Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333

We read the article by Theodoraki K and colleagues entitled 'Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter' with interest [...].

Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure

BACKGROUND

Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown.

METHODS

A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF).

RESULTS

We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023).

CONCLUSIONS

There was a complex U‑shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

Starch Wars-New Episodes of the Saga. Changes in Regulations on Hydroxyethyl Starch in the European Union

After a safety review of hydroxyethyl starch (HES) solutions in 2013, restrictions on the use of HES were introduced in the European Union (EU) to reduce the risk of kidney injury and death in certain patient populations. Similar restrictions were introduced by the Food and Drug Administration in the United States and other countries. In October 2017, a second safety review of HES solutions was triggered by the European pharmacovigilance authorities based on a request by the Swedish Medical Products Agency to completely suspend HES. After several meetings and repeated evaluations, the recommendation to ban HES was ultimately not endorsed by the responsible committee; however, there was a vote for more restricted access to the drug and rigorous monitoring of policy adherence. This review delineates developments in the European pharmacovigilance risk assessment of HES solutions between 2013 and 2018. In addition, the divergent experts' opinions and the controversy surrounding this official assessment are described. As the new decisions might influence the availability of HES products for veterinary patients, potential alternatives to HES solutions, such as albumin solutions and gelatin, are briefly discussed.

Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients.

Methods

The CRISTAL trial prospectively defined patients as critically ill surgical patients whenever they underwent emergency or scheduled surgery immediately before or within 24 h of intensive care unit admission and had hypovolemic shock. The primary outcome measure was death by day 28. Secondary outcome measures included death by day 90, the need for renal replacement therapy, or the need for fresh frozen plasma transfusion.

Results

There were 741 critically ill surgical patients, 356 and 385 in the crystalloid and colloid arm, respectively. Median (interquartile range) age was 66 (52 to 76) yr, and 484 (65.3%) patients were male. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) versus colloids 100 (26%; adjusted odds ratio, 0.86; 95% CI, 0.61 to 1.21; P = 0.768). Death by day 90 (111 [31.2%] vs. 122 [31.7%]; adjusted odds ratio, 0.97; 95% CI, 0.70 to 1.33; P = 0.919) did not significantly differ between groups. Renal replacement therapy was required for 42 (11.8%) patients in the crystalloids arm versus 49 (12.7%) in the colloids arm (P = 0.871).

Conclusions

The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.

Does Fluid Type and Amount Affect Kidney Function in Critical Illness?

Acute kidney injury (AKI) is common, although commonly used clinical diagnostic markers are imperfect. Intravenous fluid administration remains a cornerstone of therapy worldwide, but there is minimal evidence of efficacy for the use of fluid bolus therapy outside of specific circumstances, and emerging evidence associates fluid accumulation with worse renal outcomes and even increased mortality among critically ill patients. Artificial colloid solutions have been associated with harm, and chloride-rich solutions may adversely affect renal function. Large trials to provide guidance regarding the optimal fluid choices to prevent or ameliorate AKI, and promote renal recovery, are urgently required.

Maintenance fluid therapy in a tertiary hospital: A prevalence study

OBJECTIVE

To assess the types of maintenance fluids used in our hospital, comparing their volume and composition to the standards recommended by the guidelines.

MATERIAL AND METHODS

Observational, cross-sectional study. Volume and type of fluid therapy administered during 24h to patients admitted to various hospital departments were recorded. Patients receiving fluid therapy because of water-electrolyte imbalance were excluded.

RESULTS

Out of 198 patients registered, 74 (37.4%) were excluded because they did not meet the criteria for inclusion. Mean administered volume was 2,500cc/day. Mean daily glucose dose was 36g per 24h (SD: 31.4). The most frequent combination included normal saline solution (NSS) and glucose 5% (64.4%). Mean daily dose of sodium and chlorine was, respectively, 173mEq (SD: 74.8) and 168mEq (SD: 75), representing a surplus daily dose of +87.4mEq and +85mEq. Potassium, magnesium and calcium daily deficit was, respectively, -50mEq, -22mEq and -21mEq per day. Buffer administration was exceptional, bicarbonate (2.29%), acetate (1.29%), lactate (1.15%) and gluconate (1.10%) being the buffering agents most frequently used.

CONCLUSION

NNS is the most frequently used solution. In contrast to excess doses of sodium and chlorine, there is a great deficit of other ions, buffering agents and caloric intake in the fluid therapy regimens that are usually prescribed.

Comparison of hydroxyethyl starch regulatory summaries from the Food and Drug Administration and the European Medicines Agency

This article aims to highlight the positions of the Food and Drug Administration and the European Medicines Agency regarding use and marketing of hydroxyethyl starch (HES) products, and how these have changed over recent years. In 2013, warnings from both agencies advised against use of HES in critically ill patients, including patients with sepsis, when several large randomized controlled trials on volume resuscitation in critical illness failed to observe clinically beneficial effects of HES. In areas such as patient monitoring and requirements for further clinical trials, the FDA and EMA are very much in agreement in their recommendations. However, EMA guidance is generally more restrictive on HES usage compared to that from the FDA. Differences in data presented to regulatory authorities, bias in study results and inherent weakness of meta-analyses used for drug surveillance purposes, plus different risk-management approaches used by the two regulatory authorities, likely contribute to different outcomes in their regulations concerning use of HES.

Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care

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.

The effect of tranexamic acid on blood coagulation in total hip replacement arthroplasty: rotational thromboelastographic (ROTEM®) analysis

We evaluated changes in rotational thromboelastometry (ROTEM(®) ) parameters and clinical outcomes in patients undergoing total hip replacement arthroplasty, with concomitant infusions of tranexamic acid and of 6% hydroxyethyl starch 130/0.4. Fifty-five patients were randomly assigned to either the tranexamic acid (n = 29) or the control (n = 26) group. Hydroxyethyl starch was administered in the range of 10-15 ml.kg(-1) during the operation in both groups. In the control group, the clot formation time and maximum clot firmness of APTEM showed significant differences when compared with those of EXTEM at one hour postoperatively, suggestive of fibrinolysis. In the tranexamic acid group, there was no significant difference between each postoperative EXTEM and APTEM parameter. In the tranexamic acid and control group, postoperative blood loss was 308 ml (210-420 [106-745]) and 488 ml (375-620 [170-910], p = 0.002), respectively, and total blood loss was 1168 ml (922-1470 [663-2107]) and 1563 ml (1276-1708 [887-1494], p = 0.003). Haemoglobin concentration was higher in the tranexamic acid group on the second postoperative day (10.5 (9.4-12.1 [7.9-14.0]) vs. 9.6 (8.9-10.5[7.3-16.0]) g.dl(-1) , p = 0.027). In patients undergoing total hip replacement arthroplasty, postoperative fibrinolysis aggravated by hydroxyethyl starch was attenuated by co-administration of 10 mg.kg(-1) tranexamic acid, which may have led to less postoperative blood loss.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

OBJECTIVE

To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.

DESIGN

Retrospective cohort study of population based data between 2006 and 2013.

SETTING

Data from 510 different hospitals across the United States participating in the Premier Perspective database.

PARTICIPANTS

1,051,441 patients undergoing elective total hip and knee arthroplasties.

EXPOSURES

Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither.

MAIN OUTCOME MEASURES

Acute renal failure and thromboembolic, cardiac, and pulmonary complications.

RESULTS

Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased.

CONCLUSIONS

Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.

Acute kidney injury with hydroxyethyl starch 130/0.42 in severe sepsis

BACKGROUND

We aimed to detail the effects of hydroxyethyl starch (HES) vs. Ringer's on kidney function including the interaction with mortality in post-hoc analyses as resuscitation with HES 130/0.42 increased mortality in the Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial.

METHODS

In all 798 randomised patients, we assessed the incidence and effect on mortality of acute kidney injury (AKI) in the HES vs. Ringer's acetate groups using the Kidney Disease: Improving Global Outcome criteria. We also assessed the intervention effect on time to and duration of renal replacement therapy (RRT).

RESULTS

At baseline, the intervention groups were similar. The maximal AKI stage was higher in the HES vs. Ringer's group within the first 5 days after randomisation (P = 0.03), the average difference being 0.2 points (P < 0.01). An increase in AKI stage was associated with mortality (hazard ratio (HR) 1.35; 95% CI 1.22 to 1.49; P < 0.01). Significantly, more patients in the HES group received RRT within the first 5 days (P = 0.01), and the time to initiation of RRT was also shorter compared with the Ringer's group (HR 1.40; 95% CI 1.01-1.93; P = 0.04). The intervention effect of HES on mortality was reduced when adjusting for AKI stage as a time-dependent covariate (P = 0.15).

CONCLUSION

In patients with severe sepsis, HES appeared to increase the rate of severe AKI and use of RRT within the first 5 days. The increased mortality observed with HES may have been partly mediated through acute kidney impairment.

Fluid resuscitation in acute medicine: what is the current situation?

The administration of intravenous fluids for resuscitation is the most common intervention in acute medicine. There is increasing evidence that the type of fluid may directly affect patient-centred outcomes. There is a lack of evidence that colloids confer clinical benefit over crystalloids and they may be associated with harm. Hydroxyethyl starch preparations are associated with increased mortality and use of renal replacement therapy in critically ill patients, particularly those with sepsis; albumin is associated with increased mortality in patients with severe traumatic brain injury. Crystalloids, such as saline or balanced salt solutions, are increasingly recommended as first-line resuscitation fluids for the majority of patients with hypovolaemia. There is emerging evidence that saline may be associated with adverse outcomes due to the development of hyperchloraemic metabolic acidosis, although the safety of balanced salt solutions has not been established. Fluid requirements vary over the course of critical illness. The excessive use of fluids during the resuscitative period is associated with increased cumulative fluid balance and adverse outcomes in critically ill patients. The selection of fluid depends on the clinical context in which it is administered and requires careful consideration of the dose and potential for toxicity. There is an urgent need to conduct further high-quality randomized controlled trials of currently available fluid therapy in patients with critical illness.

Colloid versus crystalloid fluid therapy in surgical patients

An appraisal of illogical guidance