative fluid therapy in cardiac surgery patients and postoperative prognosis. METHODS The Ovid MEDLINE(R) ALL, Embase, and Cochrane Central Register of Controlled Trials databases were searched for eligible studies on fluid management strategies using colloids and crystalloids for cardiac surgery patients published before August 25th, 2023. RESULTS Ten randomized controlled trials met the eligibility criteria. Compared to the use of crystalloids, the use of colloids, including hydroxyethyl starch (HES), albumin, and gelatine, did not show any differences in mortality, transfusion, acute kidney injury, and atrial fibrillation rates, postoperative blood loss, the length of hospital stay, or the length of intensive care unit (ICU) stay. The results of this meta-analysis showed that the crystalloid group had significantly reduced postoperative chest tube output compared to the colloid group. In the subgroup analysis, the amount of fresh frozen plasma (FFP) infused was significantly lower when using fluid management in the ICU and when using isotonic crystalloids compared to the colloids. In addition, when using fluid management in the ICU, patients in the colloid group had a significant increase in urine volume 24 h after surgery. However, other related factors, including the type of crystalloid solution, type of colloidal solution, and timing of liquid management, did not affect most outcomes. CONCLUSION Both colloids and crystalloids could be used as alternatives for perioperative fluid management after cardiac surgery. The use of crystalloids significantly reduced the postoperative chest tube output, and the need for FFP infusion decreased significantly with the use of isotonic crystalloids or fluid management during the ICU stay. ICU patients in the colloid group had higher urine output 24 h after surgery. In addition, although the infusion method was not related to most outcomes, the rates of red blood cell and FFP transfusion and postoperative blood loss in the crystalloid group seemed to be lower, which needed to be further studied in high-quality and large-sample RCTs. TRIAL REGISTRATION PROSPERO, CRD42023415234.
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Affiliation(s)
- Shan-Dong Chen
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
- Department of Anesthesia, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Yu-Tong Ma
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Hui-Xia Wei
- Department of Anesthesia, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Xin-Rong Ou
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Jia-Yi Liu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Ya-Lan Tian
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China.
| | - Yun-Jin Xu
- Department of Pediatric, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China.
| | - Yao Kong
- Department of Spine, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China.
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Behem CR, Friedheim T, Holthusen H, Rapp A, Suntrop T, Graessler MF, Pinnschmidt HO, Wipper SH, von Lucadou M, Schwedhelm E, Renné T, Pfister K, Schierling W, Trepte CJC. Goal-directed colloid versus crystalloid therapy and microcirculatory blood flow following ischemia/reperfusion. Microvasc Res 2024; 152:104630. [PMID: 38048876 DOI: 10.1016/j.mvr.2023.104630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/11/2023] [Accepted: 11/25/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE Ischemia/reperfusion can impair microcirculatory blood flow. It remains unknown whether colloids are superior to crystalloids for restoration of microcirculatory blood flow during ischemia/reperfusion injury. We tested the hypothesis that goal-directed colloid - compared to crystalloid - therapy improves small intestinal, renal, and hepatic microcirculatory blood flow in pigs with ischemia/reperfusion injury. METHODS This was a randomized trial in 32 pigs. We induced ischemia/reperfusion by supra-celiac aortic-cross-clamping. Pigs were randomized to receive either goal-directed isooncotic hydroxyethyl-starch colloid or balanced isotonic crystalloid therapy. Microcirculatory blood flow was measured using Laser-Speckle-Contrast-Imaging. The primary outcome was small intestinal, renal, and hepatic microcirculatory blood flow 4.5 h after ischemia/reperfusion. Secondary outcomes included small intestinal, renal, and hepatic histopathological damage, macrohemodynamic and metabolic variables, as well as specific biomarkers of tissue injury, renal, and hepatic function and injury, and endothelial barrier function. RESULTS Small intestinal microcirculatory blood flow was higher in pigs assigned to isooncotic hydroxyethyl-starch colloid therapy than in pigs assigned to balanced isotonic crystalloid therapy (768.7 (677.2-860.1) vs. 595.6 (496.3-694.8) arbitrary units, p = .007). There were no important differences in renal (509.7 (427.2-592.1) vs. 442.1 (361.2-523.0) arbitrary units, p = .286) and hepatic (604.7 (507.7-701.8) vs. 548.7 (444.0-653.3) arbitrary units, p = .376) microcirculatory blood flow between groups. Pigs assigned to colloid - compared to crystalloid - therapy also had less small intestinal, but not renal and hepatic, histopathological damage. CONCLUSIONS Goal-directed isooncotic hydroxyethyl-starch colloid - compared to balanced isotonic crystalloid - therapy improved small intestinal, but not renal and hepatic, microcirculatory blood flow in pigs with ischemia/reperfusion injury. Whether colloid therapy improves small intestinal microcirculatory blood flow in patients with ischemia/reperfusion needs to be investigated in clinical trials.
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Affiliation(s)
- Christoph R Behem
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Till Friedheim
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Holthusen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adina Rapp
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timo Suntrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael F Graessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine H Wipper
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg (UHZ), Hamburg, Germany
| | - Mirjam von Lucadou
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Wilma Schierling
- Department of Vascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Pompili E, Zaccherini G, Baldassarre M, Iannone G, Caraceni P. Albumin administration in internal medicine: A journey between effectiveness and futility. Eur J Intern Med 2023; 117:28-37. [PMID: 37423819 DOI: 10.1016/j.ejim.2023.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
Albumin is the most abundant circulating protein and provides about 70% of the plasma oncotic power. The molecule also carries many other biological functions (binding, transport and detoxification of endogenous and exogenous compounds, antioxidation, and modulation of inflammatory and immune responses). Hypoalbuminemia is a frequent finding in many diseases, representing usually only a biomarker of poor prognosis rather than a primary pathophysiological event. Despite that, albumin is prescribed in many conditions based on the assumption that correction of hypoalbuminemia would lead to clinical benefits for the patients. Unfortunately, many of these indications are not supported by scientific evidence (or have been even disproved), so that a large part of albumin use is nowadays still inappropriate. Decompensated cirrhosis is the clinical area where albumin administration has been extensively studied and solid recommendations can be made. Besides prevention and treatment of acute complications, long-term albumin administration in patients with ascites has emerged in the last decade has a potential new disease-modifying treatment. In non-hepatological settings, albumin is widely used for fluid resuscitation in sepsis and critical illnesses, with no clear superiority over crystalloids. In many other conditions, scientific evidence supporting albumin prescription is weak or even absent. Thus, given its high cost and limited availability, action is needed to avoid the use of albumin for inappropriate and futile indications to ensure its availability in those conditions for which albumin has been demonstrated to have a real effectiveness and an advantage for the patient.
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Affiliation(s)
- Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Centre for Applied Biomedical Research (CRBA), Alma Mater Studiorum of Bologna, Italy
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy.
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5
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Lazzareschi DV, Fong N, Mavrothalassitis O, Whitlock EL, Chen CL, Chiu C, Adelmann D, Bokoch MP, Chen LL, Liu KD, Pirracchio R, Mathis MR, Legrand M. Intraoperative Use of Albumin in Major Noncardiac Surgery: Incidence, Variability, and Association With Outcomes. Ann Surg 2023; 278:e745-e753. [PMID: 36521076 PMCID: PMC10481928 DOI: 10.1097/sla.0000000000005774] [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] [Indexed: 12/23/2022]
Abstract
BACKGROUND The impact of albumin use during major surgery is unknown, and a dearth of evidence governing its use in major noncardiac surgery has long precluded its standardization in clinical guidelines. OBJECTIVE In this study, we investigate institutional variation in albumin use among medical centers in the United States during major noncardiac surgery and explore the association of intraoperative albumin administration with important postoperative outcomes. METHODS The study is an observational retrospective cohort analysis performed among 54 U.S. hospitals in the Multicenter Perioperative Outcomes Group and includes adult patients who underwent major noncardiac surgery under general anesthesia between January 2014 and June 2020. The primary endpoint was the incidence of albumin administration. Secondary endpoints are acute kidney injury (AKI), net-positive fluid balance, pulmonary complications, and 30-day mortality. Albumin-exposed and albumin-unexposed cases were compared within a propensity score-matched cohort to evaluate associations of albumin use with outcomes. RESULTS Among 614,215 major surgeries, predominantly iso-oncotic albumin was administered in 15.3% of cases and featured significant inter-institutional variability in use patterns. Cases receiving intraoperative albumin involved patients of higher American Society of Anesthesiologists physical status and featured larger infused crystalloid volumes, greater blood loss, and vasopressor use. Overall, albumin was most often administered at high-volume surgery centers with academic affiliation, and within a propensity score-matched cohort (n=153,218), the use of albumin was associated with AKI (aOR 1.24, 95% CI 1.20-1.28, P <0.001), severe AKI (aOR 1.45, 95% CI 1.34-1.56, P <0.001), net-positive fluid balance (aOR 1.18, 95% CI 1.16-1.20, P <0.001), pulmonary complications (aOR 1.56, 95% CI 1.30-1.86, P <0.001), and 30-day all-cause mortality (aOR 1.37, 95% CI 1.26-1.49, P <0.001). CONCLUSIONS Intravenous albumin is commonly administered among noncardiac surgeries with significant inter-institutional variability in use in the United States. Albumin administration was associated with an increased risk of postoperative complications.
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Affiliation(s)
| | - Nicholas Fong
- University of California, San Francisco, School of Medicine
| | | | | | - Catherine L. Chen
- University of California, San Francisco, School of Medicine
- Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco
| | - Catherine Chiu
- University of California, San Francisco, School of Medicine
| | | | | | - Lee-Lynn Chen
- University of California, San Francisco, School of Medicine
| | | | | | - Michael R. Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, San Francisco, CA
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Lazzareschi DV, Fong N, Pirracchio R, Mathis MR, Legrand M. Leveraging observational data to identify targeted patient populations for future randomized trials. RESEARCH SQUARE 2023:rs.3.rs-2641628. [PMID: 37205590 PMCID: PMC10187375 DOI: 10.21203/rs.3.rs-2641628/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Randomized controlled trials reported in the literature are often affected by poor generalizability, and pragmatic trials have become an increasingly utilized workaround approach to overcome logistical limitations and explore routine interventions demonstrating equipoise in clinical practice. Intravenous albumin, for example, is commonly administered in the perioperative setting despite lacking supportive evidence. Given concerns for cost, safety, and efficacy, randomized trials are needed to explore the clinical equipoise of albumin therapy in this setting, and we therefore present an approach to identifying populations exposed to perioperative albumin to encourage clinical equipoise in patient selection and optimize study design for clinical trials.
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Long DA, Slaughter E, Mihala G, Macfarlane F, Ullman AJ, Keogh S, Stocker C. Patient blood management in critically ill children undergoing cardiac surgery: A cohort study. Aust Crit Care 2023; 36:201-207. [PMID: 35221230 DOI: 10.1016/j.aucc.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this study was to audit current patient blood management practice in children throughout cardiac surgery and paediatric intensive care unit (PICU) admission. DESIGN This was a prospective observational cohort study. SETTING This was a single-centre study in the cardiac operating room (OR) and PICU in a major tertiary children's hospital in Australia. PATIENTS Children undergoing corrective cardiac surgery and requiring admission to PICU for postoperative recovery were included in the study. MEASUREMENTS AND MAIN RESULTS Fifty-six patients and 1779 blood sampling episodes were audited over a 7-month period. The median age was 9 months (interquartile range [IQR] = 1-102), with the majority (n = 30 [54%]) younger than 12 months. The median number of blood sampling episodes per patient per day was 6.6 (IQR = 5.8-8.0) in total, with a median of 5.0 (IQR = 4.0-7.5) episodes in the OR and 5.0 (IQR = 3.4-6.2) episodes per day throughout PICU admission. The most common reason for blood tests across both OR and PICU settings was arterial blood gas analysis (total median = 86%, IQR = 79-96). The overall median blood sampling volume per kg of bodyweight, patient, and day was 0.63 mL (IQR = 0.20-1.14) in total. Median blood loss for each patient was 3.5 mL/kg per patient per day (IQR = 1.7-5.6) with negligible amounts in the OR and a median of 3.6 mL/kg (IQR = 1.7-5.7) in the PICU. The median Cell Saver® transfusion volume was 9.9 mL/kg per patient per day (IQR = 4.0-19.1) in the OR. The overall median volume of other infusion products (albumin 4%, albumin 20%, packed red blood cells) received by each patient was 20.1 mL/kg (IQR = 10.7-36.4) per day. Sampling events and blood loss were positively associated with PICU stay. CONCLUSIONS Patient blood management practices observed in this study largely conform to National Blood Authority guidelines. Further implementation projects and research are needed to accelerate implementation of known effective blood conservation strategies within paediatric critical care environments.
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Affiliation(s)
- Debbie A Long
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia; Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.
| | - Eugene Slaughter
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia; Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia
| | - Gabor Mihala
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia; Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Fiona Macfarlane
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Amanda J Ullman
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia; School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Samantha Keogh
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia; Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia
| | - Christian Stocker
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
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Katona H, Dobronte L, Soltesz A, Tamaska E, Fabry S, Csikos G, Szakal-Toth Z, Fule BK, Lang Z, Merkely B, Gal J, Nemeth E. Perioperative Gelatin Use Is Associated With Increased Complication Rates and Does Not Prevent Postoperative Fluid Overload in Patients Undergoing Elective Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:399-406. [PMID: 36621371 DOI: 10.1053/j.jvca.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/20/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The benefit of using gelatin solution in cardiac surgery is still controversial. Previous data suggested adverse interactions of gelatin infusion with acute kidney injury (AKI) or coagulopathy. The purpose of this study was to evaluate the association between perioperative gelatin use and fluid overload (FO), hemodynamic stability, and outcomes compared to crystalloid-based fluid management. DESIGN A retrospective study design. SETTING At a single-center tertiary university setting. PARTICIPANTS Propensity score-matched cohort study of 191 pairs of patients scheduled for cardiac surgery. INTERVENTIONS Patients received either gelatin + crystalloid or pure crystalloid-based perioperative fluid management. The primary outcomes were the frequency of FO and hemodynamic stability defined by the vasoactive-inotropic score. Postoperative complications and 3-year survival were analyzed also. MEASUREMENTS AND MAIN RESULTS Patients who received gelatin experienced more frequent postoperative FO than controls (11.0% v 3.1%, p = 0.006) despite comparable hemodynamic stability in both groups. Gelatin administration was linked with a higher rate of postoperative complications, including blood loss, AKI, and new-onset postoperative atrial fibrillation. Use of gelatin infusion resulted in an adjusted odds ratio of 1.982 (95% CI 1.051-3.736, p = 0.035) for developing early postoperative AKI. This study confirmed a dose-dependent relationship between gelatin infusion and AKI. Thirty-day mortality and 3-year survival were similar in the groups. CONCLUSIONS Gelatin administration versus crystalloid fluid management showed a significant association with a higher rate of FO and an increased risk for early postoperative AKI in a dose-dependent manner.
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Affiliation(s)
- Hajna Katona
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Laszlo Dobronte
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eszter Tamaska
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Szabolcs Fabry
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Balazs Krisztian Fule
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary; Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Zsolt Lang
- Department of Biomathematics and Informatics, University of Veterinary Medicine, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Janos Gal
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Endre Nemeth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
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9
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Beukers AM, de Ruijter JAC, Loer SA, Vonk A, Bulte CSE. Effects of crystalloid and colloid priming strategies for cardiopulmonary bypass on colloid oncotic pressure and haemostasis: a meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6581082. [PMID: 35512381 PMCID: PMC9419694 DOI: 10.1093/icvts/ivac127] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anne Maria Beukers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | | | - Stephan Alexander Loer
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | - Alexander Vonk
- Amsterdam UMC Location University of Amsterdam, Department of Cardiothoracic Surgery , Amsterdam, Netherlands
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10
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Pesonen E, Vlasov H, Suojaranta R, Hiippala S, Schramko A, Wilkman E, Eränen T, Arvonen K, Mazanikov M, Salminen US, Meinberg M, Vähäsilta T, Petäjä L, Raivio P, Juvonen T, Pettilä V. Effect of 4% Albumin Solution vs Ringer Acetate on Major Adverse Events in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass: A Randomized Clinical Trial. JAMA 2022; 328:251-258. [PMID: 35852528 PMCID: PMC9297113 DOI: 10.1001/jama.2022.10461] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE In cardiac surgery, albumin solution may maintain hemodynamics better than crystalloids and reduce the decrease in platelet count and excessive fluid balance, but randomized trials are needed to compare the effectiveness of these approaches in reducing surgical complications. OBJECTIVE To assess whether 4% albumin solution compared with Ringer acetate as cardiopulmonary bypass prime and perioperative intravenous volume replacement solution reduces the incidence of major perioperative and postoperative complications in patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS A randomized, double-blind, single-center clinical trial in a tertiary university hospital during 2017-2020 with 90-day follow-up postoperatively involving patients undergoing on-pump coronary artery bypass grafting; aortic, mitral, or tricuspid valve surgery; ascending aorta surgery without hypothermic circulatory arrest; and/or the maze procedure were randomly assigned to 2 study groups (last follow-up was April 13, 2020). INTERVENTIONS The patients received in a 1:1 ratio either 4% albumin solution (n = 693) or Ringer acetate solution (n = 693) as cardiopulmonary bypass priming and intravenous volume replacement intraoperatively and up to 24 hours postoperatively. MAIN OUTCOMES AND MEASURES The primary outcome was the number of patients with at least 1 major adverse event: death, myocardial injury, acute heart failure, resternotomy, stroke, arrhythmia, bleeding, infection, or acute kidney injury. RESULTS Among 1407 patients randomized, 1386 (99%; mean age, 65.4 [SD, 9.9] years; 1091 men [79%]; 295 women [21%]) completed the trial. Patients received a median of 2150 mL (IQR, 1598-2700 mL) of study fluid in the albumin group and 3298 mL (IQR, 2669-3500 mL) in the Ringer group. The number of patients with at least 1 major adverse event was 257 of 693 patients (37.1%) in the albumin group and 234 of 693 patients (33.8%) in the Ringer group (relative risk albumin/Ringer, 1.10; 95% CI, 0.95-1.27; P = .20), an absolute difference of 3.3 percentage points (95% CI, -1.7 to 8.4). The most common serious adverse events were pulmonary embolus (11 [1.6%] in the albumin group vs 8 [1.2%] in the Ringer group), postpericardiotomy syndrome (9 [1.3%] in both groups), and pleural effusion with intensive care unit or hospital readmission (7 [1.0%] in the albumin group vs 9 [1.3%] in the Ringer group). CONCLUSIONS AND RELEVANCE Among patients undergoing cardiac surgery with cardiopulmonary bypass, treatment with 4% albumin solution for priming and perioperative intravenous volume replacement solution compared with Ringer acetate did not significantly reduce the risk of major adverse events over the following 90 days. These findings do not support the use of 4% albumin solution in this setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02560519.
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Affiliation(s)
- Eero Pesonen
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Vlasov
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raili Suojaranta
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Seppo Hiippala
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexey Schramko
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erika Wilkman
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Eränen
- HUS Pharmacy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kaapo Arvonen
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maxim Mazanikov
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ulla-Stina Salminen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mihkel Meinberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tommi Vähäsilta
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Petäjä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tatu Juvonen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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11
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Huan S, Dai J, Song S, Zhu G, Ji Y, Yin G. Stroke volume variation for predicting responsiveness to fluid therapy in patients undergoing cardiac and thoracic surgery: a systematic review and meta-analysis. BMJ Open 2022; 12:e051112. [PMID: 35584881 PMCID: PMC9119189 DOI: 10.1136/bmjopen-2021-051112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the reliability of stroke volume variation (SVV) for predicting responsiveness to fluid therapy in patients undergoing cardiac and thoracic surgery. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, EMBASE, Cochrane Library, Web of Science up to 9 August 2020. METHODS Quality of included studies were assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We conducted subgroup analysis according to different anaesthesia and surgical methods with Stata V.14.0, Review Manager V.5.3 and R V.3.6.3. We used random-effects model to pool sensitivity, specificity and diagnostic odds ratio with 95% CI. The area under the curve (AUC) of receiver operating characteristic was calculated. RESULTS Among the 20 relevant studies, 7 were conducted during thoracic surgery, 8 were conducted during cardiac surgery and the remaining 5 were conducted in intensive critical unit (ICU) after cardiac surgery. Data from 854 patients accepting mechanical ventilation were included in our systematic review. The pooled sensitivity and specificity were 0.73 (95% CI: 0.59 to 0.83) and 0.62 (95% CI: 0.46 to 0.76) in the thoracic surgery group, 0.71 (95% CI: 0.65 to 0.77) and 0.76 (95% CI: 0.69 to 0.82) in the cardiac surgery group, 0.85 (95% CI: 0.60 to 0.96) and 0.85 (95% CI: 0.74 to 0.92) in cardiac ICU group. The AUC was 0.73 (95% CI: 0.69 to 0.77), 0.80 (95% CI: 0.77 to 0.83) and 0.88 (95% CI: 0.86 to 0.92), respectively. Results of subgroup of FloTrac/Vigileo system (AUC=0.80, Youden index=0.38) and large tidal volume (AUC=0.81, Youden index=0.48) in thoracic surgery, colloid (AUC=0.85, Youden index=0.55) and postoperation (AUC=0.85, Youden index=0.63) in cardiac surgery, passive leg raising (AUC=0.90, Youden index=0.72) in cardiac ICU were reliable. CONCLUSION SVV had good predictive performance in cardiac surgery or ICU after cardiac surgery and had moderate predictive performance in thoracic surgery. Nevertheless, technical and clinical variables may affect the predictive value potentially.
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Affiliation(s)
- Sheng Huan
- Department of Anesthesiology, Nanjing Second Hospital, Nanjing, Jiangsu, China
- Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, Jangsu, China
| | - Jin Dai
- Department of Anesthesiology, Nanjing Second Hospital, Nanjing, Jiangsu, China
| | - Shilian Song
- Department of Anesthesiology, Nanjing Second Hospital, Nanjing, Jiangsu, China
| | - Guining Zhu
- Department of Anesthesiology, Nanjing Second Hospital, Nanjing, Jiangsu, China
| | - Yihao Ji
- Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, Jangsu, China
- Department of Critical Medicine, The Second Hospital of Nanjing, Nanjing, Jiangsu, China
| | - Guoping Yin
- Department of Anesthesiology, Nanjing Second Hospital, Nanjing, Jiangsu, China
- Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, Jangsu, China
- College of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
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12
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Morath B, Meid AD, Rickmann J, Soethoff J, Verch M, Karck M, Zaradzki M. Renal Safety of Hydroxyethyl starch 130/0.42 After Cardiac Surgery: A Retrospective Cohort Analysis. Drug Saf 2021; 44:1311-1321. [PMID: 34564829 PMCID: PMC8626393 DOI: 10.1007/s40264-021-01116-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/27/2022]
Abstract
Introduction The risk for renal complications from hydroxyethyl starch 130/0.42 (HES) impacts treatment decisions in patients after cardiac surgery. Objective The objective of this study was to determine the impact of postoperatively administered HES on renal function and 90-day mortality compared to sole crystalloid administration in patients after elective cardiac surgery. Methods Using electronic health records from a university hospital, confounding-adjusted models analyzed the associations between postoperative HES administration and the occurrence of postoperative acute kidney injury. In addition, 90-day mortality was evaluated. The impact of HES dosage and timing on renal function on trajectories of estimated glomerular filtration rates over the postoperative period was investigated using linear mixed-effects models. Results Overall 1009 patients (45.0%) experienced acute kidney injury. Less acute kidney injury occurred in patients receiving HES compared with patients receiving only crystalloids for fluid resuscitation (43.7% vs 51.2%, p = 0.008). In multivariate acute kidney injury models, HES had a protective association (odds ratio: 0.89; 95% confidence interval 0.82–0.96). Crystalloids were not as protective as HES (odds ratio: 0.98; 95% confidence interval 0.95–1.00). There was no association between HES and 90-day mortality (odds ratio: 1.05; 95% confidence interval 0.88–1.25). Renal function trajectories were dose dependent and biphasic, HES appeared to slow down the late postoperative decline. Conclusions This study showed no association between HES and the postoperative occurrence of acute kidney injury and thus further closes the evidence gap on HES safety in cardiac surgery patients. Although this was a retrospective cohort study, the results indicated that HES might be safely administered to cardiac surgery patients with regard to renal outcomes, especially if it was administered early and dosed appropriately. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-021-01116-5.
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Affiliation(s)
- Benedict Morath
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
- Hospital Pharmacy, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Rickmann
- Center for Information and Medical Technology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jasmin Soethoff
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Verch
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.
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13
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Smart L, Boyd C, Litton E, Pavey W, Vlaskovsky P, Ali U, Mori T, Barden A, Ho KM. A randomised controlled trial of succinylated gelatin (4%) fluid on urinary acute kidney injury biomarkers in cardiac surgical patients. Intensive Care Med Exp 2021; 9:48. [PMID: 34549356 PMCID: PMC8455786 DOI: 10.1186/s40635-021-00412-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Fluid resuscitation is frequently required for cardiac surgical patients admitted to the intensive care unit. The ideal fluid of choice in regard to efficacy and safety remains uncertain. Compared with crystalloid fluid, colloid fluid may result in less positive fluid balance. However, some synthetic colloids are associated with increased risk of acute kidney injury (AKI). This study compared the effects of succinylated gelatin (4%) (GEL) with compound sodium lactate (CSL) on urinary AKI biomarkers in patients after cardiac surgery. Methods Cardiac surgical patients who required an intravenous fluid bolus of at least 500 mL postoperatively were randomly allocated to receive GEL or CSL as the resuscitation fluid of choice for the subsequent 24 h. Primary outcomes were serial urinary neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C concentrations measured at baseline, 1 h, 5 h and 24 h after enrolment, with higher concentrations indicating greater kidney injury. Secondary biomarker outcomes included urinary clusterin, α1-microglobulin and F2-isoprostanes concentrations. Differences in change of biomarker concentration between the two groups over time were compared with mixed-effects regression models. Statistical significance was set at P < 0.05. Results Forty cardiac surgical patients (n = 20 per group) with similar baseline characteristics were included. There was no significant difference in the median volume of fluid boluses administered over 24 h between the GEL (1250 mL, Q1–Q3 500–1750) and CSL group (1000 mL, Q1–Q3 500–1375) (P = 0.42). There was a significantly greater increase in urinary cystatin C (P < 0.001), clusterin (P < 0.001), α1-microglobulin (P < 0.001) and F2-isoprostanes (P = 0.020) concentrations over time in the GEL group, compared to the CSL group. Change in urinary NGAL concentration (P = 0.68) over time was not significantly different between the groups. The results were not modified by adjustment for either urinary osmolality or EuroSCORE II predicted risk of mortality. Conclusions This preliminary randomised controlled trial showed that use of succinylated gelatin (4%) for fluid resuscitation after cardiac surgery was associated with increased biomarker concentrations of renal tubular injury and dysfunction, compared to crystalloid fluid. These results generate concern that use of intravenous gelatin fluid may contribute to clinically relevant postoperative AKI. Trial registration ANZCTR.org.au, ACTRN12617001461381. Registered on 16th October, 2017, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373619&isReview=true. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00412-9.
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Affiliation(s)
- Lisa Smart
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia. .,Centre for Clinical Research in Emergency Medicine, Perth, Australia.
| | - Corrin Boyd
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Australia.,Intensive Care Unit, St John of God Hospital, Subiaco, Australia
| | - Warren Pavey
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia.,Department of Anaesthesia, Fiona Stanley Hospital, Murdoch, Australia
| | | | - Umar Ali
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Murdoch, Australia
| | - Trevor Mori
- Medical School, University of Western Australia, Perth, Australia
| | - Anne Barden
- Medical School, University of Western Australia, Perth, Australia
| | - Kwok Ming Ho
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia.,Medical School, University of Western Australia, Perth, Australia.,Intensive Care Unit, Royal Perth Hospital, Perth, Australia
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14
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Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial. Br J Anaesth 2021; 127:521-531. [PMID: 34389168 DOI: 10.1016/j.bja.2021.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).
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15
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Xu Y, Wang S, He L, Yu H, Yu H. Hydroxyethyl starch 130/0.4 for volume replacement therapy in surgical patients: a systematic review and meta-analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:16. [PMID: 33971968 PMCID: PMC8111748 DOI: 10.1186/s13741-021-00182-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/22/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The safety of perioperative intravenous hydroxyethyl starch (HES) products, specifically HES 130/0.4, continues to be the source of much debate. The aim of this meta-analysis was to update the existing evidence and gain further insight into the clinical effects of HES 130/0.4 on postoperative outcomes for volume replacement therapy in surgical patients. METHODS MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to March 2020 for relevant randomized controlled trials (RCTs) on perioperative use of HES 130/0.4 in adult surgical patients. The primary outcome was postoperative mortality and secondary outcomes were the incidence of acute kidney injury (AKI) and requirement for renal replacement therapy (RRT). The analysis was performed using the random-effects method and the risk ratio (RR) with a 95% confidence interval (CI). We performed the risk-of-bias assessment of eligible studies and assessed the overall quality of evidence for each outcome. RESULTS Twenty-five RCTs with 4111 participants were finally included. There were no statistical differences between HES 130/0.4 and other fluids in mortality at 30 days (RR 1.28, 95% CI 0.88 to 1.86, p = 0.20), the incidence of AKI (RR 1.23, 95% CI 0.99 to 1.53, p = 0.07), or requirement for RRT (RR 0.75, 95% CI 0.37 to 1.53, p = 0.43). Overall, there was a moderate certainty of evidence for all the outcomes. There was no subgroup difference related to the type of surgery (p = 0.17) in the incidence of AKI. As for the type of comparator fluids, however, there was a trend that was not statistically significant (p = 0.06) towards the increased incidence of AKI in the HES 130/0.4 group (RR 1.22, 95% CI 0.97 to 1.54) compared with the crystalloid group (RR 1.21, 95% CI 0.27 to 3.91). Subgroup analyses according to the type of surgery demonstrated consistent findings. CONCLUSIONS This systematic review and meta-analysis suggests that the use of HES 130/0.4 for volume replacement therapy compared with other fluids resulted in no significant difference in postoperative mortality or kidney dysfunction among surgical patients. Given the absent evidence of confirmed benefit and the potential trend of increased kidney injury, we cannot recommend the routine clinical use of HES 130/0.4 for volume replacement therapy in surgical patients from the perspective of benefit/risk profile. However, the results need to be interpreted with caution due to the limited sample size, and further well-powered RCTs are warranted. TRIAL REGISTRATION PROSPERO registry reference: CRD42020173058.
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Affiliation(s)
- Yi Xu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Siying Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Leilei He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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16
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Santer D, Miazza J, Koechlin L, Gahl B, Rrahmani B, Hollinger A, Eckstein FS, Siegemund M, Reuthebuch OT. Hemoadsorption during Cardiopulmonary Bypass in Patients with Endocarditis Undergoing Valve Surgery: A Retrospective Single-Center Study. J Clin Med 2021; 10:jcm10040564. [PMID: 33546164 PMCID: PMC7913197 DOI: 10.3390/jcm10040564] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department of Cardiac Surgery, University Hospital of Basel. We compared patients who received HA during surgery (n = 41) versus patients without HA (n = 200), after applying inverse probability of treatment weighting. Results: In-hospital mortality, major adverse cardiac and cerebrovascular events and postoperative renal failure were similar in both groups. Demand for norepinephrine (88.4 vs. 52.8%; p = 0.001), milrinone (42.2 vs. 17.2%; p = 0.046), red blood cell concentrates (65.2 vs. 30.6%; p = 0.003), and platelets (HA vs. Control: 36.7 vs. 9.8%; p = 0.013) were higher in the HA group. In addition, a higher incidence of reoperation for bleeding (34.0 vs. 7.7 %; p = 0.011), and a prolonged length of in-hospital stay (15.2 (11.8 to 19.6) vs. 9.0 (7.1 to 11.3) days; p = 0.017) were observed in the HA group. Conclusions: No benefits of HA-therapy were observed in patients with infective endocarditis undergoing valve surgery.
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Affiliation(s)
- David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
| | - Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
| | - Bejtush Rrahmani
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
| | - Alexa Hollinger
- Department of Intensive Care Medicine, University Hospital Basel, 4031 Basel, Switzerland; (A.H.); (M.S.)
- Department of Clinical Research, University Hospital Basel, 4031 Basel, Switzerland
| | - Friedrich S. Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
| | - Martin Siegemund
- Department of Intensive Care Medicine, University Hospital Basel, 4031 Basel, Switzerland; (A.H.); (M.S.)
- Department of Clinical Research, University Hospital Basel, 4031 Basel, Switzerland
| | - Oliver T. Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (D.S.); (J.M.); (L.K.); (B.G.); (B.R.); (F.S.E.)
- Correspondence: ; Tel.: +41-61-265-77-53
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17
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Nagpal AD, Cowan A, Li L, Nusca G, Guo L, Novick RJ, Harle CC, House AA, Fox S, Jones PM. Starch or Saline After Cardiac Surgery: A Double-Blinded Randomized Controlled Trial. Can J Kidney Health Dis 2020; 7:2054358120940434. [PMID: 32782813 PMCID: PMC7388134 DOI: 10.1177/2054358120940434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/20/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Despite decades of investigation, the balance of clinical risks and benefits
of fluid supplementation with starch remain unresolved. Patient-centered
outcomes have not been well explored in a “real-world” trial in cardiac
surgery. Objective: We sought to compare a starch-based fluid strategy with a saline-based fluid
strategy in the cardiac surgery patient. Design: A pragmatic blinded randomized controlled trial comparing starch-based with
saline-based fluid strategy. Setting: A large tertiary academic center in London Ontario between September 2009 and
February 2011. Participants: Patients undergoing planned, isolated coronary revascularization. Measurements: Serum creatinine and patient weight were measured daily postoperatively. Methods: Patients were randomized to receive 6% hydroxyethyl starch (Voluven) or
saline for perioperative fluid requirements. Fluid administration was not
protocolized. Co-primary outcomes were incidence of acute kidney injury
(AKI) and maximum postoperative weight gain. Secondary outcomes included
bleeding, transfusion, inotropic and ventilator support, and fluid
utilization. Results: The study was prematurely terminated due to resource limitations. A total of
69 patients (19% female, mean age = 65) were randomized. Using RIFLE
criteria for AKI, “risk” occurred in 12 patients in each group (risk ratio
[RR] = 1.0; 95% confidence interval [CI] = 0.5-1.9; P =
1.00), whereas “injury” occurred in 7 of 35 (20%) and 3 of 34 (9%) of
patients in the starch and saline groups, respectively (RR = 2.3; 95% CI =
0.6-8.1; P = .31). Maximum weight gain, bleeding and blood
product usage, and overall fluid requirement were similar between
groups. Limitations: The study had to be prematurely terminated due to resource limitations which
led to a small sample size which was not sufficiently powered to detect a
difference in the primary outcomes. Conclusions: This pragmatic double-blinded randomized controlled trial revealed a number
of interesting hypothesis-generating trends and confirmed the feasibility of
undertaking a logistically complex trial in a pragmatic fashion.
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Affiliation(s)
- A Dave Nagpal
- Department of Surgery, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada.,Critical Care Western, Western University, London, ON, Canada
| | - Andrea Cowan
- Department of Medicine, Division of Nephrology, Western University, London, ON, Canada
| | - Linna Li
- Department of Surgery, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Graeme Nusca
- Department of Surgery, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Linrui Guo
- Department of Surgery, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Richard J Novick
- Department of Surgery, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada.,Critical Care Western, Western University, London, ON, Canada
| | - Chris C Harle
- Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
| | - Andrew A House
- Department of Medicine, Division of Nephrology, Western University, London, ON, Canada
| | - Stephanie Fox
- Department of Surgery, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada.,Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
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18
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Abstract
Objectives To investigate the effect of albumin exposure in ICU after cardiac surgery on hospital mortality, complications, and costs. Design A retrospective, single-center cohort study with economic evaluation. Setting Cardiothoracic ICU in Australia. Patients Adult patients admitted to the ICU after cardiac surgery. Interventions None. Measurements and Main Results Comparison of outcomes and costs in ICU after cardiac surgery based on 4% human albumin exposure. During the study period, 3,656 patients underwent cardiac surgery. After exclusions, 2,594 patients were suitable for analysis. One-thousand two-hundred sixty-four (48.7%) were exposed to albumin and 19 (1.4%) of those died. The adjusted hospital mortality of albumin exposure compared with no albumin was not significant (odds ratio, 1.24; 95% CI, 0.56-2.79; p = 0.6). More patients exposed to albumin returned to the operating theater for bleeding and/or tamponade (6.1% vs 2.1%; odds ratio, 2.84; 95% CI, 1.81-4.45; p < 0.01) and received packed red cell transfusions (p < 0.001). ICU and hospital lengths of stay were prolonged in those exposed to albumin (mean difference, 18 hr; 95% CI, 10.3-25.6; p < 0.001 and 87.5 hr; 95% CI, 40.5-134.6; p < 0.001). Costs (U.S. dollar) were higher in patients exposed to albumin, compared with those with no albumin exposure (mean difference in ICU costs, $2,728; 95% CI, $1,566-3,890 and mean difference in hospital costs, $5,427; 95% CI, $3,294-7,560). Conclusions There is no increased mortality in patients who are exposed to albumin after cardiac surgery. The patients exposed to albumin had higher illness severity, suffered more complications, and incurred higher healthcare costs. A randomized controlled trial is required to determine whether albumin use is effective and safe in this setting.
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Futier E, Garot M, Godet T, Biais M, Verzilli D, Ouattara A, Huet O, Lescot T, Lebuffe G, Dewitte A, Cadic A, Restoux A, Asehnoune K, Paugam-Burtz C, Cuvillon P, Faucher M, Vaisse C, El Amine Y, Beloeil H, Leone M, Noll E, Piriou V, Lasocki S, Bazin JE, Pereira B, Jaber S. Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial. JAMA 2020; 323:225-236. [PMID: 31961418 PMCID: PMC6990683 DOI: 10.1001/jama.2019.20833] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. OBJECTIVE To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. INTERVENTIONS Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. RESULTS Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). CONCLUSIONS AND RELEVANCE Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02502773.
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Affiliation(s)
- Emmanuel Futier
- Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Université Clermont Auvergne, CNRS, Inserm U-1103, Clermont-Ferrand, France
| | - Matthias Garot
- CHU de Lille, Pôle Anesthésie Réanimation, Hôpital Claude Huriez, Lille, France
| | - Thomas Godet
- CHU de Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Clermont-Ferrand, France
| | - Matthieu Biais
- CHU de Bordeaux, Département Anesthésie et Réanimation, Hôpital Pellegrin, Bordeaux, France
| | - Daniel Verzilli
- CHU Montpellier, Département Anesthésie et Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Montpellier, France
| | - Alexandre Ouattara
- CHU de Bordeaux, Service Anesthésie et Réanimation, Centre Medico-chirugical Magellan, Bordeaux, France
- Inserm, UMR 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Olivier Huet
- CHU de Brest, Département Anesthésie et Réanimation, Hôpital La cavale Blanche, Brest, France
| | | | - Gilles Lebuffe
- CHU de Lille, Pôle Anesthésie Réanimation, Hôpital Claude Huriez, Lille, France
| | - Antoine Dewitte
- CHU de Bordeaux, Service Anesthésie et Réanimation, Centre Medico-chirugical Magellan, Bordeaux, France
- Inserm, UMR 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Anna Cadic
- CHU de Brest, Département Anesthésie et Réanimation, Hôpital La cavale Blanche, Brest, France
| | - Aymeric Restoux
- AP-HP, Département Anesthésie et Réanimation, Hôpital Beaujon, Clichy, Paris, France
| | - Karim Asehnoune
- CHU de Nantes, Département Anesthésie et Réanimation, Hôpital Hôtel Dieu, Nantes, France
| | | | - Philippe Cuvillon
- CHU de Nîmes, Section d’Anesthésie, Département Anesthésie et Réanimation, Nîmes, France
| | - Marion Faucher
- Institut Paoli Calmettes, Département Anesthésie et Réanimation, Marseille, France
| | - Camille Vaisse
- Assistance Publique Hôpitaux de Marseille (AP-HM), Service Anesthésie et Réanimation, Hôpital Timone, Marseille, France
| | - Younes El Amine
- Centre Hospitalier de Valenciennes, Département Anesthésie et Réanimation, Valenciennes, France
| | - Hélène Beloeil
- Université de Rennes, Inserm, INRA, CHU Rennes, CIC 1414, Numecan, Pôle Anesthésie et Réanimation, Rennes, France
| | - Marc Leone
- AP-HM, Service Anesthésie et Réanimation, Hôpital Nord, Université Aix Marseille, Marseille, France
| | - Eric Noll
- Hôpitaux Universitaires de Strasbourg, Service d’Anesthésie Réanimation Chirurgicale, Hôpital Hautepierre, Strasbourg, France
| | - Vincent Piriou
- Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Service d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Lyon, France
| | | | - Jean-Etienne Bazin
- CHU de Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Direction de la Recherche Clinique (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Samir Jaber
- CHU Montpellier, Département Anesthésie et Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Montpellier, France
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20
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Abstract
Colloid solutions have been advocated for use in treating hypovolemia due to their expected effect on improving intravascular retention compared with crystalloid solutions. Because the ultimate desired effect of fluid resuscitation is the improvement of microcirculatory perfusion and tissue oxygenation, it is of interest to study the effects of colloids and crystalloids at the level of microcirculation under conditions of shock and fluid resuscitation, and to explore the potential benefits of using colloids in terms of recruiting the microcirculation under conditions of hypovolemia. This article reviews the physiochemical properties of the various types of colloid solutions (eg, gelatin, dextrans, hydroxyethyl starches, and albumin) and the effects that they have under various conditions of hypovolemia in experimental and clinical scenarios.
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Affiliation(s)
- Huaiwu He
- From the Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- From the Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Can Ince
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Intensive Care, Erasmus MC, University Hospital Rotterdam, Rotterdam, the Netherlands
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21
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Ali A, Dorman Y, Abdullah T, Yasa C, Orhan-Sungur M, Akinci IO, Ergin-Ozcan P. Ability of mini-fluid challenge to predict fluid responsiveness in obese patients undergoing surgery in the prone position. Minerva Anestesiol 2019; 85:981-988. [PMID: 30994311 DOI: 10.23736/s0375-9393.19.13276-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pulse pressure variation (PPV) and stroke volume variation (SVV) can predict fluid responsiveness effectively. However, high Body Mass Index (BMI) can restrict their use due to changes in respiratory system compliance (CS), intra-abdominal pressure, and stroke volume (SV) in the prone position. Therefore, we aimed to investigate the effectiveness of mini-fluid challenge (MFC) in predicting fluid responsiveness in obese (BMI ≥30 kg/m2) patients in the prone position. METHODS A total of 33 patients undergoing neurosurgery were included. After standardized anesthesia induction, patients' PPV, SVV, stroke volume index (SVI) and CS values were recorded in the prone position (T1), after the infusion of 100 mL of crystalloid named as MFC (T2) and after fluid loading was completed with additional 400 mL of crystalloid. Patients whose SVI increased more than 15% after the fluid loading were defined as volume responders. RESULTS Fifteen (45%) patients were responders to 500 mL fluid loading. After the 100 mL fluid load, a higher percentage increase in SVI was observed among responders (P<0.001), with values of 6.6% (6.2-8.6%) and 3.5% (1.7-4.8%) in responders and non-responders, respectively. Areas under the receiver operating characteristic curves of MFC, PPV, and SVV were 0.967 (95% CI: 0.838-0.999), 0.683 (95% CI: 0.499-0.834), and 0.709 (95% CI: 0.526-0.853), respectively. The area under the curve of MFC was significantly higher than that of PPV (P=0.003) and SVV (P=0.005). CONCLUSIONS The increase in SVI after a rapid infusion of 100 mL crystalloid could predict fluid responsiveness in patients with BMI ≥30 kg/m2 in the prone position.
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Affiliation(s)
- Achmet Ali
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Yeser Dorman
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Taner Abdullah
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey -
| | - Ceren Yasa
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mukadder Orhan-Sungur
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ibrahim O Akinci
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Perihan Ergin-Ozcan
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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22
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Abstract
OBJECTIVES To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation in children admitted after cardiac surgery. DESIGN Retrospective pre-/postintervention cohort study. SETTING Stollery Children's Hospital tertiary care pediatric cardiac ICU. PATIENTS Children admitted to the pediatric cardiac ICU after cardiac surgery. INTERVENTIONS Fluid resuscitation policy change in which crystalloids replaced albumin 5% as the primary fluid strategy for resuscitation after cardiac surgery. MEASUREMENTS AND MAIN RESULTS Children who underwent cardiac surgery in the 6 months prior to the policy change (5% albumin group) were compared with children admitted during the 6 months after (crystalloid group). Demographic, perioperative, and outcome variables (fluid intake days 1-4 postoperative, vasoactive therapy, blood products, time to negative fluid balance, renal replacement therapies, mechanical ventilation, pediatric cardiac ICU, and length of stay) were collected. Data were analyzed using linear and logistic multivariate analysis. The study included 360 children. There was no association between fluid group and fluid intake (mL/kg) on day 1 postoperatively (coefficient, 2.84; 95% CI, 5.37-11.05; p = 0.497). However, crystalloid group was associated with significantly less fluid intake on day 2 (coefficient, -12.8; 95% CI, -22.0 to -3.65; p = 0.006), day 3 (coefficient, -14.9; 95% CI, -24.3 to -5.57; p = 0.002), and on the first 48 hours postoperative (coefficient, 10.1; 95% CI, -27.9 to -1.29; p = 0.032). Pediatric cardiac ICU stay (coefficient, -1.29; 95% CI, -2.50 to -0.08; p = 0.036) was shorter for the crystalloid group. There were no significant differences in the time to negative balance, need for renal replacement therapy, mechanical ventilation days, hospital stay, or pediatric cardiac ICU survival. CONCLUSIONS In our study, the use of albumin 5% for resuscitation after cardiac surgery was not associated with less fluid intake but rather the opposite. Albumin administration did not provide measured clinical benefit while exposing children to side effects and generating higher costs to the healthcare system.
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23
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Lewis SR, Pritchard MW, Evans DJW, Butler AR, Alderson P, Smith AF, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev 2018; 8:CD000567. [PMID: 30073665 PMCID: PMC6513027 DOI: 10.1002/14651858.cd000567.pub7] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Critically ill people may lose fluid because of serious conditions, infections (e.g. sepsis), trauma, or burns, and need additional fluids urgently to prevent dehydration or kidney failure. Colloid or crystalloid solutions may be used for this purpose. Crystalloids have small molecules, are cheap, easy to use, and provide immediate fluid resuscitation, but may increase oedema. Colloids have larger molecules, cost more, and may provide swifter volume expansion in the intravascular space, but may induce allergic reactions, blood clotting disorders, and kidney failure. This is an update of a Cochrane Review last published in 2013. OBJECTIVES To assess the effect of using colloids versus crystalloids in critically ill people requiring fluid volume replacement on mortality, need for blood transfusion or renal replacement therapy (RRT), and adverse events (specifically: allergic reactions, itching, rashes). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two other databases on 23 February 2018. We also searched clinical trials registers. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of critically ill people who required fluid volume replacement in hospital or emergency out-of-hospital settings. Participants had trauma, burns, or medical conditions such as sepsis. We excluded neonates, elective surgery and caesarean section. We compared a colloid (suspended in any crystalloid solution) versus a crystalloid (isotonic or hypertonic). DATA COLLECTION AND ANALYSIS Independently, two review authors assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 69 studies (65 RCTs, 4 quasi-RCTs) with 30,020 participants. Twenty-eight studied starch solutions, 20 dextrans, seven gelatins, and 22 albumin or fresh frozen plasma (FFP); each type of colloid was compared to crystalloids.Participants had a range of conditions typical of critical illness. Ten studies were in out-of-hospital settings. We noted risk of selection bias in some studies, and, as most studies were not prospectively registered, risk of selective outcome reporting. Fourteen studies included participants in the crystalloid group who received or may have received colloids, which might have influenced results.We compared four types of colloid (i.e. starches; dextrans; gelatins; and albumin or FFP) versus crystalloids.Starches versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using starches or crystalloids in mortality at: end of follow-up (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.86 to 1.09; 11,177 participants; 24 studies); within 90 days (RR 1.01, 95% CI 0.90 to 1.14; 10,415 participants; 15 studies); or within 30 days (RR 0.99, 95% CI 0.90 to 1.09; 10,135 participants; 11 studies).We found moderate-certainty evidence that starches probably slightly increase the need for blood transfusion (RR 1.19, 95% CI 1.02 to 1.39; 1917 participants; 8 studies), and RRT (RR 1.30, 95% CI 1.14 to 1.48; 8527 participants; 9 studies). Very low-certainty evidence means we are uncertain whether either fluid affected adverse events: we found little or no difference in allergic reactions (RR 2.59, 95% CI 0.27 to 24.91; 7757 participants; 3 studies), fewer incidences of itching with crystalloids (RR 1.38, 95% CI 1.05 to 1.82; 6946 participants; 2 studies), and fewer incidences of rashes with crystalloids (RR 1.61, 95% CI 0.90 to 2.89; 7007 participants; 2 studies).Dextrans versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using dextrans or crystalloids in mortality at: end of follow-up (RR 0.99, 95% CI 0.88 to 1.11; 4736 participants; 19 studies); or within 90 days or 30 days (RR 0.99, 95% CI 0.87 to 1.12; 3353 participants; 10 studies). We are uncertain whether dextrans or crystalloids reduce the need for blood transfusion, as we found little or no difference in blood transfusions (RR 0.92, 95% CI 0.77 to 1.10; 1272 participants, 3 studies; very low-certainty evidence). We found little or no difference in allergic reactions (RR 6.00, 95% CI 0.25 to 144.93; 739 participants; 4 studies; very low-certainty evidence). No studies measured RRT.Gelatins versus crystalloidsWe found low-certainty evidence that there may be little or no difference between gelatins or crystalloids in mortality: at end of follow-up (RR 0.89, 95% CI 0.74 to 1.08; 1698 participants; 6 studies); within 90 days (RR 0.89, 95% CI 0.73 to 1.09; 1388 participants; 1 study); or within 30 days (RR 0.92, 95% CI 0.74 to 1.16; 1388 participants; 1 study). Evidence for blood transfusion was very low certainty (3 studies), with a low event rate or data not reported by intervention. Data for RRT were not reported separately for gelatins (1 study). We found little or no difference between groups in allergic reactions (very low-certainty evidence).Albumin or FFP versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using albumin or FFP or using crystalloids in mortality at: end of follow-up (RR 0.98, 95% CI 0.92 to 1.06; 13,047 participants; 20 studies); within 90 days (RR 0.98, 95% CI 0.92 to 1.04; 12,492 participants; 10 studies); or within 30 days (RR 0.99, 95% CI 0.93 to 1.06; 12,506 participants; 10 studies). We are uncertain whether either fluid type reduces need for blood transfusion (RR 1.31, 95% CI 0.95 to 1.80; 290 participants; 3 studies; very low-certainty evidence). Using albumin or FFP versus crystalloids may make little or no difference to the need for RRT (RR 1.11, 95% CI 0.96 to 1.27; 3028 participants; 2 studies; very low-certainty evidence), or in allergic reactions (RR 0.75, 95% CI 0.17 to 3.33; 2097 participants, 1 study; very low-certainty evidence). AUTHORS' CONCLUSIONS Using starches, dextrans, albumin or FFP (moderate-certainty evidence), or gelatins (low-certainty evidence), versus crystalloids probably makes little or no difference to mortality. Starches probably slightly increase the need for blood transfusion and RRT (moderate-certainty evidence), and albumin or FFP may make little or no difference to the need for renal replacement therapy (low-certainty evidence). Evidence for blood transfusions for dextrans, and albumin or FFP, is uncertain. Similarly, evidence for adverse events is uncertain. Certainty of evidence may improve with inclusion of three ongoing studies and seven studies awaiting classification, in future updates.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - David JW Evans
- Lancaster UniversityLancaster Health HubLancasterUKLA1 4YG
| | - Andrew R Butler
- Royal Lancaster InfirmaryDepartment of AnaesthesiaLancasterUK
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaLancasterUK
| | - Ian Roberts
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupNorth CourtyardKeppel StreetLondonUKWC1E 7HT
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A mini-fluid challenge of 150 mL predicts fluid responsiveness using Modelflow R pulse contour cardiac output directly after cardiac surgery. J Clin Anesth 2018; 46:17-22. [DOI: 10.1016/j.jclinane.2017.12.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 12/01/2017] [Accepted: 12/21/2017] [Indexed: 01/20/2023]
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25
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Juri T, Suehiro K, Kuwata S, Tsujimoto S, Mukai A, Tanaka K, Yamada T, Mori T, Nishikawa K. Hydroxyethyl starch 130/0.4 versus crystalloid co-loading during general anesthesia induction: a randomized controlled trial. J Anesth 2017; 31:878-884. [DOI: 10.1007/s00540-017-2416-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/09/2017] [Indexed: 12/22/2022]
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Aronson S, Nisbet P, Bunke M. Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers. Perioper Med (Lond) 2017; 6:15. [PMID: 29075482 PMCID: PMC5649061 DOI: 10.1186/s13741-017-0071-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Fluid resuscitation during cardiac surgery is common with significant variability in clinical practice. Our goal was to investigate current practice patterns of fluid volume expansion in patients undergoing cardiac surgeries in the USA. Methods We conducted a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists. Survey questions were designed to assess clinical decision-making patterns of intravenous (IV) fluid utilization in cardiovascular surgery for five types of patients who need volume expansion: (1) patients undergoing cardiopulmonary bypass (CPB) without bleeding, (2) patients undergoing CPB with bleeding, (3) patients undergoing acute normovolemic hemodilution (ANH), (4) patients requiring extracorporeal membrane oxygenation (ECMO) or use of a ventricular assist device (VAD), and (5) patients undergoing either off-pump coronary artery bypass graft (OPCABG) surgery or transcatheter aortic valve replacement (TAVR). First-choice fluid used in fluid boluses for these five patient types was requested. Descriptive statistics were performed using Kruskal-Wallis test and follow-up tests, including t tests, to evaluate differences among respondent groups. Results The most commonly preferred indicators of volume status were blood pressure, urine output, cardiac output, central venous pressure, and heart rate. The first choice of fluid for patients needing volume expansion during CPB without bleeding was crystalloids, whereas 5% albumin was the most preferred first choice of fluid for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most frequently used adjunct fluid to crystalloids. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one third preferred a mixture of 25% albumin and crystalloids. Less interstitial edema and more sustained volume expansion were considered the most important colloid traits in volume expansion. Conclusions Fluid utilization practice patterns in the USA varied depending on patient characteristics and clinical specialties of health care professionals. Electronic supplementary material The online version of this article (10.1186/s13741-017-0071-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Solomon Aronson
- Department of Anesthesiology, Duke University, 201 Trent Drive, 101 Baker House, Durham, NC 27710 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungryneck Blvd. Suite C-303, Mt. Pleasant, SC 29464 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 T.W. Alexander Drive, 4101 Research Commons, Research Triangle Park, Raleigh, NC 27709 USA
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Heming N, Elatrous S, Jaber S, Dumenil AS, Cousson J, Forceville X, Kimmoun A, Trouillet JL, Fichet J, Anguel N, Darmon M, Martin C, Chevret S, Annane D. Haemodynamic response to crystalloids or colloids in shock: an exploratory subgroup analysis of a randomised controlled trial. BMJ Open 2017; 7:e016736. [PMID: 28988172 PMCID: PMC5640079 DOI: 10.1136/bmjopen-2017-016736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To compare the haemodynamic effect of crystalloids and colloids during acute severe hypovolaemic shock. DESIGN Exploratory subgroup analysis of a multicentre randomised controlled trial (Colloids Versus Crystalloids for the Resuscitation of the Critically Ill, CRISTAL, ClinicalTrials.gov NCT00318942). SETTING CRISTAL was conducted in intensive care units in Europe, North Africa and Canada. PARTICIPANTS Current analysis included all patients who had a pulmonary artery catheter in place at randomisation. 220 patients (117 received crystalloids vs 103 colloids) underwent pulmonary artery catheterisation. INTERVENTION Crystalloids versus colloids for fluid resuscitation in hypovolaemic shock. OUTCOME MEASURES Haemodynamic data were collected at the time of randomisation and subsequently on days 1, 2, 3, 4, 5, 6 and 7. RESULTS Median cumulative volume of fluid administered during the first 7 days was higher in the crystalloids group than in the colloids group (3500 (2000-6000) vs 2500 (1000-4000) mL, p=0.01). Patients in the colloids arm exhibited a lower heart rate over time compared with those allocated to the crystalloids arm (p=0.014). There was no significant difference in Cardiac Index (p=0.053), mean blood pressure (p=0.4), arterial lactates (p=0.9) or global Sequential Organ Failure Assessment score (p=0.3) over time between arms. CONCLUSIONS During acute severe hypovolaemic shock, patients monitored by a pulmonary artery catheter achieved broadly similar haemodynamic outcomes, using lower volumes of colloids than crystalloids. The heart rate was lower in the colloids arm.
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Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France
- U1173 Lab Inflammation& Infection, University of Versailles SQY-Paris Saclay - INSERM, Garches, France
| | - Souheil Elatrous
- service de réanimation, Centre Hospitalo-Universitaire Tahar Sfar, University of Monastir, Mahdia, Tunisia
| | - Samir Jaber
- Saint Eloi University Hospital, Montpellier, France
| | | | - Joël Cousson
- Reims University Hospital, Robert Debré Hospital, Reims, France
| | | | - Antoine Kimmoun
- Intensive Care Unit Brabois, Heart and Vessels Institute, Nancy University Hospital, Nancy, France
| | | | | | | | | | | | | | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France
- U1173 Lab Inflammation& Infection, University of Versailles SQY-Paris Saclay - INSERM, Garches, France
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Abstract
BACKGROUND Mini-fluid challenge of 100 ml colloids is thought to predict the effects of larger amounts of fluid (500 ml) in intensive care units. This study sought to determine whether a low quantity of crystalloid (50 and 100 ml) could predict the effects of 250 ml crystalloid in mechanically ventilated patients in the operating room. METHODS A total of 44 mechanically ventilated patients undergoing neurosurgery were included. Volume expansion (250 ml saline 0.9%) was given to maximize cardiac output during surgery. Stroke volume index (monitored using pulse contour analysis) and pulse pressure variations were recorded before and after 50 ml infusion (given for 1 min), after another 50 ml infusion (given for 1 min), and finally after 150 ml infusion (total = 250 ml). Changes in stroke volume index induced by 50, 100, and 250 ml were recorded. Positive fluid challenges were defined as an increase in stroke volume index of 10% or more from baseline after 250 ml. RESULTS A total of 88 fluid challenges were performed (32% of positive fluid challenges). Changes in stroke volume index induced by 100 ml greater than 6% (gray zone between 4 and 7%, including 19% of patients) predicted fluid responsiveness with a sensitivity of 93% (95% CI, 77 to 99%) and a specificity of 85% (95% CI, 73 to 93%). The area under the receiver operating curve of changes in stroke volume index induced by 100 ml was 0.95 (95% CI, 0.90 to 0.99) and was higher than those of changes in stroke volume index induced by 50 ml (0.83 [95% CI, 0.75 to 0.92]; P = 0.01) and pulse pressure variations (0.65 [95% CI, 0.53 to 0.78]; P < 0.005). CONCLUSIONS Changes in stroke volume index induced by rapid infusion of 100 ml crystalloid predicted the effects of 250 ml crystalloid in patients ventilated mechanically in the operating room.
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Rabin J, Meyenburg T, Lowery AV, Rouse M, Gammie JS, Herr D. Restricted Albumin Utilization Is Safe and Cost Effective in a Cardiac Surgery Intensive Care Unit. Ann Thorac Surg 2017; 104:42-48. [DOI: 10.1016/j.athoracsur.2016.10.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 09/02/2016] [Accepted: 10/07/2016] [Indexed: 11/25/2022]
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Spoelstra–de Man AME, Smorenberg A, Groeneveld ABJ. Different effects of fluid loading with saline, gelatine, hydroxyethyl starch or albumin solutions on acid-base status in the critically ill. PLoS One 2017; 12:e0174507. [PMID: 28380062 PMCID: PMC5381890 DOI: 10.1371/journal.pone.0174507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 03/01/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction Fluid administration in critically ill patients may affect acid-base balance. However, the effect of the fluid type used for resuscitation on acid-base balance remains controversial. Methods We studied the effect of fluid resuscitation of normal saline and the colloids gelatine 4%, hydroxyethyl starch (HES) 6%, and albumin 5% on acid-base balance in 115 clinically hypovolemic critically ill patients during a 90 minute filling pressure-guided fluid challenge by a post-hoc analysis of a prospective randomized clinical trial. Results About 1700 mL was infused per patient in the saline and 1500 mL in each of the colloid groups (P<0.001). Overall, fluid loading slightly decreased pH (P<0.001) and there was no intergroup difference. This mildly metabolic acidifying effect was caused by a small increase in chloride concentration and decrease in strong ion difference in the saline- and HES-, and an increase in (uncorrected) anion gap in gelatine- and albumin-loaded patients, independent of lactate concentrations. Conclusion In clinically hypovolemic, critically ill patients, fluid resuscitation by only 1500–1700 mL of normal saline, gelatine, HES or albumin, resulted in a small decrease in pH, irrespective of the type of fluid used. Therefore, a progressive metabolic acidosis, even with increased anion gap, should not be erroneously attributed to insufficient fluid resuscitation. Trial registration ISRCTN Registry ISRCTN19023197
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Affiliation(s)
| | - Annemieke Smorenberg
- Department of Internal Medicine, Ziekenhuis Amstelland, Amstelveen, The Netherlands
- * E-mail:
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Prone Versus Sitting Position in Neurosurgery—Differences in Patients' Hemodynamic Management. World Neurosurg 2017; 97:261-266. [DOI: 10.1016/j.wneu.2016.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 09/28/2016] [Accepted: 10/01/2016] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW Evidence-based fluid therapy is complicated by blurred boundaries toward other fields of therapy and the majority of trials not focusing on patient-relevant outcomes. Additionally, recent trials unsettled the faith in traditional concepts on fluid therapy. The article reviews the evidence on diagnosis and treatment of hypovolemia and discusses the use of balanced solutions and early goal-directed therapy (EGDT) in septic shock resuscitation. RECENT FINDINGS Hypovolemia should be diagnosed and its treatment guided by a multifaceted approach, including medical history, physical examination, volume responsiveness, and technical parameters - dynamic indicators, volumetric indicators, sonography, and metabolic indicators. Central venous pressure and pulmonary artery occlusion pressure should be avoided. In ICU patients, balanced crystalloids should primarily be used, because unbalanced infusions (especially saline) cause hyperchloremic acidosis which is associated with renal impairment and infections. Colloids are beneficial to restore blood volume rapidly. Hydroxyethyl starch may be harmful although the validity of the respective recent studies is limited by methodological flaws. Early aggressive fluid therapy is still beneficial in septic shock resuscitation, despite recent trials challenging the EGDT concept. Today, 10 years after Rivers, 'usual care' includes aggressive fluid resuscitation that is as effective as formal EGDT. SUMMARY Evidence-based fluid therapy includes a multifaceted diagnostic approach, the primary use of balanced crystalloids and early aggressive (septic) shock resuscitation.
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Moeller C, Fleischmann C, Thomas-Rueddel D, Vlasakov V, Rochwerg B, Theurer P, Gattinoni L, Reinhart K, Hartog CS. How safe is gelatin? A systematic review and meta-analysis of gelatin-containing plasma expanders vs crystalloids and albumin. J Crit Care 2016; 35:75-83. [DOI: 10.1016/j.jcrc.2016.04.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/07/2016] [Accepted: 04/08/2016] [Indexed: 12/22/2022]
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Rasmussen KC, Secher NH, Pedersen T. Effect of perioperative crystalloid or colloid fluid therapy on hemorrhage, coagulation competence, and outcome: A systematic review and stratified meta-analysis. Medicine (Baltimore) 2016; 95:e4498. [PMID: 27495098 PMCID: PMC4979852 DOI: 10.1097/md.0000000000004498] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A meta-analysis concerning perioperative coagulation competence, hemorrhage, and outcome was conducted including the use of hydroxyethyl starches (HESs), dextran, or albumin versus administration of a crystalloid as control to assess the efficacy and safety of colloids and crystalloids for fluid administration during major elective surgery. Surgery was restricted to cardiovascular and noncardiovascular surgery, and HESs were stratified to HES 130/0.4 and HES 200/0.5. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, ISI Web of Science, EMBASE, conference proceedings, reference lists, and databases of ongoing trials. RESULTS Thirty one primary clinical randomized controlled trials included 2287 patients undergoing major surgery from January 2000 to August 2015. The perioperative changes in coagulation competence were measured by thromboelastography (TEG) maximum amplitude (MA) in 9 studies administering crystalloids versus HES and in 4 studies administering albumin versus HES. All studies but 1 disclosed increased reduction in TEG-MA following HES administration (P = 0.0001 and 0.0002). The total loss of blood was reported in 17 studies in which crystalloids were compared to HES and 12 studies reported increased blood loss after administration of HES (P < 0.003). When administering albumin versus HES, 6 studies reported reduced hemorrhage associated with albumin administration (P = 0.005). Reoperation was not significantly reduced by the use of crystalloids, but may be more frequent after HESs compared to albumin (P < 0.03). In this analysis, more patients admitted to administration of HESs were exposed to decrease coagulation competence, compared to perioperative crystalloids and albumin administration. CONCLUSION This stratified meta-analysis showed that increased blood loss was found in noncardiovascular surgery among patients receiving HES compared with crystalloids, followed by a marked reduction in TEG-MA, and infusion of 3rd-generation HES products did not influence the results significantly.
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Affiliation(s)
| | | | - Tom Pedersen
- Center of Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Denmark
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Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
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Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. DATA SOURCES Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HUMAN DATA SYNTHESIS HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. VETERINARY DATA SYNTHESIS The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. CONCLUSIONS Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.
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Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 382] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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Green RS, Butler MB, Hicks SD, Erdogan M. Effect of Hydroxyethyl Starch on Outcomes in High-Risk Vascular Surgery Patients: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2016; 30:967-72. [PMID: 27222051 DOI: 10.1053/j.jvca.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients. DESIGN Retrospective case series. SETTING Single-center academic hospital. PARTICIPANTS The study included 1,395 adult vascular surgery patients with peripheral vascular disease. INTERVENTIONS Retrospective review of hospital databases. MEASUREMENTS AND MAIN RESULTS Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41). CONCLUSIONS Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.
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Affiliation(s)
- Robert S Green
- Departments of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada; Trauma Nova Scotia, Halifax, Nova Scotia, Canada.
| | - Michael B Butler
- Critical Care, Department of Mathematics and Statistics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shawn D Hicks
- Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mete Erdogan
- Trauma Nova Scotia, Halifax, Nova Scotia, Canada
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Futier E, Biais M, Godet T, Bernard L, Rolhion C, Bourdier J, Morand D, Pereira B, Jaber S. Fluid loading in abdominal surgery - saline versus hydroxyethyl starch (FLASH Trial): study protocol for a randomized controlled trial. Trials 2015; 16:582. [PMID: 26690683 PMCID: PMC4687283 DOI: 10.1186/s13063-015-1085-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/26/2015] [Indexed: 12/29/2022] Open
Abstract
Background Inappropriate fluid therapy during surgery is associated with significant morbidity and mortality. Few studies have examined the effects of particular types of fluids (crystalloid or colloid solutions) in surgical patients, especially with the goal of hemodynamic optimization. Isotonic saline is the most commonly used fluid worldwide but may be associated with potential nephrotoxicity. Hydroxyethyl starch (HES) solutions are widely used in surgical patients as a component of goal-directed fluid optimization strategies, but several large multicenter studies have suggested increased rates of acute kidney injury and adverse events with the use of HES in ICU patients. Despite what may be inferred from physiological studies, the benefit and harm of 0.9 % saline and HES during hemodynamic therapy have not been clearly established in surgical patients. Methods/Design The FLASH trial is an investigator-initiated, prospective, multicenter, randomized, double-blinded, two-arm trial, randomizing 826 patients with moderate-to-high risk of postoperative complications to receive 6 % HES 130/0.4 or 0.9 % saline during individualized goal-directed fluid optimization. The primary outcome measure is a composite of death or major postoperative complications within 14 days following surgery. The sample size will allow the detection of a 10 % absolute between-group difference in the primary outcome measure with a type 1 error rate of 5 % and power of 95 %, assuming a 5 % mortality rate and 20 % morbidity (thus 25 % for the composite endpoint). Discussion The FLASH trial may provide important data on the efficacy and safety of commonly used fluid solutions and could have a significant impact on future treatment of surgical patients. Trial registration ClinicalTrials.gov Identifier: NCT02502773. Registered 16 June 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1085-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emmanuel Futier
- CHU de Clermont-Ferrand, Département Anesthésie et Réanimation, Pôle Médecine Périopératoire (MPO), Hôpital Estaing, 1 place Lucie Aubrac, 63001, Clermont-Ferrand cedex 1, France.
| | - Matthieu Biais
- CHU de Bordeaux, Service Anesthésie et Réanimation III, Unité de Neuro-Réanimation, Hôpital Pellegrin, Tripode, Bordeaux, F-33076, France.
| | - Thomas Godet
- CHU de Clermont-Ferrand, Département Anesthésie et Réanimation, Pôle Médecine Périopératoire (MPO), Hôpital Estaing, 1 place Lucie Aubrac, 63001, Clermont-Ferrand cedex 1, France.
| | - Lise Bernard
- CHU de Clermont-Ferrand, Pôle Pharmacie, et EA 467 C-BIOSENSS, BP 10448, Clermont-Ferrand, F-63003, France.
| | - Christine Rolhion
- CHU de Clermont-Ferrand, Direction de la Recherche Clinique (DRCI), Clermont-Ferrand, F-63003, France.
| | - Justine Bourdier
- CHU de Clermont-Ferrand, Direction de la Recherche Clinique (DRCI), Clermont-Ferrand, F-63003, France.
| | - Dominique Morand
- CHU de Clermont-Ferrand, Direction de la Recherche Clinique (DRCI), Clermont-Ferrand, F-63003, France.
| | - Bruno Pereira
- CHU de Clermont-Ferrand, Biostatistics unit, Direction de la Recherche Clinique (DRCI), Clermont-Ferrand, F-63003, France.
| | - Samir Jaber
- CHU de Montpellier, Département Anesthésie et Réanimation B (DAR B), Hôpital Saint-Eloi, et INSERM U-1046, Montpellier, F-34295, France.
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Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients. Br J Surg 2015; 103:14-26. [DOI: 10.1002/bjs.9943] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/24/2015] [Accepted: 08/19/2015] [Indexed: 11/10/2022]
Abstract
Abstract
Background
There is uncertainty regarding the safety of different volume replacement solutions. The aim of this study was systematically to review evidence of crystalloid versus colloid solutions, and to determine whether these results are influenced by trial design or clinical setting.
Methods
PubMed, Embase and the Cochrane Central Register of Controlled Trials were used to identify randomized clinical trials (RCTs) that compared crystalloids with colloids as volume replacement solutions in patients with traumatic injuries, those undergoing surgery and in critically ill patients. Adjusted odds ratios (ORs) for mortality and major morbidity including renal injury were pooled using fixed-effect and random-effects models.
Results
Some 59 RCTs involving 16 889 patients were included in the analysis. Forty-one studies (69 per cent) were found to have selection, detection or performance bias. Colloid administration did not lead to increased mortality (32 trials, 16 647 patients; OR 0·99, 95 per cent c.i. 0·92 to 1·06), but did increase the risk of developing acute kidney injury requiring renal replacement therapy (9 trials, 11 648 patients; OR 1·35, 1·17 to 1·57). Sensitivity analyses that excluded small and low-quality studies did not substantially alter these results. Subgroup analyses by type of colloid showed that increased mortality and renal replacement therapy were associated with use of pentastarch, and increased risk of renal injury and renal replacement therapy with use of tetrastarch. Subgroup analysis indicated that the risks of mortality and renal injury attributable to colloids were observed only in critically ill patients with sepsis.
Conclusion
Current general restrictions on the use of colloid solutions are not supported by evidence.
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Affiliation(s)
- S H Qureshi
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - S I Rizvi
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - N N Patel
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - G J Murphy
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
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Mini-fluid challenge predicts fluid responsiveness during spontaneous breathing under spinal anaesthesia. Eur J Anaesthesiol 2015; 32:645-9. [DOI: 10.1097/eja.0000000000000175] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clemente G, Tuttolomondo A, Colomba D, Pecoraro R, Renda C, Della Corte V, Maida C, Simonetta I, Pinto A. When sepsis affects the heart: A case report and literature review. World J Clin Cases 2015; 3:743-750. [PMID: 26301236 PMCID: PMC4539415 DOI: 10.12998/wjcc.v3.i8.743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/24/2014] [Accepted: 06/16/2015] [Indexed: 02/05/2023] Open
Abstract
A 59-year-old nursing home patient with Down syndrome was brought to the internal medicine department of our hospital due to fever, cough without expectorate, and dyspnea. A thoracic computed tomography revealed the presence of bilateral basal parenchymal opacities. Her condition deteriorated after admission and troponin reached a peak serum concentration of 16.9 ng/mL. The patient was in cardiogenic shock. In addition to fluid resuscitation, vaso-active amine infusion was administered to achieve hemodynamic stabilization. The differential diagnosis investigated possible pulmonary embolism, myocardial infarction, and myocarditis. Furthermore, a second transthoracic echocardiogram suggested Tako-Tsubo syndrome. This is a septic patient. The purpose of this manuscript is to review studies which formerly examined the possible association between high levels of troponin and mortality to see if it can be considered a positive predictive factor of fatal prognosis as the case of thrombocytopenia, already a positive independent predictive factor of multiple organ failure syndrome, and generally to characterize risk profile in a septic patient.
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Orbegozo Cortés D, Gamarano Barros T, Njimi H, Vincent JL. Crystalloids Versus Colloids. Anesth Analg 2015; 120:389-402. [DOI: 10.1213/ane.0000000000000564] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Fluid management in the cardiothoracic intensive care unit: diuresis--diuretics and hemofiltration. Curr Opin Anaesthesiol 2014; 27:133-9. [PMID: 24514030 DOI: 10.1097/aco.0000000000000055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The present review discusses the current concepts of fluid management in cardiothoracic surgery, and its clinical implications with special reference to organ-related complications and their prevention. RECENT FINDINGS Current strategies in fluid management for cardiothoracic patients, various fluid formulation, and the preventive strategies for minimizing fluid-related complications are described, with particular reference to new discoveries and controversies that have arisen from recent literature. SUMMARY The optimal fluid management in cardiothoracic patients has not been settled. Results of recent clinical published trials highlight the need for minimizing fluid administration and attempting to use diuretics to achieve a negative fluid, although hypovolemia and hypoperfusion should be carefully considered. An individualized optimization of fluid status, using goal-directed therapy, has emerged as a possible preferable approach. The old debate between crystalloid and colloid solutions has been partially solved, as some colloids have demonstrated deleterious effect on renal function and coagulation system. Various preventive strategies have also emerged for minimizing fluid-related complications.
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Lindroos AC, Niiya T, Randell T, Niemi TT. Stroke volume-directed administration of hydroxyethyl starch (HES 130/0.4) and Ringer’s acetate in prone position during neurosurgery: a randomized controlled trial. J Anesth 2014; 28:189-97. [PMID: 24077833 DOI: 10.1007/s00540-013-1711-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 09/04/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE General anesthesia in the prone position is associated with hypotension. We studied stroke volume (SV)-directed administration of hydroxyethyl starch (HES 130 kDa/0.4) and Ringer’s acetate (RAC) in neurosurgical patients operated on in a prone position to determine the volumes required for stable hemodynamics and possible coagulatory effects. METHODS Thirty elective neurosurgical patients received either HES (n = 15) or RAC (n = 15). Before positioning, SV measured by arterial pressure waveform analysis was maximized by fluid boluses until SV did not increase more than 10 %. SV was maintained by repeated administration of fluid. RAC 3 ml/kg/h was infused in both groups. Thromboelastometry assessed coagulation. Mann–Whitney U test, Wilcoxon signed-rank test, ANOVA on ranks, and a linear mixed model were applied. RESULTS Comparable hemodynamics were achieved with the mean cumulative (SD) boluses of HES or RAC 240 (51) or 267 (62) ml (P = 0.207) before positioning, 340 (124) or 453 (160) ml (P = 0.039) 30 min after positioning, and 440 (229) or 653 (368) ml at the end of surgery (P = 0.067). The mean dose of basal RAC infusion was 813 (235) and 868 (354) ml (P = 0.620) in the HES and RAC group, respectively. Formation and maximum strength of the fibrin clot were decreased in the HES group. Intraoperative blood loss was comparable between groups (P = 0.861). CONCLUSION The amount of RAC needed in the prone position was 25 % greater. The cumulative dose of 440 ml HES induced a slight disturbance in fibrin formation and clot strength. We suggest cautious administration of HES during neurosurgery.
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Coetzee A, Dyer RA, James MFM, Joubert IA, Levin A, Piercy J, Swanevelder J, Van der Merwe W. Evidence-based approach to the use of starch-containing intravenous fluids: an official response by two Western Cape University Hospitals. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2013.10872922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- A Coetzee
- 1Department of Anesthesiology and Critical Care, University of Stellenbosch and Tygerberg Hospital
| | - RA Dyer
- 2Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital
| | - MFM James
- 2Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital
| | - IA Joubert
- 3Department of Critical Care, University of Cape Town and Groote Schuur Hospital Authors in alphabetical order
| | - A Levin
- 1Department of Anesthesiology and Critical Care, University of Stellenbosch and Tygerberg Hospital
| | - J Piercy
- 3Department of Critical Care, University of Cape Town and Groote Schuur Hospital Authors in alphabetical order
| | - J Swanevelder
- 2Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital
| | - W Van der Merwe
- 1Department of Anesthesiology and Critical Care, University of Stellenbosch and Tygerberg Hospital
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Nunes TSO, Ladeira RT, Bafi AT, de Azevedo LCP, Machado FR, Freitas FGR. Duration of hemodynamic effects of crystalloids in patients with circulatory shock after initial resuscitation. Ann Intensive Care 2014; 4:25. [PMID: 25593742 PMCID: PMC4273721 DOI: 10.1186/s13613-014-0025-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 07/14/2014] [Indexed: 12/30/2022] Open
Abstract
Background In the later stages of circulatory shock, monitoring should help to avoid fluid overload. In this setting, volume expansion is ideally indicated only for patients in whom the cardiac index (CI) is expected to increase. Crystalloids are usually the choice for fluid replacement. As previous studies evaluating the hemodynamic effect of crystalloids have not distinguished responders from non-responders, the present study was designed to evaluate the duration of the hemodynamic effects of crystalloids according to the fluid responsiveness status. Methods This is a prospective observational study conducted after the initial resuscitation phase of circulatory shock (>6 h vasopressor use). Critically ill, sedated adult patients monitored with a pulmonary artery catheter who received a fluid challenge with crystalloids (500 mL infused over 30 min) were included. Hemodynamic variables were measured at baseline (T0) and at 30 min (T1), 60 min (T2), and 90 min (T3) after a fluid bolus, totaling 90 min of observation. The patients were analyzed according to their fluid responsiveness status (responders with CI increase >15% and non-responders ≤15% at T1). The data were analyzed by repeated measures of analysis of variance. Results Twenty patients were included, 14 of whom had septic shock. Overall, volume expansion significantly increased the CI: 3.03 ± 0.64 L/min/m2 to 3.58 ± 0.66 L/min/m2 (p < 0.05). From this period, there was a progressive decrease: 3.23 ± 0.65 L/min/m2 (p < 0.05, T2 versus T1) and 3.12 ± 0.64 L/min/m2 (p < 0.05, period T3 versus T1). Similar behavior was observed in responders (13 patients), 2.84 ± 0.61 L/min/m2 to 3.57 ± 0.65 L/min/m2 (p < 0.05) with volume expansion, followed by a decrease, 3.19 ± 0.69 L/min/m2 (p < 0.05, T2 versus T1) and 3.06 ± 0.70 L/min/m2 (p < 0.05, T3 versus T1). Blood pressure and cardiac filling pressures also decreased significantly after T1 with similar findings in both responders and non-responders. Conclusions The results suggest that volume expansion with crystalloids in patients with circulatory shock after the initial resuscitation has limited success, even in responders.
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Affiliation(s)
- Thieme Souza Oliveira Nunes
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5° andar, São Paulo SP 04024-900, Brazil
| | - Renata Teixeira Ladeira
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5° andar, São Paulo SP 04024-900, Brazil
| | - Antônio Tonete Bafi
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5° andar, São Paulo SP 04024-900, Brazil
| | - Luciano Cesar Pontes de Azevedo
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5° andar, São Paulo SP 04024-900, Brazil
| | - Flavia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5° andar, São Paulo SP 04024-900, Brazil
| | - Flávio Geraldo Rezende Freitas
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5° andar, São Paulo SP 04024-900, Brazil
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Patel A, Laffan MA, Waheed U, Brett SJ. Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality. BMJ 2014; 349:g4561. [PMID: 25099709 PMCID: PMC4106199 DOI: 10.1136/bmj.g4561] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of pooled human albumin solutions as part of fluid volume expansion and resuscitation (with or without improvement of baseline hypoalbuminaemia) in critically unwell adults with sepsis of any severity. DESIGN Systematic review and meta-analysis of randomised clinical trials, with trial sequential analysis, subgroup, and meta-regression analyses. DATA SOURCES PubMed, PubMed Central, Web of Science (includes Medline, Conference Proceedings Citation Index, Data Citation Index, Chinese Science Citation Database, CAB abstracts, Derwent Innovations Index), OvidSP (includes Embase, Ovid Medline, HMIC, PsycINFO, Maternity and Infant Care, Transport Database), Cochrane Library, clinicaltrials.gov, controlled-trials.com, online material, relevant conference proceedings, hand searching of reference lists, and contact with authors as necessary. ELIGIBILITY CRITERIA Prospective randomised clinical trials of adults with sepsis of any severity (with or without baseline hypoalbuminaemia) in critical or intensive care who received pooled human albumin solutions as part of fluid volume expansion and resuscitation (with or without improvement of hypoalbuminaemia) compared with those who received control fluids (crystalloid or colloid), were included if all-cause mortality outcome data were available. No restriction of language, date, publication status, or primary study endpoint was applied. DATA EXTRACTION Two reviewers independently assessed articles for inclusion, extracted data to assess risk of bias, trial methods, patients, interventions, comparisons, and outcome. The relative risk of all-cause mortality was calculated using a random effects model accounting for clinical heterogeneity. PRIMARY OUTCOME MEASURE All-cause mortality at final follow-up. RESULTS Eighteen articles reporting on 16 primary clinical trials that included 4190 adults in critical or intensive care with sepsis, severe sepsis, or septic shock. A median of 70.0 g daily of pooled human albumin was received over a median of 3 days by adults with a median age of 60.8 years as part of fluid volume expansion and resuscitation, with or without correction of hypoalbuminaemia. The relative risk of death was similar between albumin groups (that received a median of 175 g in total) and control fluid groups (relative risk 0.94; 95% confidence interval 0.87 to 1.01; P=0.11; I(2)=0%). Trial sequential analysis corrected the 95% confidence interval for random error (0.85 to 1.02; D(2)=0%). Eighty eight per cent of the required information size (meta-analysis sample size) of 4894 patients was achieved, and the cumulative effect size measure (z score) entered the futility area, supporting the notion of no relative benefit of albumin (GRADE quality of evidence was moderate). Evidence of no difference was also found when albumin was compared with crystalloid fluid (relative risk 0.93; 0.86 to 1.01; P=0.07; I(2)=0%) in 3878 patents (GRADE quality of evidence was high; 79.9% of required information size) or colloid fluids in 299 patients (relative risk 1.04; 0.79 to 1.38; P=0.76; I(2)=0%) (GRADE quality of evidence was very low; 5.8% of required information size). When studies at high risk of bias were excluded in a predefined subgroup analysis, the finding of no mortality benefit remained, and the cumulative z score was just outside the boundary of futility. Overall, the meta-analysis was robust to sensitivity, subgroup, meta-regression, and trial sequential analyses. CONCLUSIONS In this analysis, human albumin solutions as part of fluid volume expansion and resuscitation for critically unwell adults with sepsis of any severity (with or without baseline hypoalbuminaemia) were not robustly effective at reducing all-cause mortality. Albumin seems to be safe in this setting, as a signal towards harm was not detected, but this analysis does not support a recommendation for use.
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Affiliation(s)
- Amit Patel
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK MRC Clinical Sciences Centre, Hammersmith Hospital, Imperial College London, London, UK Centre for Haematology, Hammersmith Hospital, Imperial College London, London, UK
| | - Michael A Laffan
- Centre for Haematology, Hammersmith Hospital, Imperial College London, London, UK
| | - Umeer Waheed
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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Wu Y, Zhou S, Zhou Z, Liu B. A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R108. [PMID: 24886990 PMCID: PMC4075154 DOI: 10.1186/cc13891] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 05/12/2014] [Indexed: 12/29/2022]
Abstract
Introduction The accurate assessment of intravascular volume status for the therapy of severe hypovolemia and shock is difficult and critical to critically ill patients. Non-invasive evaluation of fluid responsiveness by the rapid infusion of a very limited amount of volume is an important clinical goal. This study aimed to test whether echocardiographic parameters could predict fluid responsiveness in critically ill patients following a low-volume (50-ml crystalloid solution) infusion over 10 seconds. Methods We prospectively studied 55 mechanically ventilated patients. Echocardiography was performed during a 50-ml infusion of crystalloid solution over 10 seconds and a further 450 ml over 15 minutes. Cardiac output (CO), stroke volume (SV), aortic velocity time index (VTI), and left ventricular ejection fraction (LVEF) were recorded. Patients were classified as responders (Rs) if CO increased by at least 15% following the 500-ml volume expansion or were classified as non-responders (NRs) if CO increased by less than 15%. Area under the receiver operating characteristic curves (AUC) compared CO variations after 50 ml over 10 seconds (∆CO50) and 500 ml over 15 minutes (∆CO500) and the variation of VTI after infusion of 50 ml of fluid over 10 seconds (∆VTI50). Results In total, 50 patients were enrolled, and 27 (54%) of them were Rs. General characteristics, LVEF, heart rate, and central venous pressure were similar between Rs and NRs. In the Rs group, the AUC for ∆CO50 was 0.95 ± 0.03 (P <0.01; best cutoff value, 6%; sensitivity, 93%; specificity, 91%). Moreover, ∆CO50 and ∆CO500 were strongly correlated (r = 0.87; P <0.01). The AUC for ∆VTI50 was 0.91 ± 0.04 (P <0.01; best cutoff value, 9%; sensitivity, 74%; specificity, 95%). ∆VTI50 and ∆CO500 were positively correlated (r = 0.72; P <0.01). Conclusion In critically ill patients, the variation of CO and VTI after the administration of 50-ml crystalloid solution over 10 seconds (∆CO50 and ∆VTI50) can accurately predict fluid responsiveness. Trial registration Current Controlled Trials ISRCTN10524328. Registered 12 December 2013.
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