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Hahn RG, Van Regenmortel N. Is the NICE Guideline for maintenance fluid therapy in adults in hospital appropriate? Clin Nutr ESPEN 2024; 63:113-120. [PMID: 38943651 DOI: 10.1016/j.clnesp.2024.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/13/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND AND AIMS The National Institute for Health and Care Excellence's (NICE) Guideline for Maintenance Fluid Therapy in Adults in Hospital is widely used, but the recommendations have not been evaluated properly. In this study, we investigated whether the recommendation of providing 25-30 mL/kg/day of fluid and 1 mmol/kg each of sodium and potassium is sufficient for human needs. METHODS First, we calculated the distribution of fluid between the extracellular fluid volume (ECV) and intracellular fluid volume (ICV) during a cross-over infusion experiment where 12 volunteers received 25 mL/kg/day of either a high-sodium (154 mmol/L) or low-sodium (54 mmol/L) solution over 48 h. Second, urine samples from 719 volunteers and clinical patients were used to quantify their renal water conservation and excretion of sodium and potassium. Third, retrospective analysis of a diet study was used to extrapolate how large the fluid intake and the electrolyte excretion likely had been in the 719 volunteers and hospital patients who delivered urine. RESULTS The high-sodium fluid maintained the ECV but the ICV had decreased by 1.3 L after 48 h. The low-sodium fluid resulted in a volume deficit of 1.7 L that equally affected the ECV and the ICV. Regression equations based on the diet study suggested that the daily intake of water in the 719 subjects averaged 2.6 L and that 2 mmol/kg of sodium and 1 mmol/kg of potassium was excreted. CONCLUSION The NICE guideline recommends too little water and sodium for a human to adequately maintain the ECV and ICV. CLINICAL TRIAL REGISTRATIONS EudraCT 2016-001846-24 and ISRCTN 12215472.
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Affiliation(s)
- Robert G Hahn
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden.
| | - Niels Van Regenmortel
- Intensive Care Physician, Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium; Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Antwerp, Belgium
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Hahn RG. Fluid distribution during surgery in the flat recumbent, Trendelenburg, and the reverse Trendelenburg body positions. Acta Anaesthesiol Scand 2024. [PMID: 38816073 DOI: 10.1111/aas.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The distribution and elimination of infused crystalloid fluid is known to be affected by general anesthesia, but it is unclear whether changes differ depending on whether the patient is operated in the flat recumbent position, the Trendelenburg ("legs up") position, or the reverse Trendelenburg ("head up") position. METHODS Retrospective data on hemodilution and urine output obtained during and after infusion of 1-2 L of Ringer's solution over 30-60 min were collected from 61 patients undergoing surgery under general anesthesia and 106 volunteers matched with respect to the infusion volume and infusion time. Parameters describing fluid distribution in the anesthetized and awake subjects were compared by population volume kinetic analysis. RESULTS General anesthesia decreased the rate constant for urine output by 79% (flat recumbent), 91% (legs up) and 91% (head up), suggesting that laparoscopic surgery per se intensified the already strong anesthesia-induced fluid retention. General anesthesia also decreased the rate constant governing the return of the distributed fluid to the plasma by 32%, 15%, and 70%, respectively. These results agree with laboratory data showing a depressive effect of anesthetic drugs on lymphatic pumping, and further suggest that the "legs up" position facilitates lymphatic flow, whereas the "head up" position slows this flow. Both Trendelenburg positions increased swelling of the "third fluid space". CONCLUSIONS General anesthesia caused retention of infused fluid with preferential distribution to the extravascular space. Both Trendelenburg positions had a modifying influence on the kinetic adaptations that agreed with the gravitational forces inflicted by tilting to body.
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Affiliation(s)
- Robert G Hahn
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Krnić J, Madirazza K, Pecotić R, Benzon B, Carev M, Đogaš Z. The Effects of Volatile Anesthetics on Renal Sympathetic and Phrenic Nerve Activity during Acute Intermittent Hypoxia in Rats. Biomedicines 2024; 12:910. [PMID: 38672264 PMCID: PMC11048470 DOI: 10.3390/biomedicines12040910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/07/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Coordinated activation of sympathetic and respiratory nervous systems is crucial in responses to noxious stimuli such as intermittent hypoxia. Acute intermittent hypoxia (AIH) is a valuable model for studying obstructive sleep apnea (OSA) pathophysiology, and stimulation of breathing during AIH is known to elicit long-term changes in respiratory and sympathetic functions. The aim of this study was to record the renal sympathetic nerve activity (RSNA) and phrenic nerve activity (PNA) during the AIH protocol in rats exposed to monoanesthesia with sevoflurane or isoflurane. Adult male Sprague-Dawley rats (n = 24; weight: 280-360 g) were selected and randomly divided into three groups: two experimental groups (sevoflurane group, n = 6; isoflurane group, n = 6) and a control group (urethane group, n = 12). The AIH protocol was identical in all studied groups and consisted in delivering five 3 min-long hypoxic episodes (fraction of inspired oxygen, FiO2 = 0.09), separated by 3 min recovery intervals at FiO2 = 0.5. Volatile anesthetics, isoflurane and sevoflurane, blunted the RSNA response to AIH in comparison to urethane anesthesia. Additionally, the PNA response to acute intermittent hypoxia was preserved, indicating that the respiratory system might be more robust than the sympathetic system response during exposure to acute intermittent hypoxia.
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Affiliation(s)
- Josip Krnić
- Department of Emergency Medicine, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
- Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Katarina Madirazza
- Department of Neuroscience, University of Split School of Medicine, Šoltanska 2A, 21000 Split, Croatia
| | - Renata Pecotić
- Department of Neuroscience, University of Split School of Medicine, Šoltanska 2A, 21000 Split, Croatia
| | - Benjamin Benzon
- Department of Anatomy, University of Split School of Medicine, Šoltanska 2A, 21000 Split, Croatia
| | - Mladen Carev
- Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Zoran Đogaš
- Department of Neuroscience, University of Split School of Medicine, Šoltanska 2A, 21000 Split, Croatia
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Abstract
Perioperative oliguria is an alarm signal. The initial assessment includes closer patient monitoring, evaluation of volemic status, risk-benefit of fluid challenge or furosemide stress test, and investigation of possible perioperative complications.
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Affiliation(s)
- Roberta T. Tallarico
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco
| | - Ian E. McCoy
- Department of Medicine, Division of Nephrology, University of California San Francisco
| | - Francois Dépret
- Department of Anesthesiology and Critical Care Medicine, St-Louis Hospital, Assistance-Publique Hopitaux de Paris, France
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco
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Schmitz-Peiffer F, Lukas M, Mohan AM, Albrecht J, Aschenbach JR, Brenner W, Beindorff N. Effects of isoflurane anaesthesia depth and duration on renal function measured with [ 99mTc]Tc-mercaptoacetyltriglycine SPECT in mice. EJNMMI Res 2024; 14:4. [PMID: 38180547 PMCID: PMC10769950 DOI: 10.1186/s13550-023-01065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/20/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND The influence of anaesthetic depth and the potential influence of different anaesthetic beds and thus different handling procedures were investigated in 86 severe combined immunodeficient (SCID) mice using semi-stationary dynamic single photon emission computed tomography (SPECT) for kidney scintigraphy. Therefore, isoflurane concentrations were adjusted using respiratory rate for low (80-90 breath/min) and deep anaesthesia (40-45 breath/min). At low anaesthesia, we additionally tested the influence of single bed versus 3-mouse bed hotel; the hotel mice were anaesthetized consecutively at ~ 30, 20, and 10 min before tracer injections for positions 1, 2, and 3, respectively. Intravenous [99mTc]Tc-MAG3 injection of ~ 28 MBq was performed after SPECT start. Time-activity curves were used to calculate time-to-peak (Tmax), T50 (50% clearance) and T25 (75% clearance). RESULTS Low and deep anaesthesia corresponded to median isoflurane concentrations of 1.3% and 1.5%, respectively, with no significant differences in heart rate (p = 0.74). Low anaesthesia resulted in shorter aortic blood clearance half-life (p = 0.091) and increased relative renal tracer influx rate (p = 0.018). A tendency toward earlier Tmax occurred under low anaesthesia (p = 0.063) with no differences in T50 (p = 0.40) and T25 (p = 0.24). Variance increased with deep anaesthesia. Compared to single mouse scans, hotel mice in position 1 showed a delayed Tmax, T50, and T25 (p < 0.05 each). Furthermore, hotel mice in position 1 showed delayed Tmax versus position 3, and delayed T50 and T25 versus position 2 and 3 (p < 0.05 each). No difference occurred between single bed and positions 2 (p = 1.0) and 3 (p = 1.0). CONCLUSIONS Deep anaesthesia and prolonged low anaesthesia should be avoided during renal scintigraphy because they result in prolonged blood clearance half-life, delayed renal influx and/or later Tmax. Vice versa, low anaesthesia with high respiratory rates of 80-90 rpm and short duration (≤ 20 min) should be preferred to obtain representative data with low variance.
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Affiliation(s)
- Fabian Schmitz-Peiffer
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mathias Lukas
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ajay-Mohan Mohan
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jakob Albrecht
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg R Aschenbach
- Institute of Veterinary Physiology, School of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Winfried Brenner
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nicola Beindorff
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Hahn RG. Evidence of serial connection between the plasma volume and two interstitial fluid compartments. Microvasc Res 2024; 151:104599. [PMID: 37659464 DOI: 10.1016/j.mvr.2023.104599] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Kinetic analysis of fluid volume shifts can identify two interstitial fluid compartments with different turnover rates, but how they are connected to the bloodstream is unknown. METHODS Retrospective data were retrieved from 217 experiments where 1.5 L of Ringer's solution (mean) had been administered by intravenous infusion over 30 min to awake and anesthetized humans (mean age 40 years). Urinary excretion and hemoglobin-derived plasma dilution served as input variables in a volume kinetic analysis using mixed models software. Possible modes of connection between the two interstitial fluid compartments and the bloodstream were judged by covariance analysis between kinetic rate constants, physiological variables, and time factors. RESULTS The return flow of already distributed fluid to the plasma via a fast-exchange interstitial compartment was inhibited ongoing infusion of fluid (-38 %), which was probably due to increase of the venous pressure during volume loading. Ongoing infusion also greatly retarded the entrance of fluid to the slow-exchange compartment (-85 %), which suggests that infused Ringer's first had to enter the fast-exchange compartment. A high mean arterial pressure markedly increased the urine output and, to a lesser degree, also the rate of entrance of fluid to the fast-exchange compartment. Moreover, a high blood hemoglobin concentration retarded the rate of entrance of fluid to the fast-exchange compartment. CONCLUSIONS The fast-exchange but not the slow-exchange interstitial fluid compartment was affected by intravascular events, which suggests that only the fast-exchange compartment is directly connected to the circulating blood.
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Affiliation(s)
- Robert G Hahn
- Karolinska institutet at Danderyds sjukhus (KIDS), 171 77 Stockholm, Sweden.
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Roberts DN, Vallén P, Cronhjort M, Alfvén T, Sandblom G, Törnroth-Horsefield S, Jensen BL, Lönnqvist PA, Frithiof R, Carlström M, Krmar RT. Perioperative water and electrolyte balance and water homeostasis regulation in children with acute surgery. Pediatr Res 2023; 94:1373-1379. [PMID: 36759747 PMCID: PMC9909148 DOI: 10.1038/s41390-023-02509-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/25/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Hospital-acquired hyponatremia remains a feared event in patients receiving hypotonic fluid therapy. Our objectives were to assess post-operative plasma-sodium concentration and to provide a physiological explanation for plasma-sodium levels over time in children with acute appendicitis. METHODS Thirteen normonatremic (plasma-sodium ≥135 mmol/L) children (8 males), median age 12.3 (IQR 11.5-13.5) years participated in this prospective observational study (ACTRN12621000587808). Urine was collected and analyzed. Blood tests, including renin, aldosterone, arginine-vasopressin, and circulating nitric oxide substrates were determined on admission, at induction of anesthesia, and at the end of surgery. RESULTS On admission, participants were assumed to be mildly dehydrated and were prescribed 50 mL/kg of Ringer's acetate intravenously followed by half-isotonic saline as maintenance fluid therapy. Blood tests, urinary indices, plasma levels of aldosterone, arginine-vasopressin, and net water-electrolyte balance indicated that participants were dehydrated on admission. Although nearly 50% of participants still had arginine-vasopressin levels that would have been expected to produce maximum antidiuresis at the end of surgery, electrolyte-free water clearance indicated that almost all participants were able to excrete net free water. No participant became hyponatremic. CONCLUSIONS The use of moderately hypotonic fluid therapy after correction of extracellular fluid deficit is not necessarily associated with post-operative hyponatremia. IMPACT Our observations show that in acutely ill normonatremic children not only the composition but also the amount of volume infused influence on the risk of hyponatremia. Our observations also suggest that perioperative administration of hypotonic fluid therapy is followed by a tendency towards hyponatremia if extracellular fluid depletion is left untreated. After correcting extracellular deficit almost all patients were able to excrete net free water. This occurred despite nearly 50% of the cohort having high circulating plasma levels of arginine-vasopressin at the end of surgery, suggesting a phenomenon of renal escape from arginine-vasopressin-induced antidiuresis.
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Affiliation(s)
| | - Paula Vallén
- Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Alfvén
- Sachsska Children and Youth Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | | | - Boye L Jensen
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- Department of Urology, Odense University Hospital, Odense, Denmark
| | - Per-Arne Lönnqvist
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Biomedicum 5B, Stockholm, Sweden
| | - Robert Frithiof
- Department of Surgical Sciences, Anesthesiology, and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Mattias Carlström
- Department of Physiology and Pharmacology, Karolinska Institutet, Biomedicum 5B, Stockholm, Sweden
| | - Rafael T Krmar
- Department of Physiology and Pharmacology, Karolinska Institutet, Biomedicum 5B, Stockholm, Sweden.
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8
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Lorente JV, Hahn RG, Jover JL, Del Cojo E, Hervías M, Jiménez I, Uña R, Clau-Terré F, Monge MI, Llau JV, Colomina MJ, Ripollés-Melchor J. Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols. J Clin Med 2023; 12:5930. [PMID: 37762871 PMCID: PMC10531658 DOI: 10.3390/jcm12185930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.
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Affiliation(s)
- Juan V. Lorente
- Department of Anesthesiology and Critical Care, Juan Ramón Jiménez University Hospital, 21005 Huelva, Spain
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Robert G. Hahn
- Karolinska Institute, Danderyds Hospital (KIDS), 171 77 Stockholm, Sweden
| | - José L. Jover
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Verge del Lliris Hospital, 03802 Alcoy, Spain
| | - Enrique Del Cojo
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Don Benito-Villanueva de la Serena Health District, 06400 Don Benito, Spain
| | - Mónica Hervías
- Department of Anesthesiology and Critical Care, Gregorio Marañón General University Hospital, 28007 Madrid, Spain
- Paediatric Anaesthesiology Section, Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Ignacio Jiménez
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Virgen del Rocío University Hospital, 41013 Seville, Spain
| | - Rafael Uña
- Department of Anesthesiology and Critical Care, La Paz University General Hospital, 28046 Madrid, Spain
| | - Fernando Clau-Terré
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Vall d’Hebron Institut Recerca, Vall d’Hebrón University Hospital, 08035 Barcelona, Spain
| | - Manuel I. Monge
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Juan V. Llau
- Department of Anesthesiology and Critical Care, Doctor Peset Hospital, 46017 Valencia, Spain
| | - Maria J. Colomina
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Bellvitge University Hospital, University of Barcelona, 08907 Barcelona, Spain
| | - Javier Ripollés-Melchor
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Infanta Leonor Hospital, 28031 Madrid, Spain
- Department of Toxicology, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Hahn RG, Weinberg L, Li Y, Bahlmann H, Bellomo R, Wuethrich PY. Concentrated urine, low urine flow, and postoperative elevation of plasma creatinine: A retrospective analysis of pooled data. PLoS One 2023; 18:e0290071. [PMID: 37590224 PMCID: PMC10434918 DOI: 10.1371/journal.pone.0290071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
Elevations of plasma creatinine are common after major surgery, but their pathophysiology is poorly understood. To identify possible contributing mechanisms, we pooled data from eight prospective studies performed in four different countries to study circumstances during which elevation of plasma creatinine occurs. We included 642 patients undergoing mixed major surgeries, mostly open gastrointestinal. Plasma and urinary creatinine and a composite index for renal fluid conservation (Fluid Retention Index, FRI) were measured just before surgery and on the first postoperative morning. Urine flow was measured during the surgery. The results show that patients with a postoperative increase in plasma creatinine by >25% had a high urinary creatinine concentration (11.0±5.9 vs. 8.3±5.6 mmol/L; P< 0001) and higher FRI value (3.2±1.0 vs. 2.9±1.1; P< 0.04) already before surgery was initiated. Progressive increase of plasma creatinine was associated with a gradually lower urine flow and larger blood loss during the surgery (Kruskal-Wallis test, P< 0.001). The patients with an elevation > 25% also showed higher creatinine and a higher FRI value on the first postoperative morning (P< 0.001). Elevations to > 50% of baseline were associated with slightly lower mean arterial pressure (73 ± 10 vs. 80 ± 12 mmHg; P< 0.005). We conclude that elevation of plasma creatinine in the perioperative period was associated with low urine flow and greater blood loss during surgery and with concentrated urine both before and after the surgery. Renal water conservation-related mechanisms seem to contribute to the development of increased plasma creatinine after surgery.
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Affiliation(s)
- Robert G. Hahn
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Laurence Weinberg
- Department of Anesthesia, Austin Hospital; Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Yuhong Li
- Department of Anesthesiology, Shulan International Hospital, Shuren University, Hangzhou, 3100004, Zhejiang Province, PR of China
| | - Hans Bahlmann
- Department of Anesthesiology and Intensive Care in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, The University of Melbourne; Melbourne, Australia
| | - Patrick Y. Wuethrich
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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10
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Dull RO, Hahn RG. Hypovolemia with peripheral edema: What is wrong? Crit Care 2023; 27:206. [PMID: 37245039 DOI: 10.1186/s13054-023-04496-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023] Open
Abstract
Fluid normally exchanges freely between the plasma and interstitial space and is returned primarily via the lymphatic system. This balance can be disturbed by diseases and medications. In inflammatory disease states, such as sepsis, the return flow of fluid from the interstitial space to the plasma seems to be very slow, which promotes the well-known triad of hypovolemia, hypoalbuminemia, and peripheral edema. Similarly, general anesthesia, for example, even without mechanical ventilation, increases accumulation of infused crystalloid fluid in a slowly equilibrating fraction of the extravascular compartment. Herein, we have combined data from fluid kinetic trials with previously unconnected mechanisms of inflammation, interstitial fluid physiology and lymphatic pathology to synthesize a novel explanation for common and clinically relevant examples of circulatory dysregulation. Experimental studies suggest that two key mechanisms contribute to the combination of hypovolemia, hypoalbuminemia and edema; (1) acute lowering of the interstitial pressure by inflammatory mediators such as TNFα, IL-1β, and IL-6 and, (2) nitric oxide-induced inhibition of intrinsic lymphatic pumping.
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Affiliation(s)
- Randal O Dull
- Department of Anesthesiology, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Suite 4401, PO Box 245114, Tucson, AZ, 85724-5114, USA.
- Department of Pathology, University of Arizona College of Medicine, Tucson, AZ, USA.
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Robert G Hahn
- Karolinska Institute at Danderyds Hospital (KIDS), 171 77, Stockholm, Sweden
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11
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Franzén S, Frithiof R, Hultström M. Postoperative acute kidney injury after volatile or intravenous anesthesia: a meta-analysis. Am J Physiol Renal Physiol 2023; 324:F329-F334. [PMID: 36794753 DOI: 10.1152/ajprenal.00316.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Postoperative acute kidney injury (AKI) is a common complication after surgery. The pathophysiology of postoperative AKI is complex. One potentially important factor is anesthetic modality. We, therefore, conducted a meta-analysis of the available literature regarding anesthetic modality and incidence of postoperative AKI. Records were retrieved until January 17, 2023, with the search terms ("propofol" OR "intravenous") AND ("sevoflurane" OR "desflurane" OR "isoflurane" OR "volatile" OR "inhalational") AND ("acute kidney injury" OR "AKI"). A meta-analysis for common effects and random effects was performed after exclusion assessment. Eight records were included in the meta-analysis with a total of 15,140 patients (n = 7,542 propofol and n = 7,598 volatile). The common and random effects model revealed that propofol was associated with a lower incidence of postoperative AKI compared with volatile anesthesia [odds ratio: 0.63 (95% confidence interval: 0.56-0.72) and 0.49 (95% confidence interval: 0.33-0.73), respectively]. In conclusion, the meta-analysis revealed that propofol anesthesia is associated with a lower incidence of postoperative AKI compared with volatile anesthesia. This may motivate choosing propofol-based anesthesia in patients with increased risk of postoperative AKI due to preexisting renal impairment or surgery with a high risk of renal ischemia.NEW & NOTEWORTHY This study analyzed the available literature on anesthetic modality and incidence of postoperative AKI. The meta-analysis revealed that propofol is associated with lower incidence of AKI compared with volatile anesthesia. It might therefore be considerable to use propofol anesthesia in surgeries with increased susceptibility for developing renal injuries such as cardiopulmonary bypass and major abdominal surgery.
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Affiliation(s)
- Stephanie Franzén
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Robert Frithiof
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Michael Hultström
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Department of Medical Cell Biology, Integrative Physiology, Uppsala University, Uppsala, Sweden
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Koh RGL, Zariffa J, Jabban L, Yen SC, Donaldson N, Metcalfe BW. Tutorial: A guide to techniques for analysing recordings from the peripheral nervous system. J Neural Eng 2022; 19. [PMID: 35772397 DOI: 10.1088/1741-2552/ac7d74] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/30/2022] [Indexed: 11/11/2022]
Abstract
The nervous system, through a combination of conscious and automatic processes, enables the regulation of the body and its interactions with the environment. The peripheral nervous system is an excellent target for technologies that seek to modulate, restore or enhance these abilities as it carries sensory and motor information that most directly relates to a target organ or function. However, many applications require a combination of both an effective peripheral nerve interface and effective signal processing techniques to provide selective and stable recordings. While there are many reviews on the design of peripheral nerve interfaces, reviews of data analysis techniques and translational considerations are limited. Thus, this tutorial aims to support new and existing researchers in the understanding of the general guiding principles, and introduces a taxonomy for electrode configurations, techniques and translational models to consider.
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Affiliation(s)
- Ryan G L Koh
- IBBME, University of Toronto, Rosebrugh Bldg, 164 College St Room 407, Toronto, Ontario, M5S 3G9, CANADA
| | - Jose Zariffa
- Research, Toronto Rehabilitation Institute - University Health Network, 550 University Ave, #12-102, Toronto, Ontario, M5G 2A2, CANADA
| | - Leen Jabban
- Electronic and Electrical Engineering, University of Bath, Electronic and Electrical Engineering, Claverton Down, Bath, Bath, BA2 7AY, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Shih-Cheng Yen
- Engineering Design and Innovation Centre, National University of Singapore, 21 Lower Kent Ridge Road, Singapore, 119077, SINGAPORE
| | - Nick Donaldson
- Medical Physics and Bioengineering, University College London, Gower Street, London, WC1E 6BT, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Benjamin W Metcalfe
- Electronics & Electrical Engineering, University of Bath, Claverton Down, Bath, Somerset, BA2 7JY, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
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Franzén S, Semenas E, Taavo M, Mårtensson J, Larsson A, Frithiof R. Renal function during sevoflurane or total intravenous propofol anaesthesia a single-centre parallel randomised controlled study. Br J Anaesth 2022; 128:838-848. [DOI: 10.1016/j.bja.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/02/2022] Open
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Osborn JW, Cruz-Lynch A. Volatile Anesthesia Activates Renal Sympathetic Nerves to Reduce Renal Excretory Function: Implications for Surgically-Induced Acute Kidney Injury. FUNCTION (OXFORD, ENGLAND) 2021; 2:zqab056. [PMID: 35330790 PMCID: PMC8788718 DOI: 10.1093/function/zqab056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/04/2021] [Indexed: 01/07/2023]
Affiliation(s)
| | - Arthur Cruz-Lynch
- The Graduate Program in Integrative Biology and Physiology, University of Minnesota, Minneapolis, MN 55455, USA
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