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Nasa P, Wise R, Malbrain MLNG. Fluid management in the septic peri-operative patient. Curr Opin Crit Care 2024:00075198-990000000-00205. [PMID: 39248089 DOI: 10.1097/mcc.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications. RECENT FINDINGS Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content). SUMMARY Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, UK
| | - Robert Wise
- Discipline of Anesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Adult Intensive Care, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- Medical Data Management, Medaman, Geel
- International Fluid Academy, Lovenjoel, Belgium
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Abdelhamid S, Achermann R, Hollinger A, Hauser M, Trutmann M, Gallacchi L, Siegemund M. The Effect of Albumin Administration in Critically Ill Patients: A Retrospective Single-Center Analysis. Crit Care Med 2024; 52:e234-e244. [PMID: 38502807 PMCID: PMC11008457 DOI: 10.1097/ccm.0000000000006218] [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: 03/21/2024]
Abstract
OBJECTIVES The aim of this study was to analyze the development of albumin administration in patients admitted to the adult ICU. In addition, we assessed the impact of albumin administration on serum hemoglobin concentration. DESIGN We conducted a retrospective single-center study including all patients who were admitted to the ICU from January 2013 to December 2021 and stayed at least 24 hours. SETTING The study was conducted in an academic hospital (University Hospital Basel, Switzerland). PATIENTS A total of 20,927 admissions were included, of which 3748 received albumin at least once during their ICU stay. To analyze volume expansion, 2006 admissions met the inclusion criteria, namely at least two hemoglobin measurements within 12 hours, one albumin delivery, and experienced no bleeding, dialysis, or transfusions during this period. INTERVENTIONS None. MEASUREMENTS We examined the hemoglobin levels before and after albumin administration and compared them with a matched control group to assess the amount and duration of volume expansion. MAIN RESULTS From 2013 to 2021 the proportion of critically ill patients treated with albumin rose from 5.0% to 32.5%. An overproportioned increase in albumin use could be seen in surgical patients (4.7-47.2%) and in those receiving RBC transfusion (13.7-72.6%). In those patients receiving albumin, a significant drop in hemoglobin of around 5 g/L on average could be observed following treatment with albumin. CONCLUSION Hemodilution was observable for at least 12 hours after albumin administration and may have caused a decrease in hemoglobin concentration of greater than 8 g/L when isooncotic albumin solution (5%, 25 g in 500 mL) was administered. This makes albumin, especially in its isooncotic form, an ideal colloid to achieve long-lasting volume expansion. However, RBC transfusions may increase under albumin therapy, as transfusion thresholds may be undershot after albumin administration.
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Affiliation(s)
- Salim Abdelhamid
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Rita Achermann
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Madlaina Hauser
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Maren Trutmann
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Laura Gallacchi
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Lu H, Zhang Y, Liu P. Identifying new safety risk of human serum albumin: a retrospective study of real-world data. Front Pharmacol 2024; 15:1319900. [PMID: 38292942 PMCID: PMC10825956 DOI: 10.3389/fphar.2024.1319900] [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: 10/11/2023] [Accepted: 01/03/2024] [Indexed: 02/01/2024] Open
Abstract
Objective: To mine and analyze the adverse reaction signals of human serum albumin (HSA) using the FDA adverse event reporting system (FAERS) database for the safe clinical use of this drug. Methods: Data cleaning and analysis of adverse event reports in the FAERS database for a total of 76 quarters from Q1 2004 to Q4 2022 were performed using the reporting odds ratio (ROR), Medicines and Healthcare Products Regulatory Agency (MHRA), and Bayesian confidence propagation neural network (BCPNN). Gender-differentiated signal detection was used to investigate the gender differences in the occurrence of HSA adverse events. Results: Through a combination of three methods, a total of 535 adverse event reports were identified. These reports involved 1,885 cases of adverse reactions, with respiratory, thoracic, and mediastinal disorders, as well as general disorders and administration site conditions, as the most common. One noteworthy new signal was the occurrence of transfusion-related acute lung injury. Additionally, gender-differentiated signals were present, with females experiencing paraesthesia, hypertension, pulmonary oedema, loss of consciousness, and vomiting. Conclusion: This study has revealed that HSA poses a risk of causing transfusion-related acute lung injury. It has also been observed that adverse reactions, including paraesthesia, hypertension, pulmonary oedema, loss of consciousness, and vomiting, are more prevalent in females. These findings should be taken into account when using HSA in a clinical setting.
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Affiliation(s)
- Hui Lu
- Shanghai RAAS Blood Products Co., Ltd., Shanghai, China
| | - Yuwei Zhang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Pengcheng Liu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
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4
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Wiedermann CJ. Controversies Surrounding Albumin Use in Sepsis: Lessons from Cirrhosis. Int J Mol Sci 2023; 24:17606. [PMID: 38139434 PMCID: PMC10743695 DOI: 10.3390/ijms242417606] [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: 11/11/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 12/24/2023] Open
Abstract
This narrative review critically examines the role of albumin in sepsis management and compares it to its well-established application in liver cirrhosis. Albumin, a key plasma protein, is effective in the management of fluid imbalance, circulatory dysfunction, and inflammation-related complications. However, its role in sepsis is more intricate and characterized by ongoing debate and varied results from clinical studies. In sepsis, the potential benefits of albumin include maintaining vascular integrity and modulating inflammation, yet its consistent clinical efficacy is not as definitive as that in cirrhosis. This review evaluated various clinical trials and evidence, highlighting their limitations and providing practical insights for clinicians. It emphasizes identifying sepsis patient subgroups that are most likely to benefit from albumin therapy, particularly exploring the correction of hypoalbuminemia. This condition, which is significantly corrected in patients with cirrhosis, may have similar therapeutic advantages in sepsis. The potential effectiveness of albumin in the low-volume resuscitation and deresuscitation phases of sepsis management was noted. Given the safety concerns observed in cirrhosis, such as pulmonary edema and hypervolemia associated with albumin therapy, cautious integration of albumin into sepsis treatment is mandatory. Personalized albumin therapy is advocated for tailoring strategies to the specific needs of each patient, based on their clinical presentation and underlying conditions. The need for further research to delineate the role of albumin in sepsis pathophysiology is underscored. The review emphasizes the importance of conducting trials to assess the effectiveness of albumin in correcting hypoalbuminemia in sepsis, its impact on patient outcomes, and the establishment of appropriate dosing and administration methods. This approach to albumin use in sepsis management is posited as a way to potentially improve patient outcomes in this complex clinical scenario while being mindful of the lessons learned from its use in cirrhosis.
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Affiliation(s)
- Christian J. Wiedermann
- Institute of General Practice and Public Health, Claudiana—College of Health Professions, 39100 Bolzano, Italy;
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology-Tyrol, 6060 Hall, Austria
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5
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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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6
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Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [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: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
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Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
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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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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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Kopitkó C, Fülöp T, Tapolyai M, Gondos T. A Critical Reassessment of the Kidney Risk Caused by Tetrastarch Products in the Perioperative and Intensive Care Environments. J Clin Med 2023; 12:5262. [PMID: 37629303 PMCID: PMC10455866 DOI: 10.3390/jcm12165262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusions: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.
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Affiliation(s)
- Csaba Kopitkó
- Department of Anesthesiology and Intensive Therapy, Uzsoki Teaching Hospital of Semmelweis University, Uzsoki u. 29–41, H-1145 Budapest, Hungary
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA
- Medicine Service, Ralph H. Johnson VA Medical Center, 109 Bee St, Charleston, SC 29401, USA;
| | - Mihály Tapolyai
- Medicine Service, Ralph H. Johnson VA Medical Center, 109 Bee St, Charleston, SC 29401, USA;
- Szent Margit Hospital, Bécsi út 132, H-1032 Budapest, Hungary
| | - Tibor Gondos
- Doctoral School of Pathological Sciences, Semmelweis University, Üllői út 26, H-1088 Budapest, Hungary;
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10
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Hyperoncotic human albumin solutions for intravenous fluid therapy: Effectiveness of pathogen safety and purification methods, and clinical safety. BIOSAFETY AND HEALTH 2022. [DOI: 10.1016/j.bsheal.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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11
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Choix du soluté pour le remplissage vasculaire en situation critique. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Seitz KP, Qian ET, Semler MW. Intravenous fluid therapy in sepsis. Nutr Clin Pract 2022; 37:990-1003. [PMID: 35801708 PMCID: PMC9463107 DOI: 10.1002/ncp.10892] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 12/19/2022] Open
Abstract
Sepsis is the dysregulated immune response to severe infection that is common and lethal among critically ill patients. Fluid administration is a common treatment for hypotension and shock in early sepsis. Fluid therapy can also cause edema and organ dysfunction. Research on the best treatment strategies for sepsis has provided insights on the optimal timing, dose, and type of fluid to treat patients with sepsis. Initial research on early goal-directed therapy for sepsis included an initial bolus of 30 ml/kg of fluid, but more recent research has supported use of smaller volumes. After initial fluid resuscitation, minimizing additional fluid administration may be beneficial, but no single measure has been established as the best method to guide ongoing fluid management in sepsis. Dynamic measures of "fluid responsiveness" can predict which patients will experience an increase in cardiac output from a fluid bolus. Use of such a measure in clinical care remains limited by applicability to patient populations and uncertainty regarding the effect on clinical outcomes. Recent research informs the effect of fluid composition on outcomes for patients with sepsis. Current data support the use of balanced crystalloids, rather than saline, and the use of crystalloids, rather than semisynthetic colloids. The role for albumin administration in sepsis remains uncertain. Future research should focus on determining the optimal volume of fluid during sepsis resuscitation, the effectiveness of measures of "fluid responsiveness" in improving outcomes, the optimal composition of crystalloid solutions, the role of albumin, and the effects of "deresuscitation" after septic shock.
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Affiliation(s)
- Kevin P. Seitz
- Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine
| | - Edward T. Qian
- Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine
| | - Matthew W. Semler
- Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine
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13
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Barry M, Wu F, Pati S, Chipman A, Geng H, Kozar R. Lyophilized plasma resuscitation downregulates inflammatory gene expression in a mouse model of sepsis. J Trauma Acute Care Surg 2022; 93:S119-S127. [PMID: 35881828 DOI: 10.1097/ta.0000000000003658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Plasma resuscitation may improve outcomes by targeting endotheliopathy induced by severe sepsis or septic shock. Given the logistical constraints of using fresh frozen plasma in military settings or areas with prolonged prehospital care, dried products such as lyophilized plasma (LP) have been developed. We hypothesized that resuscitation with LP would decrease lung injury, inflammation, and mortality in a mouse sepsis model. METHODS Adult male C57BL/6J mice received an intraperitoneal injection of cecal slurry. Twenty-two hours later, the mice were anesthetized, the femoral artery was cannulated, and the mice were randomized to receive resuscitation with LP (10 mL/kg) or lactated Ringer's (LR; 30 mL/kg) for 1 hour. At 48-hours post-cecal slurry injection, bronchoalveolar lavage fluid was collected, the lungs were harvested, and plasma was obtained. Mortality and bronchoalveolar lavage total protein concentration (as an indicator of permeability) were compared between groups. The lungs were analyzed for histopathology and inflammatory gene expression using NanoString, and the plasma was analyzed for biomarkers of inflammation and endothelial function. RESULTS There was no significant difference in short-term mortality between LR and LP mice, 38% versus 47%, respectively ( p = 0.62). Bronchoalveolar lavage protein levels were similar among mice resuscitated with LR or LP, and there was a lack of significant histopathologic lung injury in all groups. However, LP resuscitation resulted in downregulation of pulmonary inflammatory genes, including signaling pathways such as Janus kinase-signal transducer and activator of transcription and nuclear factor κB, and a circulating inflammatory biomarker profile similar to sham animals. CONCLUSION Resuscitation with LP did not improve mortality or reduce permeability or injury in this model compared with LR. However, LP downregulated pulmonary inflammatory gene signaling and may also reduce circulating biomarkers of inflammation. Future studies should evaluate LP resuscitation in combination with antibiotics and other therapeutics to determine whether the anti-inflammatory effects of LP may improve outcomes in sepsis.
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Affiliation(s)
- Mark Barry
- From the Department of Surgery (M.B., S.P.), University of California, San Francisco, San Francisco, California; Shock Trauma Center (F.W., A.C., R.K.), University of Maryland School of Medicine, Baltimore, Maryland; and Department of Laboratory Medicine (S.P., H.G.), University of California, San Francisco, San Francisco, California
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14
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Palma CD, Mamba M, Geldenhuys J, Fadahun O, Rossaint R, Zacharowski K, Brand M, Díaz-Cambronero Ó, Belda J, Westphal M, Brauer U, Dormann D, Dehnhardt T, Hernandez-Gonzalez M, Schmier S, de Korte D, Plani F, Buhre W. PragmaTic, prospEctive, randomized, controlled, double-blind, mulTi-centre, multinational study on the safety and efficacy of a 6% HydroxYethyl Starch (HES) solution versus an electrolyte solution in trauma patients: study protocol for the TETHYS study. Trials 2022; 23:456. [PMID: 35655234 PMCID: PMC9164328 DOI: 10.1186/s13063-022-06390-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma may be associated with significant to life-threatening blood loss, which in turn may increase the risk of complications and death, particularly in the absence of adequate treatment. Hydroxyethyl starch (HES) solutions are used for volume therapy to treat hypovolemia due to acute blood loss to maintain or re-establish hemodynamic stability with the ultimate goal to avoid organ hypoperfusion and cardiovascular collapse. The current study compares a 6% HES 130 solution (Volulyte 6%) versus an electrolyte solution (Ionolyte) for volume replacement therapy in adult patients with traumatic injuries, as requested by the European Medicines Agency to gain more insights into the safety and efficacy of HES in the setting of trauma care. METHODS TETHYS is a pragmatic, prospective, randomized, controlled, double-blind, multicenter, multinational trial performed in two parallel groups. Eligible consenting adults ≥ 18 years, with an estimated blood loss of ≥ 500 ml, and in whom initial surgery is deemed necessary within 24 h after blunt or penetrating trauma, will be randomized to receive intravenous treatment at an individualized dose with either a 6% HES 130, or an electrolyte solution, for a maximum of 24 h or until reaching the maximum daily dose of 30 ml/kg body weight, whatever occurs first. Sample size is estimated as 175 patients per group, 350 patients total (α = 0.025 one-tailed, power 1-β = 0.8). Composite primary endpoint evaluated in an exploratory manner will be 90-day mortality and 90-day renal failure, defined as AKIN stage ≥ 2, RIFLE injury/failure stage, or use of renal replacement therapy (RRT) during the first 3 months. Secondary efficacy and safety endpoints are fluid administration and balance, changes in vital signs and hemodynamic status, changes in laboratory parameters including renal function, coagulation, and inflammation biomarkers, incidence of adverse events during treatment period, hospital, and intensive care unit (ICU) length of stay, fitness for ICU or hospital discharge, and duration of mechanical ventilation and/or RRT. DISCUSSION This pragmatic study will increase the evidence on safety and efficacy of 6% HES 130 for treatment of hypovolemia secondary to acute blood loss in trauma patients. TRIAL REGISTRATION Registered in EudraCT, No.: 2016-002176-27 (21 April 2017) and ClinicalTrials.gov, ID: NCT03338218 (09 November 2017).
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Affiliation(s)
| | | | | | | | - Rolf Rossaint
- RWTH University Hospital, Rhineland-Westfalen Technical University, Aachen, Germany
| | - Kai Zacharowski
- Frankfurt University Hospital, Johannes Goethe University, Frankfurt, Germany
| | - Martin Brand
- Steve Biko Academic Hospital, Pretoria, South Africa
| | | | - Javier Belda
- Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | | | - Ute Brauer
- B. Braun Melsungen AG, Melsungen, Germany
| | - Dirk Dormann
- Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
| | | | | | | | - Dianne de Korte
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Frank Plani
- Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Wolfgang Buhre
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
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15
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Richter RP, Payne GA, Ambalavanan N, Gaggar A, Richter JR. The endothelial glycocalyx in critical illness: A pediatric perspective. Matrix Biol Plus 2022; 14:100106. [PMID: 35392182 PMCID: PMC8981764 DOI: 10.1016/j.mbplus.2022.100106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/18/2022] Open
Abstract
The vascular endothelium is the interface between circulating blood and end organs and thus has a critical role in preserving organ function. The endothelium is lined by a glycan-rich glycocalyx that uniquely contributes to endothelial function through its regulation of leukocyte and platelet interactions with the vessel wall, vascular permeability, coagulation, and vasoreactivity. Degradation of the endothelial glycocalyx can thus promote vascular dysfunction, inflammation propagation, and organ injury. The endothelial glycocalyx and its role in vascular pathophysiology has gained increasing attention over the last decade. While studies characterizing vascular glycocalyx injury and its downstream consequences in a host of adult human diseases and in animal models has burgeoned, studies evaluating glycocalyx damage in pediatric diseases are relatively few. As children have unique physiology that differs from adults, significant knowledge gaps remain in our understanding of the causes and effects of endothelial glycocalyx disintegrity in pediatric critical illness. In this narrative literature overview, we offer a unique perspective on the role of the endothelial glycocalyx in pediatric critical illness, drawing from adult and preclinical data in addition to pediatric clinical experience to elucidate how marked derangement of the endothelial surface layer may contribute to aberrant vascular biology in children. By calling attention to this nascent field, we hope to increase research efforts to address important knowledge gaps in pediatric vascular biology that may inform the development of novel therapeutic strategies.
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Key Words
- ACE2, angiotensin-converting enzyme 2
- CD, cell differentiation marker
- COVID-19, coronavirus disease 2019
- CPB, cardiopulmonary bypass
- CT, component therapy
- Children
- Critical illness
- DENV NS1, dengue virus nonstructural protein 1
- DM, diabetes mellitus
- ECLS, extracorporeal life support
- ECMO, extracorporeal membrane oxygenation
- EG, endothelial glycocalyx
- Endothelial glycocalyx
- FFP, fresh frozen plasma
- GAG, glycosaminoglycan
- GPC, glypican
- HPSE, heparanase
- HSV, herpes simplex virus
- IV, intravenous
- MIS-C, multisystem inflammatory syndrome in children
- MMP, matrix metalloproteinase
- Pragmatic, Randomized Optimal Platelet and Plasma Ratios
- RHAMM, receptor for hyaluronan-mediated motility
- S protein, spike protein
- SAFE, Saline versus Albumin Fluid Evaluation
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- SDC, syndecan
- SDF, sidestream darkfield
- SIRT1, sirtuin 1
- TBI, traumatic brain injury
- TBSA, total body surface area
- TMPRSS2, transmembrane protease serine 2
- Th2, type 2 helper T cell
- VSMC, vascular smooth muscle cell
- Vascular biology
- WB+CT, whole blood and component therapy
- eNOS, endothelial nitric oxide synthase
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Affiliation(s)
- Robert P. Richter
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
- Program in Protease and Matrix Biology, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory A. Payne
- Program in Protease and Matrix Biology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Namasivayam Ambalavanan
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, USA
- Translational Research in Normal and Disordered Development Program, University of Alabama, Birmingham, AL, USA
| | - Amit Gaggar
- Program in Protease and Matrix Biology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jillian R. Richter
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, USA
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16
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Joannes-Boyau O, Le Conte P, Bonnet MP, Cesareo E, Chousterman B, Chaiba D, Douay B, Futier E, Harrois A, Huraux C, Ichai C, Meaudre Desgouttes E, Mimoz O, Muller L, Oberlin M, Peschanski N, Quintard H, Rousseau G, Savary D, Tran-Dinh A, Villoing B, Chauvin A, Weiss E. Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021. Anaesth Crit Care Pain Med 2022; 41:101058. [PMID: 35526312 DOI: 10.1016/j.accpm.2022.101058] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To provide recommendations for the appropriate choice of fluid therapy for resuscitation of critically ill patients. DESIGN A consensus committee of 24 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were left ungraded. METHODS Four fields were defined: patients with sepsis or septic shock, patients with haemorrhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions: (1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and (2) Does the use of some specific crystalloids effectively reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology. RESULTS The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of rating and various amendments, strong agreement was reached for 100% of the recommendations. Out of these recommendations, two have a high level of evidence (Grade 1 +/-), six have a moderate level of evidence (Grade 2 +/-), and one is based on expert opinion. Finally, no recommendation was formulated for two questions. CONCLUSIONS Substantial agreement among experts has been obtained to provide a sizable number of recommendations aimed at optimising the choice of fluid therapy for resuscitation of critically ill patients.
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Affiliation(s)
- Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, CHU de Bordeaux, Hôpital Magellan, Bordeaux, France.
| | - Philippe Le Conte
- Nantes Université, Faculté de Médecine, CHU de Nantes, Service des Urgences, Nantes, France
| | - Marie-Pierre Bonnet
- Sorbonne Université, Service d'Anesthésie-Réanimation, Hôpital Trousseau, DMU DREAM, GRC 29, APHP, Paris, France; INSERM U1153, Equipe de Recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Epidémiologie et Statistique Sorbonne Paris Cité, Paris, France
| | - Eric Cesareo
- Samu 69, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d'Arsonval, F-69437 Lyon Cedex 03, France
| | - Benjamin Chousterman
- APHP, CHU Lariboisière, Département d'Anesthésie-Réanimation, DMU PARABOL, FHU, PROMICE, Paris, France; Université de Paris, INSERM U942 MASCOT, Paris, France
| | - Djamila Chaiba
- Service des Urgences Médico-Chirurgicales, Hôpital Simone Veil, Eaubonne, France
| | - Bénédicte Douay
- SMUR/Service des Urgences, Hôpital Beaujon, AP-HP Nord, Clichy, France
| | - Emmanuel Futier
- Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Clermont-Ferrand, France; Université Clermont Auvergne, CNRS, Inserm U-1103, Clermont-Ferrand, France
| | - Anatole Harrois
- Service d'Anesthésie-Réanimation et Médecine Périopératoire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Saclay, Paris, France
| | | | - Carole Ichai
- Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Hôpital Pasteur 2, Service de Réanimation Polyvalente, Nice, France
| | - Eric Meaudre Desgouttes
- Service Anesthésiologie-Réanimation Chirurgicale, Hôpital d'Instruction des Armées Sainte Anne, Toulon, France
| | - Olivier Mimoz
- Service des Urgences Adultes & SAMU 86, CHU de Poitiers, Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France; Inserm U1070, Pharmacology of Antimicrobial Agents, Poitiers, France
| | - Laurent Muller
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia Critical Care, Pain and Emergency Medicine, CHU Nîmes, Montpellier, France
| | - Mathieu Oberlin
- Structure des Urgences, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Nicolas Peschanski
- Service des Urgences-SAMU-SMUR-CHU Rennes, Rennes, France; Faculté de Médecine-Université Rennes-1, Rennes, France
| | - Hervé Quintard
- Service des Soins Intensifs Adultes, Hôpitaux Universitaires de Genève, Switzerland
| | | | | | - Alexy Tran-Dinh
- Service d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Barbara Villoing
- SAU-SMUR, CHU Cochin Hôtel Dieu, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Anthony Chauvin
- Services des Urgences/SMUR, Hôpital Lariboisière, Université de Paris Cité, Paris, France
| | - Emmanuel Weiss
- Service Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Centre de Recherche sur l'Inflammation, UMR_S1149, Université de Paris, Paris, France
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17
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Fluidoterapia en la sepsis y el shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Sa MB, Salaverría I, Cabas AC. [Fluid therapy in sepsis and septic shock]. Med Intensiva 2022; 46 Suppl 1:14-25. [PMID: 38341257 DOI: 10.1016/j.medine.2022.03.009] [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: 01/09/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 02/12/2024]
Abstract
Fluid resuscitation is a crucial part of the treatment of hypotension and shock of any etiology. Particularly in septic shock, it is an essential element of the initial care bundle. Like all treatments in sepsis, it is also subject to multiple controversies: what type of fluid, how much, how long to administer it, potential risks, toxicity? The main guideline, the Surviving Sepsis Campaign, continues to indicate crystalloids as the main fluid in resuscitation. But the possibility of crystalloids balanced on 0.9% saline or combined use with albumin in the resuscitation of the septic patient is still under debate. This is probably another point where we should always consider individualizing both the type and amount of fluids to be administered in both the initial and maintenance phases of the management of sepsis and septic shock.
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Affiliation(s)
- Marcio Borges Sa
- Unidad Multidisciplinar de Sepsis, Servicio Medicina Intensiva, Hospital Universitario Son Llàtzer, Palma de Mallorca, España.
| | - Iñigo Salaverría
- Grupo Multidisciplinar de Sepsis. Instituto de Investigación Sanitaria de las Islas Baleares (IDISBA), Palma de Mallorca, España; Director del Comité de Sepsis, Federación Ibérica y Panamericana de Medicina Intensiva (FEPIMCTI)
| | - Antonio Couto Cabas
- Unidad Multidisciplinar de Sepsis, Servicio Medicina Intensiva, Hospital Universitario Son Llàtzer, Palma de Mallorca, España; Servicio de Medicina Intensiva, Hospital General, León, México
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19
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Pensier J, Deffontis L, Rollé A, Aarab Y, Capdevila M, Monet C, Carr J, Futier E, Molinari N, Jaber S, De Jong A. Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis. Anesth Analg 2021; 134:686-695. [PMID: 34854822 DOI: 10.1213/ane.0000000000005803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement. METHODS In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant). RESULTS Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02). CONCLUSIONS In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.
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Affiliation(s)
- Joris Pensier
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Lucas Deffontis
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Amélie Rollé
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Yassir Aarab
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Mathieu Capdevila
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Clément Monet
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Julie Carr
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Emmanuel Futier
- Centre Hospitalier Universitaire Clermont-Ferrand, Département de Médecine Périopératoire, Anesthésie et Réanimation, Clermont-Ferrand, France
| | - Nicolas Molinari
- Department of Statistics, University of Montpellier Lapeyronie Hospital, UMR 729 MISTEA, Montpellier, France
| | - Samir Jaber
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France.,Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier Cedex 5 Montpellier, France
| | - Audrey De Jong
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France.,Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier Cedex 5 Montpellier, France
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20
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Affiliation(s)
- Xuan Han
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Andrew M Davis
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - William F Parker
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
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21
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 923] [Impact Index Per Article: 307.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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22
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Knowledge of and Compliance with Surviving Sepsis Campaign Guidelines among Anesthesiologists: A Nationwide Survey in China. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1877166. [PMID: 34603641 PMCID: PMC8481065 DOI: 10.1155/2021/1877166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/22/2021] [Accepted: 08/23/2021] [Indexed: 11/18/2022]
Abstract
We aimed to describe anesthesiologists' knowledge of and compliance with the Surviving Sepsis Campaign (SSC) guidelines in the perioperative management of patients with sepsis in China. We designed a questionnaire-based, cross-sectional survey. We sent out online questionnaires during 2019 to evaluate whether anesthesiologists in China were familiar with and applied SSC guidelines in perioperative management. We also compared anesthesiologists' knowledge of and compliance with the guidelines among different levels of hospital. In this study, we obtained 971 responses from anesthesiology departments across China. The survey responses showed that 39.0% of anesthesiologists rated their knowledge of the SSC guidelines as being "very familiar" or at least "somewhat familiar." In total, 68.9% of respondents chose "Initial fluid resuscitation followed by frequent hemodynamic reassessment" as their therapy strategy for patients with septic shock; 62.0% of anesthesiologists chose lactate as a marker of initial resuscitation in clinical practice, and 39.1% thought bundle therapy needed to be started within 1 hour of sepsis diagnosis. A total of 37.1% and 27.1% of respondents chose hydroxyethyl starches and gelatins, respectively, as the preferred fluids for septic shock. As the first choice of vasopressors in patients with sepsis, 727 (74.9%) anesthesiologists chose the correct answer (norepinephrine). Anesthesiologists from tertiary hospitals (class A) had greater familiarity and compliance with the SSC guidelines than those from other hospitals (P < 0.001). In summary, anesthesiologists in China have some knowledge of the SSC guidelines and tend to practice in keeping with these guidelines. However, for some items, anesthesiologists are not up to date with the latest version of the SSC guidelines. The popularity of these guidelines is not homogenous among different levels of hospital. Anesthesiologists must strengthen their knowledge of the SSC guidelines and update their practice in a regular and timely manner, especially in other tertiary and primary hospitals.
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1512] [Impact Index Per Article: 504.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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24
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Krishnamoorthy V, Motika CO, Ohnuma T, McLean D, Ellis AR, Raghunathan K. Perioperative colloid choice and bleeding in patients undergoing musculoskeletal surgery: An observational administrative database study. Int J Crit Illn Inj Sci 2021; 11:223-228. [PMID: 35070912 PMCID: PMC8725802 DOI: 10.4103/ijciis.ijciis_178_20] [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: 10/23/2020] [Revised: 12/27/2020] [Accepted: 02/02/2021] [Indexed: 11/04/2022] Open
Abstract
Background The synthetic colloid hydroxyethyl starch (HES) received a black box warning, issued by the US Food and Drug Administration (FDA) in June 2013, in patients with sepsis, due to increased risk of bleeding, renal injury, and death. Risks of HES in populations undergoing noncardiac surgery are unclear. Here, we examine the association of colloid choice - human-derived albumin versus HES - with bleeding in musculoskeletal surgery. Methods Inpatient musculoskeletal surgical patients who received colloids on the day of surgery were included during a time period before the FDA warning on HES using the Premier Healthcare database. The exposure was type of colloids administered on the day of surgery: HES versus albumin. The primary outcome was major perioperative bleeding, measured on the 1st postoperative day through hospital discharge. The secondary outcomes included acute renal failure and postoperative length of stay >75th percentile. Results We identified 41,211 patients who received albumin (n = 12,803) and HES (n = 28,408) on the day of surgery. The propensity-weighted multivariable analysis demonstrated a reduced risk of major perioperative bleeding on the day after surgery following treatment with albumin versus HES (relative risk: 0.89 [95% confidence interval, 0.84-0.93]). No significant differences were observed in the secondary outcomes. Conclusion When compared with albumin, treatment with HES on the day of musculoskeletal surgery was associated with an increased risk of major perioperative bleeding on subsequent days. Given that HES continues to be used as a colloid in multiple patient populations worldwide, further studies examining the safety of HES versus albumin solutions are needed.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Critical Care and Perioperative Population Health Research Unit, Duke University, Durham, NC, USA
| | - Calvin O Motika
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Critical Care and Perioperative Population Health Research Unit, Duke University, Durham, NC, USA
| | - Duncan McLean
- Department of Anesthesiology, The University of North Carolina, Chapel Hill, NC, USA
| | - Alan R Ellis
- School of Social Work, North Carolina State University, Raleigh, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Critical Care and Perioperative Population Health Research Unit, Duke University, Durham, NC, USA
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25
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Yanase F, Cutuli SL, Naorungroj T, Bitker L, Wilson A, Eastwood GM, Bellomo R. A comparison of the hemodynamic effects of fluid bolus therapy with crystalloids vs. 4% albumin and vs. 20% albumin in patients after cardiac surgery. Heart Lung 2021; 50:870-876. [PMID: 34403891 DOI: 10.1016/j.hrtlng.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/16/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Crystalloids, 4% albumin and 20% albumin are used for fluid bolus therapy (FBT) in patients after cardiac surgery. However, their detailed early (30 min) hemodynamic effects remain unstudied. METHODS In a comparative prospective observational trial of 120 ventilated, we studied post cardiac surgery patients who received crystalloid 500 ml FBT, 4% albumin 500 ml FBT or 20% albumin 100 ml FBT (40 per group). We recorded second-by-second hemodynamic parameters and 15-minutely cardiac index (CI) data before and for 30 min after FBT. We compared the crystalloid group (reference) vs. the 4% albumin group, and vs. the 20% albumin group. RESULTS Immediately after FBT, the mean (standard deviation) CI increase was 0.4 (0.4) L/min/m2 with crystalloids, 0.4 (0.5) L/min/m2 with 4% albumin and 0.3 (0.4) L/min/m2 with 20% albumin, despite the much smaller FBT volume with 20% albumin. Mean arterial pressure (MAP) increase was 11 (10), 12 (9) and 9 (6) mm Hg, respectively. There was no group effect or interaction for changes in CI. However, there were time-group interactions for MAP changes such that crystalloid FBT had faster MAP reduction than 4% (p<0.001) or 20% albumin (p < 0.001). Moreover, patients treated with crystalloid FBT showed a faster decline in central venous pressure, perfusion pressure than the two groups. Finally, 20% albumin attenuated the fall in temperature induced by FBT. CONCLUSION In postoperative cardiac surgery patients, after a similar initial CI and MAP response, the MAP effect of crystalloid FBT dissipates faster than that of 4% or 20% albumin FBT. These findings can be used to inform clinical practice.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Australia
| | - Salvatore L Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Service de médecine intensive et réanimation, hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Australia; Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Parkville, Victoria, Australia.
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26
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Adamik KN, Yozova ID. Colloids Yes or No? - a "Gretchen Question" Answered. Front Vet Sci 2021; 8:624049. [PMID: 34277747 PMCID: PMC8282815 DOI: 10.3389/fvets.2021.624049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/05/2021] [Indexed: 12/13/2022] Open
Abstract
Colloid solutions, both natural and synthetic, had been widely accepted as having superior volume expanding effects than crystalloids. Synthetic colloid solutions were previously considered at least as effective as natural colloids, as well as being cheaper and easily available. As a result, synthetic colloids (and HES in particular) were the preferred resuscitation fluid in many countries. In the past decade, several cascading events have called into question their efficacy and revealed their harmful effects. In 2013, the medicines authorities placed substantial restrictions on HES administration in people which has resulted in an overall decrease in their use. Whether natural colloids (such as albumin-containing solutions) should replace synthetic colloids remains inconclusive based on the current evidence. Albumin seems to be safer than synthetic colloids in people, but clear evidence of a positive effect on survival is still lacking. Furthermore, species-specific albumin is not widely available, while xenotransfusions with human serum albumin have known side effects. Veterinary data on the safety and efficacy of synthetic and natural colloids is limited to mostly retrospective evaluations or experimental studies with small numbers of patients (mainly dogs). Large, prospective, randomized, long-term outcome-oriented studies are lacking. This review focuses on advantages and disadvantages of synthetic and natural colloids in veterinary medicine. Adopting human guidelines is weighed against the particularities of our specific patient populations, including the risk-benefit ratio and lack of alternatives available in human medicine.
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Affiliation(s)
- Katja-Nicole Adamik
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Science, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ivayla D. Yozova
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
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27
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Yoshihara S, Ikemoto J, Onomoto H, Sugiyama H, Okuda N, Fukunaga K, Yoshihara K, Kaida K, Ikegame K, Tamaki H, Okada M, Osugi Y, Yamahara K, Higasa S, Fujimori Y. Impact of the use of hydroxyethyl starch in granulocyte apheresis using Spectra Optia. Transfus Med 2021; 31:365-370. [PMID: 34096118 DOI: 10.1111/tme.12795] [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: 01/02/2021] [Revised: 04/18/2021] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the impact of the use of hydroxyethyl starch (HES) in granulocyte apheresis using Spectra Optia. BACKGROUND Granulocyte transfusion (GT) is a therapeutic option for neutropenic patients with severe bacterial or fungal infections. Recent studies in emergency medicine have shown the potential risk of using HES, which is routinely used in granulocyte apheresis to increase yield by sedimenting red blood cells. We hypothesized that the use of a newer device (Spectra Optia) would spare the need for HES. METHODS We retrospectively compared granulocyte apheresis with HES (HES group, n = 89) and without HES (non-HES group, n = 36) using Spectra Optia. RESULTS The granulocyte yield was significantly higher in the HES group (7.3 × 1010 vs. 2.0 × 10, p < 0.01) and was attributed to the difference in collection efficiency (36% vs. 7.7%, p < 0.01). The absolute neutrophil count on the following morning of GT was significantly higher in the HES group than in the non-HES group (2460/μl vs. 505/μl, p < 0.01). There were no significant differences in the occurrence of adverse events between the HES and non-HES groups. The renal function was unchanged in both groups after apheresis. CONCLUSIONS We demonstrated that the advantage of using HES remained unchanged in granulocyte apheresis using Spectra Optia.
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Affiliation(s)
- Satoshi Yoshihara
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan.,Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Junko Ikemoto
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Hitomi Onomoto
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Hiroki Sugiyama
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Noriko Okuda
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Keiko Fukunaga
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Kyoko Yoshihara
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan.,Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Katsuji Kaida
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Kazuhiro Ikegame
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Hiroya Tamaki
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Masaya Okada
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Yuko Osugi
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Kenichi Yamahara
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Satoshi Higasa
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan.,Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Yoshihiro Fujimori
- Department of Transfusion Medicine and Cellular Therapy, Hyogo College of Medicine Hospital, Nishinomiya, Japan.,Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
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28
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Xiao K, Zhao F, Wan J, LE A. Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:393-399. [PMID: 33967086 PMCID: PMC10930309 DOI: 10.11817/j.issn.1672-7347.2021.190565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. METHODS This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups. RESULTS There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both P<0.05). The duration of mechanical ventilation in the experimental group was shorter than that in the control group, the percentage of continuous renal replacement therapy (CRRT) in the experimental group was lower than that in the control group, and the in-hospital mortality and 30-day mortality in the experimental group were lower than those in the control group, the differences were statistically significant (all P<0.05). The percentage of burn area and total body surface area (TBSA) was an independent risk factor for 30-day mortality of adult patients with major burn (OR=1.228, 95% CI 1.010 to 1.439, P=0.039), while the infusion ration between of frozen plasma and plasma substitutes 48 hours after admission was an independent protective factor (OR=0.016, 95% CI 0.001 to 0.960, P=0.023). The 30-day survival rate of the experimental group was significantly higher than that in the control group (P<0.001). CONCLUSIONS Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.
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Affiliation(s)
- Kun Xiao
- Department of Blood Transfusion, First Affiliated Hospital of Nanchang University, Nanchang 330006.
| | - Fei Zhao
- Department of Neurology, First Affiliated Hospital of Nanchang University, Nanchang 330006
| | - Jiangbo Wan
- Department of Burn, First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Aiping LE
- Department of Blood Transfusion, First Affiliated Hospital of Nanchang University, Nanchang 330006.
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29
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Østergaard AM, Jørgensen AN, Bøvling S, Ekeløf NP, Mose FH, Bech JN. Effect of 0.9% NaCl compared to plasma-lyte on biomarkers of kidney injury, sodium excretion and tubular transport proteins in patients undergoing primary uncemented hip replacement - a randomized trial. BMC Nephrol 2021; 22:111. [PMID: 33771116 PMCID: PMC7995716 DOI: 10.1186/s12882-021-02310-4] [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: 09/28/2020] [Accepted: 03/15/2021] [Indexed: 11/28/2022] Open
Abstract
Background Isotonic saline (IS) is widely used to secure perioperative cardiovascular stability. However, the high amount of chloride in IS can induce hyperchloremic acidosis. Therefore, IS is suspected to increase the risk of acute kidney injury (AKI). Biomarkers may have potential as indicators. Methods In a double-blinded, placebo-controlled study, 38 patients undergoing primary uncemented hip replacement were randomized to IS or PlasmaLyte (PL). Infusion was given during surgery as 15 ml/kg the first hour and 5 ml/kg the following two hours. Urinary samples were collected upon admission and the day after surgery. As surgery was initiated, urine was collected over the course of 4 h. Hereafter, another urine collection proceeded until the morning. Urine was analyzed for markers of AKI neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). Arterious and venous blood samples for measurements of pH and plasma electrolytes including chloride (p-Cl) were collected as surgery was initiated, at the end of surgery and the following morning. Results IS induced an increase in p-Cl (111 ± 2 mmol/L after IS and 108 ± 3 after PL, p = 0.004) and a decrease in pH (7.39 ± 0.02 after IS and 7.43 ± 0.03 after PL, p = 0.001). Urinary NGAL excretion increased in both groups (ΔNGAL: 5.5 [4.1; 11.7] μg/mmol creatinine p = 0.004 after IS vs. 5.5 [2.1;9.4] μg/mmol creatinine after PL, p < 0.001). No difference was found between the groups (p = 0.839). Similarly, urinary KIM-1 excretion increased in both groups (ΔKIM-1: IS 115.8 [74.1; 156.2] ng/mmol creatinine, p < 0.001 vs. PL 152.4 [120.1; 307.9] ng/mmol creatinine, p < 0.001). No difference between the groups (p = 0.064). FENa increased (1.08 ± 0.52% after IS and 1.66 ± 1.15% after PL, p = 0.032). ENaC excretion was different within groups (p = 0.019). Conclusion A significantly higher plasma chloride and a lower pH was present in the group receiving isotonic saline. However, u-NGAL and u-KIM-1 increased significantly in both groups after surgery despite absence of changes in creatinine. These results indicate that surgery induced subclinical kidney injury. Also, the IS group had a delayed sodium excretion as compared to the PL group which may indicate that IS affects renal sodium excretion differently from PL. Trial registration ClinicalTrials.gov Identifier: NCT02528448, 19/08/2015
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Affiliation(s)
- A M Østergaard
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark.
| | - A N Jørgensen
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark
| | - S Bøvling
- Department of Orthopaedic Surgery, Gødstrup Hospital, Holstebro, Denmark
| | - N P Ekeløf
- Department of Anaesthesiology, Gødstrup Hospital, Holstebro, Denmark
| | - F H Mose
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark
| | - J N Bech
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark
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30
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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31
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Yanase F, Cutuli SL, Naorungroj T, Bitker L, Belletti A, Wilson A, Eastwood GM, Bellomo R. Temperature and haemodynamic effects of a 100 mL bolus of 20% albumin at room versus body temperature in cardiac surgery patients. CRIT CARE RESUSC 2021; 23:14-23. [PMID: 38046386 PMCID: PMC10692526 DOI: 10.51893/2021.1.oa1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To study the temperature and haemodynamic effects of room versus body temperature 20% albumin fluid bolus therapy (FBT). Design: Single-centre, prospective, before-after trial. Setting: A tertiary intensive care unit (ICU) in Australia. Participants: Sixty ventilated post-cardiac surgery patients. Intervention: Room versus body temperature 100 mL 20% albumin FBT. Main outcome measures: We recorded haemodynamic data from FBT start to 30 minutes after FBT. The cardiac index (CI) response was defined by a CI increase > 15%, and the mean arterial pressure (MAP) response was defined by a MAP increase > 10%. Outcomes: Immediately after FBT, median blood temperature decreased by -0.1°C (interquartile range [IQR], -0.1 to 0.0°C) with room temperature albumin versus 0.0°C (IQR, -0.1 to 0.0°C) with body temperature albumin (P < 0.001). The CI or MAP responses were similar. There was, however, a time and study group interaction for blood temperature (P < 0.001) for absolute and relative changes. In addition, mean pulmonary arterial pressure (PAP) (P = 0.002) increased more with body temperature albumin and remained higher for most of the observation period. Conclusion: Compared with room temperature albumin FBT, body temperature 20% albumin FBT prevents FBT-associated blood temperature fall and increases mean PAP. However, CI and MAP changes were the similar between the two groups, implying that fluid temperature has limited haemodynamic effects in these patients.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Salvatore L. Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Alessandro Belletti
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Adult Critical Care, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, VIC, Australia
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2021; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
- Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Molinari L, Sakhuja A, Kellum JA. Perioperative Renoprotection: General Mechanisms and Treatment Approaches. Anesth Analg 2020; 131:1679-1692. [PMID: 33186157 DOI: 10.1213/ane.0000000000005107] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the perioperative setting, acute kidney injury (AKI) is a frequent complication, and AKI itself is associated with adverse outcomes such as higher risk of chronic kidney disease and mortality. Various risk factors are associated with perioperative AKI, and identifying them is crucial to early interventions addressing modifiable risk and increasing monitoring for nonmodifiable risk. Different mechanisms are involved in the development of postoperative AKI, frequently picturing a multifactorial etiology. For these reasons, no single renoprotective strategy will be effective for all surgical patients, and efforts have been attempted to prevent kidney injury in different ways. Some renoprotective strategies and treatments have proven to be useful, some are no longer recommended because they are ineffective or even harmful, and some strategies are still under investigation to identify the best timing, setting, and patients for whom they could be beneficial. With this review, we aim to provide an overview of recent findings from studies examining epidemiology, risk factors, and mechanisms of perioperative AKI, as well as different renoprotective strategies and treatments presented in the literature.
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Affiliation(s)
- Luca Molinari
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Ankit Sakhuja
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - John A Kellum
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Otero TMN, Aljure OD, Yu S. Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature. J Card Surg 2020; 36:1040-1049. [PMID: 33283332 DOI: 10.1111/jocs.15233] [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: 06/18/2020] [Revised: 10/12/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Over-resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature. METHODS A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020. RESULTS Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids. CONCLUSIONS In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.
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Affiliation(s)
- Tiffany M N Otero
- Department of Anesthesiology, Banner University Medical Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Oscar D Aljure
- Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Soojie Yu
- Department of Anesthesiology, Banner University Medical Center, University of Arizona College of Medicine, Tucson, Arizona, USA
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35
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Saadat-Gilani K, Zarbock A, Meersch M. Perioperative Renoprotection: Clinical Implications. Anesth Analg 2020; 131:1667-1678. [DOI: 10.1213/ane.0000000000004995] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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36
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Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary and Renal Considerations: Executive Summary. Crit Care Med 2020; 48:415-419. [PMID: 32058375 DOI: 10.1097/ccm.0000000000004193] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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37
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Joannes-Boyau O, Roquilly A, Constantin JM, Duracher-Gout C, Dahyot-Fizelier C, Langeron O, Legrand M, Mirek S, Mongardon N, Mrozek S, Muller L, Orban JC, Virat A, Leone M. Choice of fluid for critically ill patients: An overview of specific situations. Anaesth Crit Care Pain Med 2020; 39:837-845. [PMID: 33091593 DOI: 10.1016/j.accpm.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Sud, Centre Médico-Chirurgical Magellan, Centre Hospitalier Universitaire (CHU) de Bordeaux, 33000 Bordeaux, France.
| | - Antoine Roquilly
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093 Nantes, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, 75013 Paris, France
| | - Caroline Duracher-Gout
- Département d'Anesthésie Réanimation Chirurgicale et SAMU de Paris, Université René Descartes Paris, 75006 Paris Cedex, France
| | - Claire Dahyot-Fizelier
- Anaesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France. INSERM UMR1070 - Pharmacology of Anti-infective Agents, University of Poitiers, 86000 Poitiers, France
| | - Olivier Langeron
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor Assistance Publique - Hôpitaux de Paris Université Paris-Est, 94 Créteil, France
| | - Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, San Francisco, USA
| | - Sébastien Mirek
- Service d'Anesthésie Réanimation, CHU Dijon, 21000 Dijon Cedex, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor Assistance Publique - Hôpitaux de Paris Université Paris-Est, 94 Créteil, France
| | - Ségolène Mrozek
- Département d'Anesthésie-Réanimation, CHU Toulouse, Hôpital Pierre Paul Riquet, 31000 Toulouse, France
| | - Laurent Muller
- Service des réanimations et Surveillance Continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Place Du Pr Debré, 30000 Nîmes, France
| | | | - Antoine Virat
- Clinique Pont De Chaume, 330, Avenue Marcel Unal, 82000 Montauban, France
| | - Marc Leone
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, 13005 Marseille, France
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Abstract
Anesthesiologists are uniquely positioned to facilitate emergent care of patients with sepsis in the perioperative setting. A subset of sepsis patients presents with surgical pathology. Emphasis is on timely intervention with source control, antibiotic therapy, and aggressive resuscitation. Ileus, aspiration, and cardiovascular collapse must be considered when inducing patients with sepsis. Dynamic fluid responsiveness may prove an effective tool in minimizing over-resuscitation. Assessment of circulatory failure and drug therapy involves an understanding of preload, afterload, and contractility. Timely, targeted resuscitation and early source control have persisted and remain fundamental to sepsis care.
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Affiliation(s)
- Arpit Patel
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, NYU Langone Medical Center, 550 1st Avenue, New York, NY 10016, USA
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, NYU Langone Medical Center, 550 1st Avenue, New York, NY 10016, USA.
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39
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Krishnamoorthy V, Ellis AR, McLean DJ, Stefan MS, Nathanson BH, Cobert J, Lindenauer PK, Brookhart MA, Ohnuma T, Raghunathan K. Bleeding After Musculoskeletal Surgery in Hospitals That Switched From Hydroxyethyl Starch to Albumin Following a Food and Drug Administration Warning. Anesth Analg 2020; 131:1193-1200. [PMID: 32925340 DOI: 10.1213/ane.0000000000004942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND While US Food and Drug Administration (FDA) black box warnings are common, their impact on perioperative outcomes is unclear. Hydroxyethyl starch (HES) is associated with increased bleeding and kidney injury in patients with sepsis, leading to an FDA black box warning in 2013. Among patients undergoing musculoskeletal surgery in a subset of hospitals where colloid use changed from HES to albumin following the FDA warning, we examined the rate of major perioperative bleeding post- versus pre-FDA warning. METHODS The authors of this article used a retrospective, quasi-experimental, repeated cross-sectional, interrupted time series study of patients undergoing musculoskeletal surgery in hospitals within the Premier Healthcare Database, in the year before and year after the 2013 FDA black box warning. We examined patients in 23 "switcher" hospitals (where the percentage of colloid recipients receiving HES exceeded 50% before the FDA warning and decreased by at least 25% in absolute terms after the FDA warning) and patients in 279 "nonswitcher" hospitals. Among patients having surgery in "switcher" and "nonswitcher" hospitals, we determined monthly rates of major perioperative bleeding during the 12 months after the FDA warning, compared to 12 months before the FDA warning. Among patients who received surgery in "switcher" hospitals, we conducted a propensity-weighted segmented regression analysis assessing differences-in-differences (DID), using patients in "nonswitcher" hospitals as a control group. RESULTS Among 3078 patients treated at "switcher" hospitals (1892 patients treated pre-FDA warning versus 1186 patients treated post-FDA warning), demographic and clinical characteristics were well-balanced. Two hundred fifty-one (13.3%) received albumin pre-FDA warning, and 900 (75.9%) received albumin post-FDA warning. Among patients undergoing surgery in "switcher" hospitals during the pre-FDA warning period, 282 of 1892 (14.9%) experienced major bleeding during the hospitalization, compared to 149 of 1186 (12.6%) following the warning. In segmented regression, the adjusted ratio of slopes for major perioperative bleeding post- versus pre-FDA warning was 0.98 (95% confidence interval [CI], 0.93-1.04). In the DID estimate using "nonswitcher" hospitals as a control group, the ratio of ratios was 0.93 (95% CI, 0.46-1.86), indicating no significant difference. CONCLUSIONS We identified a subset of hospitals where colloid use for musculoskeletal surgery changed following a 2013 FDA black box warning regarding HES use in sepsis. Among patients undergoing musculoskeletal surgery at these "switcher" hospitals, there was no significant decrease in the rate of major perioperative bleeding following the warning, possibly due to incomplete practice change. Evaluation of the impact of systemic changes in health care may contribute to the understanding of patient outcomes in perioperative medicine.
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Affiliation(s)
- Vijay Krishnamoorthy
- From the Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alan R Ellis
- Department of Social Work, North Carolina State University, Raleigh, North Carolina
| | - Duncan J McLean
- Department of Anesthesiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mihaela S Stefan
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | | | - Julien Cobert
- Department of Anesthesiology, University of California, San Francisco, California
- Anesthesiology Service Durham VA Medical Center, Durham, North Carolina
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - M Alan Brookhart
- Department of Epidemiology, University of North Carolina (UNC) Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- NoviSci LLC, Durham, North Carolina
| | - Tetsu Ohnuma
- From the Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- From the Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
- Anesthesiology Service Durham VA Medical Center, Durham, North Carolina
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40
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Koeze J, van der Horst ICC, Wiersema R, Keus F, Dieperink W, Cox EGM, Zijlstra JG, van Meurs M. Bundled care in acute kidney injury in critically ill patients, a before-after educational intervention study. BMC Nephrol 2020; 21:381. [PMID: 32883219 PMCID: PMC7469422 DOI: 10.1186/s12882-020-02029-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/19/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) often occurs in critically ill patients. AKI is associated with mortality and morbidity. Interventions focusing on the reduction of AKI are suggested by the Kidney Disease: Improving Global Outcomes guideline. We hypothesized that these educational interventions would improve outcome in patients admitted to the Intensive Care Unit (ICU). METHODS This was a pragmatic single-centre prospective observational before-after study design in an ICU in a tertiary referral hospital. All consecutive patients admitted to the ICU irrespective their illness were included. A 'Save the Kidney' (STK) bundle was encouraged via an educational intervention targeting health care providers. The educational STK bundle consisted of optimizing the fluid balance (based on urine output, serum lactate levels and/or central venous oxygen saturation), discontinuation of diuretics, maintaining a mean arterial pressure of at least 65 mmHg with the potential use of vasopressors and critical evaluation of the indication and dose of nephrotoxic drugs. The primary outcome was the composite of mortality, renal replacement therapy (RRT), and progression of AKI. Secondary outcomes were the components of the composite outcome the severity of AKI, ICU length of stay and in-hospital mortality. MAIN RESULTS The primary outcome occurred in 451 patients (33%) in the STK group versus 375 patients (29%) in the usual care group, relative risk (RR) 1.16, 95% confidence interval (CI) 1.03-1.3, p < 0.001. Secondary outcomes were, ICU mortality in 6.8% versus 5.6%, (RR 1.22, 95% CI 0.90-1.64, p = 0.068), RRT in 1.6% versus 3.6% (RR 0.46, 95% CI 0.28-0.76, p = 0.002), and AKI progression in 28% versus 24% (RR 1.18, 95% CI 1.04-1.35, p = 0.001). CONCLUSIONS Providing education to uniformly apply an AKI care bundle, without measurement of the implementation in a non-selected ICU population, targeted at prevention of AKI progression was not beneficial.
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Affiliation(s)
- Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands.
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Eline G M Cox
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
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Meyhoff TS, Hjortrup PB, Delaney A. Fluid trials: searching for a solution to an age-old problem. Intensive Care Med 2020; 46:1743-1745. [PMID: 32808063 DOI: 10.1007/s00134-020-06188-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Tine Sylvest Meyhoff
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Peter Buhl Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anthony Delaney
- Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia.,Division of Critical Care, The George Institute for Global Health, UNSW, Newtown, NSW, Australia
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42
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Song Y, Chen G, Huang P, Hu C, Liu X. Effects of Tamsulosin Combined With Solifenacin on Lower Urinary Tract Symptoms: Evidence From a Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials. Front Pharmacol 2020; 11:763. [PMID: 32528291 PMCID: PMC7264120 DOI: 10.3389/fphar.2020.00763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/07/2020] [Indexed: 12/03/2022] Open
Abstract
This study is aimed to systematically evaluate the efficacy of tamsulosin combined with solifenacin and provide clinical evidence for treatment of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang data information service platform were searched to select randomized controlled trials (RCTs) of tamsulosin combined with solifenacin in the treatment of BPH with LUTS. After extraction of the data, the statistical information was calculated by means of STATA 12.0. The publication bias was calculated using Egger's test and Begg's funnel plot. A total of 17 articles contained 1,870 patients treated with tamsulosin in combination with solifenacin and 1,897 patients treated with tamsulosin only were included in this study. Results show that tamsulosin combined with solifenacin therapy was more effective in reducing the Total International Prostate Symptom Score (TIPSS), Storage International Prostate Symptom Score (SIPSS), Quality of life (QOL), and Overactive bladder symptom score (OABSS) in comparison with tamsulosin monotherapy treatment. However, it was found that the combination therapy may increase levels of prostate-specific antigen (PSA) and the maximal urinary flow rate (QMAX). Differences between the combination therapy and tamsulosin monotherapy were not statistically significant for urgency episodes per 24 h, micturitions per 24 h, Voiding International Prostate Symptom Score (VIPSS), and postvoid residual volume (PVR). Tamsulosin combined with solifenacin therapy is more effective than tamsulosin monotherapy for the treatment of BPH concurrent with LUTS and won't increase the risk of dysuria.
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Affiliation(s)
- Yuxuan Song
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, China
| | - Guangyuan Chen
- The Second Clinical Medical School, Nanchang University, Nanchang, China
| | - Peng Huang
- Center for Evidence-Based Medicine, School of Public Health, Nanchang University, Nanchang, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, China
| | - Cong Hu
- The Second Clinical Medical School, Nanchang University, Nanchang, China
| | - Xiaoqiang Liu
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, China
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43
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Bera KD, Shah A, English MR, Harvey D, Ploeg RJ. Optimisation of the organ donor and effects on transplanted organs: a narrative review on current practice and future directions. Anaesthesia 2020; 75:1191-1204. [PMID: 32430910 DOI: 10.1111/anae.15037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 12/16/2022]
Abstract
Mortality remains high for patients on the waiting list for organ transplantation. A marked imbalance between the number of available organs and recipients that need to be transplanted persists. Organs from deceased donors are often declined due to perceived and actual suboptimal quality. Adequate donor management offers an opportunity to reduce organ injury and maximise the number of organs than can be offered in order to respect the donor's altruistic gift. The cornerstones of management include: correction of hypovolaemia; maintenance of organ perfusion; prompt treatment of diabetes insipidus; corticosteroid therapy; and lung protective ventilation. The interventions used to deliver these goals are largely based on pathophysiological rationale or extrapolations from general critical care patients. There is currently insufficient high-quality evidence that has assessed whether any interventions in the donor after brain death may actually improve immediate post-transplant function and long-term graft survival or recipient survival after transplantation. Improvements in our understanding of the underlying mechanisms following brain death, in particular the role of immunological and metabolic changes in donors, offer promising future therapeutic opportunities to increase organ utilisation. Establishing a UK donor management research programme involves consideration of ethical, logistical and legal issues that will benefit transplanted patients while respecting the wishes of donors and their families.
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Affiliation(s)
- K D Bera
- Oxford Biomedical Research Centre and Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - M R English
- University of Oxford Medical School, Oxford, UK
| | - D Harvey
- Department of Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R J Ploeg
- Nuffield Department of Surgical Sciences and Oxford Biomedical Research Centre, University of Oxford, UK
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Zhao H, Zhu Y, Zhang J, Wu Y, Xiang X, Zhang Z, Li T, Liu L. The Beneficial Effect of HES on Vascular Permeability and Its Relationship With Endothelial Glycocalyx and Intercellular Junction After Hemorrhagic Shock. Front Pharmacol 2020; 11:597. [PMID: 32457611 PMCID: PMC7227604 DOI: 10.3389/fphar.2020.00597] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
Background Vascular leakage is a common complication of hemorrhagic shock. Endothelial glycocalyx plays a crucial role in the protection of vascular endothelial barrier function. Hydroxyethyl starch (HES) is a commonly used resuscitation fluid for hemorrhagic shock. However, whether the protective effect of HES on vascular permeability after hemorrhagic shock is associated with the endothelial glycocalyx is unclear. Methods Using hemorrhagic shock rat model and hypoxia treated vascular endothelial cells (VECs), effects of HES (130/0.4) on pulmonary vascular permeability and the relationship to endothelial glycocalyx were observed. Results Pulmonary vascular permeability was significantly increased after hemorrhagic shock, as evidenced by the increased permeability of pulmonary vessels to albumin-fluorescein isothiocyanate conjugate (FITC-BSA) and Evans blue, the decreased transendothelial electrical resistance of VECs and the increased transmittance of FITC-BSA. The structure of the endothelial glycocalyx was destroyed, showing a decrease in thickness. The expression of heparan sulfate, hyaluronic acid, and chondroitin sulfate, the components of the endothelial glycocalyx, was significantly decreased. HES (130/0.4) significantly improved the vascular barrier function, recovered the thickness and the expression of components of the endothelial glycocalyx by down-regulating the expression of heparinase, hyaluronidase, and neuraminidase, and meanwhile increased the expression of intercellular junction proteins ZO-1, occludin, and VE-cadherin. Degradation of endothelial glycocalyx with degrading enzyme (heparinase, hyaluronidase, and neuraminidase) abolished the beneficial effect of HES on vascular permeability, but had no significant effect on the recovery of the expression of endothelial intercellular junction proteins induced by HES (130/0.4). HES (130/0.4) decreased the expression of cleaved-caspase-3 induced by hemorrhagic shock. Conclusions HES (130/0.4) has protective effect on vascular barrier function after hemorrgic shock.The mechanism is mainly related to the protective effect of HES on endothelial glycocalyx and intercellular junction proteins. The protective effect of HES on endothelial glycocalyx was associated with the down-regulated expression of heparinase, hyaluronidase, and neuraminidase. HES (130/0.4) had an anti-apoptotic effect in hemorrhagic shock.
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Affiliation(s)
- Hongliang Zhao
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yu Zhu
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Jie Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yue Wu
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Xinming Xiang
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Zisen Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Tao Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Liangming Liu
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
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Muller L. Should we ban hydroxyethyl starches from the operating theatre? CON, PRO or something else? Anaesth Crit Care Pain Med 2020; 39:189-190. [PMID: 32156644 DOI: 10.1016/j.accpm.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Laurent Muller
- Service Réanimation et Surveillance Continue, Pôle ARDU (anesthésie, réanimation, douleur, urgences), CHU de Nîmes-Careameau, 30029 Nîmes cedex, France.
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46
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Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU. Crit Care Med 2020; 48:e173-e191. [DOI: 10.1097/ccm.0000000000004192] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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47
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Zampieri FG, Cavalcanti AB. Hydroxyethyl Starch for Fluid Replacement Therapy in High-Risk Surgical Patients: Context and Caution. JAMA 2020; 323:217-218. [PMID: 31961399 DOI: 10.1001/jama.2019.20141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Fernando G Zampieri
- Research Institute, HCor (Hospital do Coração), São Paulo, Brazil
- Center for Epidemiological Research, University of Southern Denmark, Odense, Denmark
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Higgins AM, Brooker JE, Mackie M, Cooper DJ, Harris AH. Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review. J Intensive Care 2020; 8:5. [PMID: 31934338 PMCID: PMC6950865 DOI: 10.1186/s40560-019-0412-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis is a global health priority. Interventions to reduce the burden of sepsis need to be both effective and cost-effective. We performed a systematic review of the literature on health economic evaluations of sepsis treatments in critically ill adult patients and summarised the evidence for cost-effectiveness. Methods We systematically searched MEDLINE, Embase, and the Cochrane Library using thesaurus (e.g. MeSH) and free-text terms related to sepsis and economic evaluations. We included all articles that reported, in any language, an economic evaluation of an intervention for the management of sepsis in critically ill adult patients. Data extracted included study details, intervention details, economic evaluation methodology, and outcomes. Included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results We identified 50 records representing 46 economic evaluations for a variety of interventions including antibiotics (n = 5), fluid therapy (n = 2), early goal-directed therapy and other resuscitation protocols (n = 8), immunoglobulins (n = 2), and interventions no longer in clinical use such as monoclonal antibodies (n = 7) and drotrecogin alfa (n = 13). Twelve (26%) evaluations were of excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (lower costs and higher effectiveness) for early goal-directed therapy, albumin, and a multifaceted sepsis education program to dominated (higher costs and lower effectiveness) for polymerase chain reaction assays (LightCycler SeptiFast testing MGRADE®, SepsiTest™, and IRIDICA BAC BSI assay). ICERs varied widely across evaluations, particularly in subgroup analyses. Conclusions There is wide variation in the cost-effectiveness of sepsis interventions. There remain important gaps in the literature, with no economic evaluations identified for several interventions routinely used in sepsis. Given the high economic and social burden of sepsis, high-quality economic evaluations are needed to increase our understanding of the cost-effectiveness of these interventions in routine clinical practice and to inform decision makers. Trial registration PROSPERO CRD42018095980
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Affiliation(s)
- Alisa M Higgins
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Joanne E Brooker
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Michael Mackie
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - D Jamie Cooper
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia.,2Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria Australia
| | - Anthony H Harris
- 3Centre for Health Economics, Monash University, Melbourne, Victoria Australia
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Bughrara N, Cha S, Safa R, Pustavoitau A. Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach. Anesthesiol Clin 2020; 38:107-122. [PMID: 32008646 DOI: 10.1016/j.anclin.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis and septic shock are medical emergencies, with high associated mortality. The Surviving Sepsis Campaign has developed definitions and management guidelines, emphasizing the use of hour-1 care bundle. Anesthesiologists frequently encounter sepsis when source control is required. The authors summarize expected manifestations of organ dysfunction and state-of-the-art management of patients with sepsis and septic shock. They highlight an increasingly vital role point-of-care ultrasound examination in the recognition and management of hemodynamic derangements in this patient population. Supporting the role of anesthesiologists as perioperative physicians, the authors provide a framework for transitions of care between operating room and intensive care units.
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Affiliation(s)
- Nibras Bughrara
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA.
| | - Stephanie Cha
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6216, Baltimore, MD 21287, USA; Division of Critical Care, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6216, Baltimore, MD 21287, USA
| | - Radwan Safa
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA
| | - Aliaksei Pustavoitau
- Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 297, Baltimore, MD 21287, USA
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N M, Lukose J, Shastry S, Mohan G, Chidangil S. Human red blood cell behaviour in hydroxyethyl starch: probed by single cell spectroscopy. RSC Adv 2020; 10:31453-31462. [PMID: 35520664 PMCID: PMC9056550 DOI: 10.1039/d0ra05842d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 08/17/2020] [Indexed: 01/18/2023] Open
Abstract
Hydroxyethyl starch (HES) is a commonly used intravenous fluid in hospital settings. The merits and demerits of its application is still a debatable topic. Investigating the interaction of external agents like intravenous fluids with blood cells is of great significance in clinical environments. Micro-Raman spectroscopy combined with an optical tweezers technique has been utilized for conducting systematic investigations of single live red blood cells (RBCs) under the influence of external stress agents. The present work deals with a detailed biophysical study on the response of human live red blood cells in hydroxyethyl starch using optical techniques. Morphological changes in red blood cells were monitored using quantitate phase imaging techniques. Micro-Raman studies suggest that there is a significant reduction in the oxy-haemoglobin level in red blood cells suspended in HES. The spectra recorded by using different probe laser powers has shown that the cells are more vulnerable in HES under the influence of externally induced stress than in blood plasma. In addition, the spectral results support the possibility of heme aggregation and membrane damage for red blood cells in HES under externally induced stress. Principle component analysis performed on the Raman spectra were able to effectively discriminate between red blood cells in HES and in blood plasma. The use of Raman tweezers can be highly beneficial in elucidating biochemical alterations happening in live, human red blood cell. Hydroxyethyl starch (HES) is a commonly used intravenous fluid in hospital settings.![]()
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Affiliation(s)
- Mithun N
- Centre of Excellence for Biophotonics
- Department of Atomic and Molecular Physics
- Manipal Academy of Higher Education
- India
| | - Jijo Lukose
- Centre of Excellence for Biophotonics
- Department of Atomic and Molecular Physics
- Manipal Academy of Higher Education
- India
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion
- Kasturba Medical College, Manipal
- Manipal Academy of Higher Education
- Manipal
- India
| | - Ganesh Mohan
- Department of Immunohematology and Blood Transfusion
- Kasturba Medical College, Manipal
- Manipal Academy of Higher Education
- Manipal
- India
| | - Santhosh Chidangil
- Centre of Excellence for Biophotonics
- Department of Atomic and Molecular Physics
- Manipal Academy of Higher Education
- India
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