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Sundaram SK, Panda NB, Kaloria N, Soni SL, Mahajan S, Karthigeyan M, Pattanaik S, Singh S, Dey S, Pal A, Tripathi M. Effect of Fluid Therapy on Acid-Base Balance in Patients Undergoing Clipping for Ruptured Intracranial Aneurysm: A Prospective Randomized Controlled Trial. Asian J Neurosurg 2024; 19:386-394. [PMID: 39205884 PMCID: PMC11349413 DOI: 10.1055/s-0044-1787086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Objectives Neurosurgical patients often receive 0.9% normal saline (NS) during the perioperative period. Theoretically, a balanced salt solution (BSS) is better than 0.9% saline. We compared the effects of two different fluids on acid-base balance, renal function, and neurological outcome in patients who underwent clipping following subarachnoid hemorrhage from a ruptured intracranial aneurysm. Materials and Methods Patients in group NS ( n = 30) received 0.9% saline and group BSS ( N = 30) received BSS (Plasmalyte-A) in the perioperative period for 48 hours. Comparison of arterial pH, bicarbonate, and base deficit measured preoperatively, intraoperatively (first and second hour), and postoperatively (at 24 and 48 hours) was the primary outcome of the study. The secondary outcome compared serum electrolytes, renal function tests, urine neutrophil gelatinase-associated lipocalin (NGAL), serum cystatin C, and the neurological outcome using modified Rankin score (MRS) at discharge, 1, and 3 months. Results In group NS, significantly low pH at 1-hour intraoperative period was seen compared with group BSS (7.37 ± 0.06 vs. 7.40 ± 0.05, p = 0.024). The bicarbonate level in group NS was significantly lower and the base deficit was higher at second intraoperative hour (bicarbonate: 17.49 vs. 21.99 mEq/L, p = 0.001; base deficit: 6.41 mmol/L vs. 1.89 mmol/L, p = 0.003) and at 24 hours post-surgery (bicarbonate: 20.38 vs. 21.96 mEq/L, p = 0.012; base deficit: 3.56 mmol/L vs. 2.12 mmol/L, p = 0.034)). Serum creatinine was higher in group NS at 24 hours (0.66 vs. 0.52 mg/dL, p = 0.013) and 48 hours (0.62 vs. 0.53 mg/dL, p = 0.047). Serum urea, electrolytes, cystatin, urine NGAL, and MRS were comparable. Conclusion In neurosurgical patients undergoing clipping for ruptured intracranial aneurysm, using a BSS during the perioperative period is associated with a better acid-base and renal profile. However, the biomarkers of kidney injury and long-term outcomes were comparable.
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Affiliation(s)
- Senthil Kumaran Sundaram
- Department of Anaesthesia and Intensive Care, Post Graduate, Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Bidyut Panda
- Division of Neuroanaesthesia, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kaloria
- Department of Anaesthesia and Intensive Care, Post Graduate, Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Lal Soni
- Department of Anaesthesia and Intensive Care, Post Graduate, Institute of Medical Education and Research, Chandigarh, India
| | - Shalvi Mahajan
- Department of Anaesthesia and Intensive Care, Post Graduate, Institute of Medical Education and Research, Chandigarh, India
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Pattanaik
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sheetal Singh
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sumit Dey
- Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arnab Pal
- Department of Biochemistry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Poh K, Bustam A, Hasan MS, Mohd Yunos N, Cham CY, Lim FJ, Ahmad Zahedi AZ, Zambri A, Noor Azhar M. Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial. Am J Emerg Med 2024; 77:106-114. [PMID: 38118385 DOI: 10.1016/j.ajem.2023.11.064] [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: 08/11/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative. OBJECTIVES This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS. DESIGN, SETTINGS AND PARTICIPANTS A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019. INTERVENTION OR EXPOSURE Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type. OUTCOMES MEASURE AND ANALYSIS The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated. MAIN RESULTS A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months. CONCLUSIONS In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.
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Affiliation(s)
- Khadijah Poh
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Aida Bustam
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Chun Yoong Cham
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Fang Jen Lim
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | | | - Aliyah Zambri
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhaimin Noor Azhar
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.
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Sankar J, Muralidharan J, Lalitha AV, Rameshkumar R, Pathak M, Das RR, Nadkarni VM, Ismail J, Subramanian M, Nallasamy K, Dev N, Kumar UV, Kumar K, Sharma T, Jaravta K, Thakur N, Aggarwal P, Jat KR, Kabra SK, Lodha R. Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med 2023; 51:1449-1460. [PMID: 37294145 DOI: 10.1097/ccm.0000000000005952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN Parallel-group, blinded multicenter trial. SETTING PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS Children up to 15 years of age with septic shock. METHODS Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.
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Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - A V Lalitha
- Department of Pediatrics Intensive Care, St Johns' Medical College Bengaluru, India
| | | | - Mona Pathak
- Research and Development Department, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | | | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Javed Ismail
- Pediatric Intensive Care Unit, NMC Royal Hospital Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mahadevan Subramanian
- Division of Pediatric Critical Care, Department of Pediatrics, JIPMER, Puducherry, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - Nishanth Dev
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - U Vijay Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Taniya Sharma
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kanika Jaravta
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Thakur
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | | | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Chen Y, Gao Y. Comparison of Balanced Crystalloids versus Normal Saline in Critically Ill Patients: A Systematic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. Ther Clin Risk Manag 2023; 19:783-799. [PMID: 37850070 PMCID: PMC10577264 DOI: 10.2147/tcrm.s416785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/25/2023] [Indexed: 10/19/2023] Open
Abstract
Background Fluid resuscitation is routinely needed for critically ill patients. However, the optimal choice between crystalloids and normal saline is in heat debate. Objective To conduct a meta-analysis comparing normal saline and balanced crystalloids in the treatment of critically ill patients with composite mortality as the primary outcome. Methods PubMed, Embase, Medline, Web of Science, and Cochrane Library were searched from inception up to March 2022. Studies of critically ill adult patients assigned to receive normal saline or balanced crystalloids were included. We conducted a meta-analysis using an inverse variance, random-effects model in addition to trial sequential analysis (TSA). The primary outcome was composite mortality. Subgroup analyses were also conducted. Results Eighteen full-text studies (n=36,224) were included. Balanced crystalloids were associated with lower mortality compared with normal saline (risk ratio [RR]=0.96; 95% confidential interval [CI] 0.93, 1; p=0.03; I2=0) and lower incidence of acute kidney injury/acute renal failure (RR =0.93; 95% CI = 0.87, 0.99; p=0.03). No significant difference was observed in other outcomes. In the sepsis patients, the balanced crystalloid showed a lower composite mortality rate compared with normal saline (RR =0.91; 95% CI = 0.85, 0.99; p=0.02). TSA analysis demonstrated that, with 80% power, the effect of balanced crystalloid is not larger than a 10% relative decrease in composite mortality compared with normal saline. Conclusion and Relevance This study demonstrated that balanced crystalloids could be an optimal choice over normal saline in critically ill patients to a reduced composite mortality rate. In patients with sepsis, the difference is especially significant. Nonetheless, the optimal resuscitation fluid option between saline and balanced crystalloid solutions should be investigated further with more evidence.
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Affiliation(s)
- Yi Chen
- Emergency Department of West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Institute of Disaster Medicine, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Nursing Key Laboratory of Sichuan Province, Chengdu City, Sichuan Province, People’s Republic of China
| | - Yongli Gao
- Emergency Department of West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Institute of Disaster Medicine, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Nursing Key Laboratory of Sichuan Province, Chengdu City, Sichuan Province, People’s Republic of China
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Husain-Syed F, Takeuchi T, Neyra JA, Ramírez-Guerrero G, Rosner MH, Ronco C, Tolwani AJ. Acute kidney injury in neurocritical care. Crit Care 2023; 27:341. [PMID: 37661277 PMCID: PMC10475203 DOI: 10.1186/s13054-023-04632-1] [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: 04/18/2023] [Accepted: 08/30/2023] [Indexed: 09/05/2023] Open
Abstract
Approximately 20% of patients with acute brain injury (ABI) also experience acute kidney injury (AKI), which worsens their outcomes. The metabolic and inflammatory changes associated with AKI likely contribute to prolonged brain injury and edema. As a result, recognizing its presence is important for effectively managing ABI and its sequelae. This review discusses the occurrence and effects of AKI in critically ill adults with neurological conditions, outlines potential mechanisms connecting AKI and ABI progression, and highlights AKI management principles. Tailored approaches include optimizing blood pressure, managing intracranial pressure, adjusting medication dosages, and assessing the type of administered fluids. Preventive measures include avoiding nephrotoxic drugs, improving hemodynamic and fluid balance, and addressing coexisting AKI syndromes. ABI patients undergoing renal replacement therapy (RRT) are more susceptible to neurological complications. RRT can negatively impact cerebral blood flow, intracranial pressure, and brain tissue oxygenation, with effects tied to specific RRT methods. Continuous RRT is favored for better hemodynamic stability and lower risk of dialysis disequilibrium syndrome. Potential RRT modifications for ABI patients include adjusted dialysate and blood flow rates, osmotherapy, and alternate anticoagulation methods. Future research should explore whether these strategies enhance outcomes and if using novel AKI biomarkers can mitigate AKI-related complications in ABI patients.
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Affiliation(s)
- Faeq Husain-Syed
- Division of Nephrology, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Tomonori Takeuchi
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ku, Tokyo, 113-8510, Japan
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Gonzalo Ramírez-Guerrero
- Critical Care Unit, Carlos Van Buren Hospital, San Ignacio 725, Valparaíso, Chile
- Dialysis and Renal Transplant Unit, Carlos Van Buren Hospital, San Ignacio 725, Valparaíso, Chile
- Department of Medicine, Universidad de Valparaíso, Hontaneda 2653, Valparaíso, Chile
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
| | - Claudio Ronco
- Department of Medicine (DIMED), Università di Padova, Via Giustiniani, 2, 35128, Padua, Italy
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37, 36100, Vicenza, Italy
| | - Ashita J Tolwani
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA.
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Shrivastava P, Murmu R, Suman S, Verma S, Lakra L, Kumar S. The Effect on Serum Electrolytes in Patients Undergoing Elective Craniotomy for Supratentorial Brain Tumors Using PlasmaLyte A and Normal Saline as Intravenous Replacement Fluid. Cureus 2023; 15:e42656. [PMID: 37644938 PMCID: PMC10461887 DOI: 10.7759/cureus.42656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/31/2023] Open
Abstract
Background and aim The type of fluid which is administered to patients is very crucial and important. In this study normal saline is compared with PlasmaLyte A in patients undergoing craniotomy for supratentorial brain tumors. Generally normal saline is used in neurosurgical patients; it is seen to be associated with hyperchloremic acidosis. A balanced crystalloid, e.g. PlasmaLyte A, maintains a better metabolic status than normal saline. This study was planned to study the metabolic effects of using PlasmaLyte A as compared with normal saline as intravenous fluids in patients undergoing supratentorial brain tumour surgeries. Methods This is a prospective, randomized, double-blinded study in patients undergoing craniotomy for supratentorial brain tumors. Written informed consent was taken from patients and they were divided into two groups, Group A and B of 40 patients each by computer-generated random numbers. Group A received PlasmaLyte A and Group B received normal saline intra-operatively as maintenance fluid. Heart rate, mean arterial pressure, total fluid administered, serum sodium, serum potassium, chloride, lactate, pH, serum urea, serum creatinine, osmolarity, and urine output were assessed at different time intervals in both groups. Blood urea and creatinine were assessed to see acute kidney injury. Results There was no difference in mean values of serum sodium, potassium, lactate, serum urea, creatinine and serum osmolarity in both groups throughout the study period. However there was a rise in serum chloride and a low pH was noted in Group B. The urine output was also similar in both groups. The metabolic status of patients receiving PlasmaLyte was better than those receiving normal saline. Conclusion Normal saline may cause hyperchloremic metabolic acidosis which may be avoided by using balanced crystalloids. The use of balanced crystalloids should be preferred to normal saline in neurosurgical patients to ensure a better metabolic status and good clinical outcome.
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Affiliation(s)
| | - Ravi Murmu
- Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Saurabh Suman
- Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Saket Verma
- Biochemistry (Trauma Centre), Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Ladhu Lakra
- Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Sanjay Kumar
- Anaesthesiology and Critical Care, All India Institute of Medical Sciences Deoghar, Deoghar, IND
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7
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Hourmant Y, Huard D, Demeure Dit Latte D, Bouras M, Asehnoune K, Pirrachio R, Roquilly A. Effect of continuous infusion of hypertonic saline solution on survival of patients with brain injury: a systematic review and meta-analysis. Anaesth Crit Care Pain Med 2023; 42:101177. [PMID: 36436787 DOI: 10.1016/j.accpm.2022.101177] [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: 08/15/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective was to determine the effects of continuous infusion of hypertonic saline solutions on outcomes of patients with brain injury. METHODS Preferred Reported Items for Systemic Reviews and Meta-Analysis guidelines were followed. We searched the MEDLINE and COCHRANE clinical trials register (through December 2021) and reference lists of articles. We included all clinical trials conducted in brain-injured patients hospitalized in intensive care units evaluating continuous infusion of hypertonic saline solution (osmolarity above 308 mOsm/L). Two reviewers extracted data that were checked by two others. The primary outcome was the in-hospital mortality rate. The main secondary outcomes were the rates of intracranial hypertension, an unfavorable neurological outcome at day 90, and adverse events. RESULTS We identified 23 clinical trials reporting the use of continuous infusion of hypertonic saline solution in brain-injured patients. The primary outcome was available in 10 studies (n = 1883 patients). The odds ratio (OR) for in-hospital death with the intervention was 0.68 (95% confidence interval (CI), 0.54-0.85, I2 = 0%). In the subgroup of studies including only traumatic brain-injured patients (7 studies, n = 1521 patients), the OR for the primary outcome was 0.74 (95%CI 0.57-0.95) with the intervention. The OR for intracranial hypertension and unfavorable neurological outcome at day 90 were 0.66 (95%CI 0.49-0.88, I2 = 42%, n = 787 patients) and 0.61 (95%CI 0.46-0.81, I2 = 15%, n = 956 patients), respectively. Regarding safety, the OR of acute kidney injury and severe hypernatremia were 0.82 (95%CI 0.47-1.44, I2 = 0%) and 3.38 (95%CI 2.16-5.27, I2 = 24%). CONCLUSIONS Continuous hypertonic saline solution infusion reduced in-hospital mortality without increasing the risk of unfavorable neurological outcome at day 90 in brain-injured patients hospitalized in intensive care units. Given the inclusion of observational and heterogeneous studies, further randomized studies are needed before developing recommendations for implementation at the bedside. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021221367. Registered 13 May 2021.
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Affiliation(s)
- Yannick Hourmant
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Donatien Huard
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Dominique Demeure Dit Latte
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Marwan Bouras
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Romain Pirrachio
- Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, United States of America
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France.
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8
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Huet O, Chapalain X, Vermeersch V, Moyer JD, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Hourmant Y, Asehnoune K, Roquilly A. Impact of continuous hypertonic (NaCl 20%) saline solution on renal outcomes after traumatic brain injury (TBI): a post hoc analysis of the COBI trial. Crit Care 2023; 27:42. [PMID: 36707841 PMCID: PMC9881296 DOI: 10.1186/s13054-023-04311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/07/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To evaluate if the increase in chloride intake during a continuous infusion of 20% hypertonic saline solution (HSS) is associated with an increase in the incidence of acute kidney injury (AKI) compared to standard of care in traumatic brain injury patients. METHODS In this post hoc analysis of the COBI trial, 370 patients admitted for a moderate-to-severe TBI in the 9 participating ICUs were enrolled. The intervention consisted in a continuous infusion of HSS to maintain a blood sodium level between 150 and 155 mmol/L for at least 48 h. Patients enrolled in the control arm were treated as recommended by the latest Brain Trauma foundation guidelines. The primary outcome of this study was the occurrence of AKI within 28 days after enrollment. AKI was defined by stages 2 or 3 according to KDIGO criteria. RESULTS After exclusion of missing data, 322 patients were included in this post hoc analysis. The patients randomized in the intervention arm received a significantly higher amount of chloride during the first 4 days (intervention group: 97.3 ± 31.6 g vs. control group: 61.3 ± 38.1 g; p < 0.001) and had higher blood chloride levels at day 4 (117.9 ± 10.7 mmol/L vs. 111.6 ± 9 mmol/L, respectively, p < 0.001). The incidence of AKI was not statistically different between the intervention and the control group (24.5% vs. 28.9%, respectively; p = 0.45). CONCLUSIONS Despite a significant increase in chloride intake, a continuous infusion of HSS was not associated with AKI in moderate-to-severe TBI patients. Our study does not confirm the potentially detrimental effect of chloride load on kidney function in ICU patients. TRIAL REGISTRATION The COBI trial was registered on clinicaltrial.gov (Trial registration number: NCT03143751, date of registration: 8 May 2017).
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Affiliation(s)
- Olivier Huet
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France.
| | - Xavier Chapalain
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France
| | - Véronique Vermeersch
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France
| | - Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Sigismond Lasocki
- Department of Anesthesia and Intensive Care Unit, Angers Hospital, Angers, France
| | - Benjamin Cohen
- Department of Anesthesia and Intensive Care Unit, Tours Hospital, Tours, France
| | | | - Kevin Chalard
- Department of Anesthesia and Intensive Care Unit, Montpellier Hospital, Montpellier, France
| | - P Seguin
- Department of Anesthesia and Intensive Care Unit, Rennes Hospital, Rennes, France
| | - Y Hourmant
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
| | - Karim Asehnoune
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
| | - Antoine Roquilly
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
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9
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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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10
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Bala R, Bansal T, Mundra A, Kamal K. Comparison and evaluation of two different crystalloids - Normal saline and plasmalyte in patients of traumatic brain injury undergoing craniotomy. Brain Circ 2022; 8:200-206. [PMID: 37181841 PMCID: PMC10167847 DOI: 10.4103/bc.bc_54_22] [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: 08/04/2022] [Revised: 10/02/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Fluid therapy is one of the most important components of the management of patients with traumatic brain injury (TBI). The present study was planned to compare plasmalyte and normal saline (NS) in patients who underwent craniotomies for TBI in terms of their effects on acid-base equilibrium, renal functions, and coagulation profile. METHODS Fifty patients of age 18-45 years of either sex, who underwent emergency craniotomy for TBI, were included in the study. The patients were randomized into two groups. Group P (n = 25) received isotonic balanced crystalloid (plasmalyte) and Group N (n = 25) received NS intraoperatively and postoperatively till 24 h after surgery. RESULTS The pH was lower in Group N (P < 0.05) at different time points after surgery. Similarly, more patients in Group N had pH <7.3 (P < 0.05); while the rest of the metabolic parameters were comparable in the two groups. Blood urea and serum creatinine were higher in Group N. Coagulation profile was comparable in the two groups. CONCLUSION Acid-base, electrolyte balance, and renal profile were better in patients receiving plasmalyte as compared to NS. Hence, it can be a wiser choice for fluid management in patients of TBI undergoing craniotomy.
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Affiliation(s)
- Renu Bala
- Department of Anaesthesiology and Critical Care, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Teena Bansal
- Department of Anaesthesiology and Critical Care, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Anshul Mundra
- Department of Anaesthesiology and Critical Care, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Kirti Kamal
- Department of Anaesthesiology and Critical Care, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
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11
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Zampieri FG, Damiani LP, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Serpa-Neto A, Manoel ALDO, Miranda TA, Corrêa TD, de Azevedo LCP, da Silva NB, Machado FR, Cavalcanti AB. Effects of balanced solution on short-term outcomes in traumatic brain injury patients: a secondary analysis of the BaSICS randomized trial. Rev Bras Ter Intensiva 2022; 34:410-417. [PMID: 36888820 PMCID: PMC9987002 DOI: 10.5935/0103-507x.20220261-en] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/18/2022] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVE To describe the effects of balanced solution use on the short-term outcomes of patients with traumatic brain injury enrolled in BaSICS trial. METHODS Patients were randomized to receive either 0.9% saline or balanced solution during their intensive care unit stay. The primary endpoint was 90-day mortality, and the secondary outcomes were days alive and free of intensive care unit stay at 28 days. The primary endpoint was assessed using Bayesian logistic regression. The secondary endpoint was assessed using a Bayesian zero-inflated beta binomial regression. RESULTS We included 483 patients (236 in the 0.9% saline arm and 247 in the balanced solution arm). A total of 338 patients (70%) with a Glasgow coma scale score ≤ 12 were enrolled. The overall probability that balanced solutions were associated with higher 90-day mortality was 0.98 (OR 1.48; 95%CrI 1.04 - 2.09); this mortality increment was particularly noticeable in patients with a Glasgow coma scale score below 6 at enrollment (probability of harm of 0.99). Balanced solutions were associated with -1.64 days alive and free of intensive care unit at 28 days (95%CrI -3.32 - 0.00) with a probability of harm of 0.97. CONCLUSION There was a high probability that balanced solutions were associated with high 90-day mortality and fewer days alive and free of intensive care units at 28 days.ClinicalTrials.gov: NCT02875873.
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Affiliation(s)
- Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração -
São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
| | | | | | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- BP-A Beneficência Portuguesa de São Paulo -
São Paulo (SP), Brazil
| | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
| | | | | | | | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital Sírio-Libanês - São Paulo (SP),
Brazil
| | | | - Flavia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Department of Anesthesiology, Pain and Intensive Care, Universidade
Federal de São Paulo - São Paulo (SP), Brazil
| | - Alexandre Biasi Cavalcanti
- Research Institute, HCor-Hospital do Coração -
São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
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12
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Zampieri FG, Damiani LP, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Serpa-Neto A, Manoel ALDO, Miranda TA, Corrêa TD, de Azevedo LCP, da Silva NB, Machado FR, Cavalcanti AB. Effects of balanced solution on short-term outcomes in traumatic brain injury patients: a secondary analysis of the BaSICS randomized trial. Rev Bras Ter Intensiva 2022; 34:410-417. [PMID: 36888820 PMCID: PMC9987002 DOI: 10.5935/0103-507x.20220261-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/18/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To describe the effects of balanced solution use on the short-term outcomes of patients with traumatic brain injury enrolled in BaSICS trial. METHODS Patients were randomized to receive either 0.9% saline or balanced solution during their intensive care unit stay. The primary endpoint was 90-day mortality, and the secondary outcomes were days alive and free of intensive care unit stay at 28 days. The primary endpoint was assessed using Bayesian logistic regression. The secondary endpoint was assessed using a Bayesian zero-inflated beta binomial regression. RESULTS We included 483 patients (236 in the 0.9% saline arm and 247 in the balanced solution arm). A total of 338 patients (70%) with a Glasgow coma scale score ≤ 12 were enrolled. The overall probability that balanced solutions were associated with higher 90-day mortality was 0.98 (OR 1.48; 95%CrI 1.04 - 2.09); this mortality increment was particularly noticeable in patients with a Glasgow coma scale score below 6 at enrollment (probability of harm of 0.99). Balanced solutions were associated with -1.64 days alive and free of intensive care unit at 28 days (95%CrI -3.32 - 0.00) with a probability of harm of 0.97. CONCLUSION There was a high probability that balanced solutions were associated with high 90-day mortality and fewer days alive and free of intensive care units at 28 days.ClinicalTrials.gov: NCT02875873.
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Affiliation(s)
- Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração -
São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
| | | | | | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- BP-A Beneficência Portuguesa de São Paulo -
São Paulo (SP), Brazil
| | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
| | | | | | | | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital Sírio-Libanês - São Paulo (SP),
Brazil
| | | | - Flavia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Department of Anesthesiology, Pain and Intensive Care, Universidade
Federal de São Paulo - São Paulo (SP), Brazil
| | - Alexandre Biasi Cavalcanti
- Research Institute, HCor-Hospital do Coração -
São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
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13
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Lombardo S, Smith MC, Semler MW, Wang L, Dear ML, Lindsell CJ, Freundlich RE, Guillamondegui OD, Self WH, Rice TW. Balanced Crystalloid versus Saline in Adults with Traumatic Brain Injury: Secondary Analysis of a Clinical Trial. J Neurotrauma 2022; 39:1159-1167. [PMID: 35443809 PMCID: PMC9422787 DOI: 10.1089/neu.2021.0465] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Balanced crystalloids may improve outcomes compared with saline for some critically ill adults. Lower tonicity of balanced crystalloids could worsen cerebral edema in patients with intracranial pathology. The effect of balanced crystalloids versus saline on clinical outcomes in patients with traumatic brain injury (TBI) requires further study. We planned an a priori subgroup analysis of TBI patients enrolled in the pragmatic, cluster-randomized, multiple-crossover Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (ClinicalTrials.gov: NCT02444988, NCT02547779). Primary outcome was 30-day in-hospital mortality. Secondary outcomes included hospital discharge disposition (home, facility, death). Regression models adjusted for pre-specified baseline covariates compared outcomes. TBI patients assigned to balanced crystalloids (n = 588) and saline (n = 569) had similar baseline characteristics including Injury Severity Score 19 (10); mean maximum head/neck Abbreviated Injury Score, 3.4 (1.0). Isotonic crystalloid volume administered between intensive care unit admission and first of hospital discharge or 30 days was 2037 (3470) mL and 1723 (2923) mL in the balanced crystalloids and saline groups, respectively (p = 0.18). During the study period, 94 (16%) and 82 (14%) patients (16%) died in the balanced crystalloid and saline groups, respectively (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.60 to 1.75; p = 0.913). Patients in the balanced crystalloid group were more likely to die or be discharged to another medical facility (aOR 1.38 [1.02-1.86]; p = 0.04). Overall, balanced crystalloids were associated with worse discharge disposition in critically injured patients with TBI compared with saline. The confidence intervals cannot exclude a clinically relevant increase in mortality when balanced crystalloids are used for patients with TBI.
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Affiliation(s)
- Sarah Lombardo
- Section of Acute Care Surgery, Division of General Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael C. Smith
- Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Robert E. Freundlich
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Oscar D. Guillamondegui
- Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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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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15
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Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L, Delaney A, Gallagher M, Gattas D, Li Q, Mackle D, Mysore J, Saxena M, Taylor C, Young P, Myburgh J. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med 2022; 386:815-826. [PMID: 35041780 DOI: 10.1056/nejmoa2114464] [Citation(s) in RCA: 118] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether the use of balanced multielectrolyte solution (BMES) in preference to 0.9% sodium chloride solution (saline) in critically ill patients reduces the risk of acute kidney injury or death is uncertain. METHODS In a double-blind, randomized, controlled trial, we assigned critically ill patients to receive BMES (Plasma-Lyte 148) or saline as fluid therapy in the intensive care unit (ICU) for 90 days. The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes were receipt of new renal-replacement therapy and the maximum increase in the creatinine level during ICU stay. RESULTS A total of 5037 patients were recruited from 53 ICUs in Australia and New Zealand - 2515 patients were assigned to the BMES group and 2522 to the saline group. Death within 90 days after randomization occurred in 530 of 2433 patients (21.8%) in the BMES group and in 530 of 2413 patients (22.0%) in the saline group, for a difference of -0.15 percentage points (95% confidence interval [CI], -3.60 to 3.30; P = 0.90). New renal-replacement therapy was initiated in 306 of 2403 patients (12.7%) in the BMES group and in 310 of 2394 patients (12.9%) in the saline group, for a difference of -0.20 percentage points (95% CI, -2.96 to 2.56). The mean (±SD) maximum increase in serum creatinine level was 0.41±1.06 mg per deciliter (36.6±94.0 μmol per liter) in the BMES group and 0.41±1.02 mg per deciliter (36.1±90.0 μmol per liter) in the saline group, for a difference of 0.01 mg per deciliter (95% CI, -0.05 to 0.06) (0.5 μmol per liter [95% CI, -4.7 to 5.7]). The number of adverse and serious adverse events did not differ meaningfully between the groups. CONCLUSIONS We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; PLUS ClinicalTrials.gov number, NCT02721654.).
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Affiliation(s)
- Simon Finfer
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Sharon Micallef
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Naomi Hammond
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Leanlove Navarra
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Rinaldo Bellomo
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Laurent Billot
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Anthony Delaney
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Martin Gallagher
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - David Gattas
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Qiang Li
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Diane Mackle
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Jayanthi Mysore
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Manoj Saxena
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Colman Taylor
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Paul Young
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - John Myburgh
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
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En-Din K, Nadyrkhanova NS, Tkachenko RA, Kulichkin YV, Nishanova FP, Mikirtichev KD, Dzhatdaev II. Anesthetic management for Placenta Accreta. PAIN MEDICINE 2021. [DOI: 10.31636/pmjua.v6i2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Дослідження виконані у 82 вагітних і породіль при кесаревому розтині з приводу передлежання плаценти з вростанням на 37–38 тижні. Органозберігаюча операція була виконана за такою методикою: лапаротомія за Джоель Кохен, донний кесарів розтин з залишенням плаценти, перев’язка трьох пар магістральних маткових судин і внутрішніх клубових артерій з обох сторін (поетапна деваскуляризація матки) з подальшим видаленням стінки матки (метропластика) при вростанні плаценти. Операції виконані в умовах спінальної анестезії (Сан) 0,5 % гіпербаричним розчином бупівакаїну. Інфузійна програма будувалася відповідно до рекомендацій з обмежувальної інфузії. Преінфузію проводили збалансованим кристалоїдом Реосорбілакт (10–15 мл/кг) з подальшим введенням на етапах операції збалансованого кристалоїду і компонентів крові за необхідності. Оцінювали гемодинаміку, КОР та електроліти крові. Оцінку крововтрати проводили гравіметричним способом.
Дослідження показали, що Сан і Реосорбілакт у програмі малооб’ємної інфузійної терапії зберігають доставку кисню на фізіологічному рівні, стабілізують гемодинамічний профіль і КОР. При вростанні плаценти використання сучасних технологій в анестезіології реаніматології та акушерстві, з мультидисциплінарним підходом, дозволяють реалізувати органозберігаючу тактику у цієї категорії жінок
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Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Lovato WJ, Amêndola CP, Serpa-Neto A, Paranhos JLR, Guedes MAV, Lúcio EA, Oliveira-Júnior LC, Lisboa TC, Lacerda FH, Maia IS, Grion CMC, Assunção MSC, Manoel ALO, Silva-Junior JM, Duarte P, Soares RM, Miranda TA, de Lima LM, Gurgel RM, Paisani DM, Corrêa TD, Azevedo LCP, Kellum JA, Damiani LP, Brandão da Silva N, Cavalcanti AB. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021; 326:2783039. [PMID: 34375394 PMCID: PMC8356144 DOI: 10.1001/jama.2021.11684] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/29/2021] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Intravenous fluids are used for almost all intensive care unit (ICU) patients. Clinical and laboratory studies have questioned whether specific fluid types result in improved outcomes, including mortality and acute kidney injury. OBJECTIVE To determine the effect of a balanced solution vs saline solution (0.9% sodium chloride) on 90-day survival in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Patients who were admitted to the ICU with at least 1 risk factor for worse outcomes, who required at least 1 fluid expansion, and who were expected to remain in the ICU for more than 24 hours were randomized between May 29, 2017, and March 2, 2020; follow-up concluded on October 29, 2020. Patients were randomized to 2 different fluid types (a balanced solution vs saline solution reported in this article) and 2 different infusion rates (reported separately). INTERVENTIONS Patients were randomly assigned 1:1 to receive either a balanced solution (n = 5522) or 0.9% saline solution (n = 5530) for all intravenous fluids. MAIN OUTCOMES AND MEASURES The primary outcome was 90-day survival. RESULTS Among 11 052 patients who were randomized, 10 520 (95.2%) were available for the analysis (mean age, 61.1 [SD, 17] years; 44.2% were women). There was no significant interaction between the 2 interventions (fluid type and infusion speed; P = .98). Planned surgical admissions represented 48.4% of all patients. Of all the patients, 60.6% had hypotension or vasopressor use and 44.3% required mechanical ventilation at enrollment. Patients in both groups received a median of 1.5 L of fluid during the first day after enrollment. By day 90, 1381 of 5230 patients (26.4%) assigned to a balanced solution died vs 1439 of 5290 patients (27.2%) assigned to saline solution (adjusted hazard ratio, 0.97 [95% CI, 0.90-1.05]; P = .47). There were no unexpected treatment-related severe adverse events in either group. CONCLUSION AND RELEVANCE Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02875873.
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Affiliation(s)
- Fernando G. Zampieri
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
| | - Flávia R. Machado
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rodrigo S. Biondi
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Instituto de Cardiologia do Distrito Federal, Brasília, Brazil
| | - Flávio G. R. Freitas
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital SEPACO, São Paulo, Brazil
| | - Viviane C. Veiga
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- BP–A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Rodrigo C. Figueiredo
- Hospital Maternidade São José, Centro Universitário do Espírito Santo, Colatina, Brazil
| | - Wilson J. Lovato
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | - Ary Serpa-Neto
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Eraldo A. Lúcio
- Hospital São Francisco, Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | | | - Thiago C. Lisboa
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital Santa Rita, Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | | | - Israel S. Maia
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital Nereu Ramos, Florianópolis, Brazil
| | - Cintia M. C. Grion
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital Universitário Regional do Norte do Paraná, Universidade Estadual de Londrina, Londrina, Brazil
| | | | | | | | | | | | | | | | | | | | - Thiago D. Corrêa
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luciano C. P. Azevedo
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, Brazil
| | - John A. Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Alexandre B. Cavalcanti
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
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Ryu T. Fluid management in patients undergoing neurosurgery. Anesth Pain Med (Seoul) 2021; 16:215-224. [PMID: 34352963 PMCID: PMC8342829 DOI: 10.17085/apm.21072] [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: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 11/17/2022] Open
Abstract
Fluid management is an important component of perioperative care for patients undergoing neurosurgery. The primary goal of fluid management in neurosurgery is the maintenance of normovolemia and prevention of serum osmolarity reduction. To maintain normovolemia, it is important to administer fluids in appropriate amounts following appropriate methods, and to prevent a decrease in serum osmolarity, the choice of fluid is essential. There is considerable debate about the choice and optimal amounts of fluids administered in the perioperative period. However, there is little high-quality clinical research on fluid therapy for patients undergoing neurosurgery. This review will discuss the choice and optimal amounts of fluids in neurosurgical patients based on the literature, recent issues, and perioperative fluid management practices.
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Affiliation(s)
- Taeha Ryu
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
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[Comments on the updated German S3 guidelines on intravascular volume therapy in adults]. Anaesthesist 2021; 70:413-419. [PMID: 33646330 DOI: 10.1007/s00101-021-00929-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
The German S3 guidelines on intravascular volume therapy in adults were updated in September 2020. Based on updated evidence recommendations for the diagnosis of isotonic dehydration and for fluid therapy with crystalloids and colloids in peri-interventional and intensive care medicine were proposed.
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Mismatch between Tissue Partial Oxygen Pressure and Near-Infrared Spectroscopy Neuromonitoring of Tissue Respiration in Acute Brain Trauma: The Rationale for Implementing a Multimodal Monitoring Strategy. Int J Mol Sci 2021; 22:ijms22031122. [PMID: 33498736 PMCID: PMC7865258 DOI: 10.3390/ijms22031122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/21/2022] Open
Abstract
The brain tissue partial oxygen pressure (PbtO2) and near-infrared spectroscopy (NIRS) neuromonitoring are frequently compared in the management of acute moderate and severe traumatic brain injury patients; however, the relationship between their respective output parameters flows from the complex pathogenesis of tissue respiration after brain trauma. NIRS neuromonitoring overcomes certain limitations related to the heterogeneity of the pathology across the brain that cannot be adequately addressed by local-sample invasive neuromonitoring (e.g., PbtO2 neuromonitoring, microdialysis), and it allows clinicians to assess parameters that cannot otherwise be scanned. The anatomical co-registration of an NIRS signal with axial imaging (e.g., computerized tomography scan) enhances the optical signal, which can be changed by the anatomy of the lesions and the significance of the radiological assessment. These arguments led us to conclude that rather than aiming to substitute PbtO2 with tissue saturation, multiple types of NIRS should be included via multimodal systemic- and neuro-monitoring, whose values then are incorporated into biosignatures linked to patient status and prognosis. Discussion on the abnormalities in tissue respiration due to brain trauma and how they affect the PbtO2 and NIRS neuromonitoring is given.
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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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Kilic O, Gultekin Y, Yazici S. The Impact of Intravenous Fluid Therapy on Acid-Base Status of Critically Ill Adults: A Stewart Approach-Based Perspective. Int J Nephrol Renovasc Dis 2020; 13:219-230. [PMID: 33061531 PMCID: PMC7534048 DOI: 10.2147/ijnrd.s266864] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/14/2020] [Indexed: 12/25/2022] Open
Abstract
One of the most important tasks of physicians working in intensive care units (ICUs) is to arrange intravenous fluid therapy. The primary indications of the need for intravenous fluid therapy in ICUs are in cases of resuscitation, maintenance, or replacement, but we also load intravenous fluid for purposes such as fluid creep (including drug dilution and keeping venous lines patent) as well as nutrition. However, in doing so, some facts are ignored or overlooked, resulting in an acid-base disturbance. Regardless of the type and content of the fluid entering the body through an intravenous route, it may impair the acid-base balance depending on the rate, volume, and duration of the administration. The mechanism involved in acid-base disturbances induced by intravenous fluid therapy is easier to understand with the help of the physical-chemical approach proposed by Canadian physiologist, Peter Stewart. It is possible to establish a quantitative link between fluid therapy and acid–base disturbance using the Stewart principles. However, it is not possible to accomplish this with the traditional approach; moreover, it may not be noticed sometimes due to the normalization of pH or standard base excess induced by compensatory mechanisms. The clinical significance of fluid-induced acid-base disturbances has not been completely clarified yet. Nevertheless, as fluid therapy may be the cause of unexplained acid-base disorders that may lead to confusion and elicit unnecessary investigation, more attention must be paid to understand this issue. Therefore, the aim of this paper is to address the effects of different types of fluid therapies on acid-base balance using the simplified perspective of Stewart principles. Overall, the paper intends to help recognize fluid-induced acid-base disturbance through bedside evaluation and choose an appropriate fluid by considering the acid-base status of a patient.
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Affiliation(s)
- Ozgur Kilic
- Siyami Ersek Thoracic and Cardiovascular Surgery Center, Cardiology Department, Cardiac Intensive Care Unit, Istanbul, Turkey
| | - Yucel Gultekin
- Mersin University Hospital, General Surgery Department, Mersin, Turkey
| | - Selcuk Yazici
- Siyami Ersek Thoracic and Cardiovascular Surgery Center, Cardiology Department, Cardiac Intensive Care Unit, Istanbul, Turkey
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Abstract
PURPOSE OF REVIEW To discuss recent updates in fluid management and use of hyperosmolar therapy in neurocritical care. RECENT FINDINGS Maintaining euvolemia with crystalloids seems to be the recommended fluid resuscitation for neurocritical care patients. Buffered crystalloids have been shown to reduce hyperchloremia in patients with subarachnoid hemorrhage without causing hyponatremia or hypo-osmolality. In addition, in patients with traumatic brain injury, buffered solutions reduce the incidence of hyperchloremic acidosis but are not associated with intracranial pressure (ICP) alteration. Both mannitol and hypertonic saline are established as effective hyperosmolar agents to control ICP. Both agents have been shown to control ICP, but their effects on neurologic outcomes are unclear. A recent surge in preference for using hypertonic saline as a hyperosmolar agent is based on few studies without strong evidence. SUMMARY Fluid resuscitation with crystalloids seems to be reasonable in this setting although no recommendations can be made regarding type of crystalloids. Based on current evidence, elevated ICP can be effectively reduced by either hypertonic saline or mannitol.
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Abstract
Intravenous fluid therapy is the most common intervention received by acutely ill patients. Historically, saline (0.9% sodium chloride) has been the most frequently administered intravenous fluid, especially in North America. Balanced crystalloid solutions (e.g., lactated Ringer's, Plasma-Lyte) are an increasingly used alternative to saline. Balanced crystalloids have a sodium, potassium, and chloride content closer to that of extracellular fluid and, when given intravenously, have fewer adverse effects on acid-base balance. Preclinical research has demonstrated that saline may cause hyperchloremic metabolic acidosis, inflammation, hypotension, acute kidney injury, and death. Studies of patients and healthy human volunteers suggest that even relatively small volumes of saline may exert physiological effects. Randomized trials in the operating room have demonstrated that using balanced crystalloids rather than saline prevents the development of hyperchloremic metabolic acidosis and may reduce the need for vasopressors. Observational studies among critically ill adults have associated receipt of balanced crystalloids with lower rates of complications, including acute kidney injury and death. Most recently, large randomized trials among critically ill adults have examined whether balanced crystalloids result in less death or severe renal dysfunction than saline. Although some of these trials are still ongoing, a growing body of evidence raises fundamental concerns regarding saline as the primary intravenous crystalloid for critically ill adults and highlights fundamental unanswered questions for future research about fluid therapy in critical illness.
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Affiliation(s)
- Matthew W Semler
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - John A Kellum
- 2 The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Williams V, Jayashree M, Nallasamy K, Dayal D, Rawat A. 0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:1. [PMID: 31898531 PMCID: PMC6939333 DOI: 10.1186/s13054-019-2683-3] [Citation(s) in RCA: 246] [Impact Index Per Article: 61.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 11/22/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is an important complication encountered during the course of diabetic ketoacidosis (DKA). Plasma-Lyte with lower chloride concentration than saline has been shown to be associated with reduced incidence of AKI in adults with septic shock. No study has compared this in DKA. METHODS This double-blind, parallel-arm, investigator-initiated, randomized controlled trial compared 0.9% saline with Plasma-Lyte-A as initial fluid in pediatric DKA. The study was done in a tertiary care, teaching, and referral hospital in India in children (> 1 month-12 years) with DKA as defined by ISPAD. Children with cerebral edema or known chronic kidney/liver disease or who had received pre-referral fluids and/or insulin were excluded. Sixty-six children were randomized to receive either Plasma-Lyte (n = 34) or 0.9% saline (n = 32). MAIN OUTCOMES Primary outcome was incidence of new or progressive AKI, defined as a composite outcome of change in creatinine (defined by KDIGO), estimated creatinine clearance (defined by p-RIFLE), and NGAL levels. The secondary outcomes were resolution of AKI, time to resolution of DKA (pH > 7.3, bicarbonate> 15 mEq/L & normal sensorium), change in chloride, pH and bicarbonate levels, proportion of in-hospital all-cause mortality, need for renal replacement therapy (RRT), and length of ICU and hospital stay. RESULTS Baseline characteristics were similar in both groups. The incidence of new or progressive AKI was similar in both [Plasma-Lyte 13 (38.2%) versus 0.9% saline 15 (46.9%); adjusted OR 1.22; 95% CI 0.43-3.43, p = 0.70]. The median (IQR) time to resolution of DKA in Plasma-Lyte-A and 0.9% saline were 14.5 (12 to 20) and 16 (8 to 20) h respectively. Time to resolution of AKI was similar in both [Plasma-Lyte 22.1 versus 0.9% saline 18.8 h (adjusted HR 1.72; 95% CI 0.83-3.57; p = 0.14)]. Length of hospital stay was also similar in both [Plasma-Lyte 9 (8 to 12) versus 0.9% saline 10 (8.25 to 11) days; p = 0.39]. CONCLUSIONS The incidence of new or progressive AKI and resolution of AKI were similar in both groups. Plasma-Lyte-A was similar to 0.9% Saline in time to resolution of DKA, need for RRT, mortality, and lengths of PICU and hospital stay. TRIAL REGISTRATION Clinical trial registry of India, CTRI/2018/05/014042 (ctri.nic.in) (Retrospectively registered).
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Affiliation(s)
- Vijai Williams
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Muralidharan Jayashree
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Devi Dayal
- Division of Pediatric Endocrinology, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Amit Rawat
- Division of Pediatric Allergy & Immunology, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
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Hypertonic Lactate to Improve Cerebral Perfusion and Glucose Availability After Acute Brain Injury. Crit Care Med 2019; 46:1649-1655. [PMID: 29923931 DOI: 10.1097/ccm.0000000000003274] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Lactate promotes cerebral blood flow and is an efficient substrate for the brain, particularly at times of glucose shortage. Hypertonic lactate is neuroprotective after experimental brain injury; however, human data are limited. DESIGN Prospective study (clinicaltrials.gov NCT01573507). SETTING Academic ICU. PATIENTS Twenty-three brain-injured subjects (13 traumatic brain injury/10 subarachnoid hemorrhage; median age, 59 yr [41-65 yr]; median Glasgow Coma Scale, 6 [3-7]). INTERVENTIONS Three-hour IV infusion of hypertonic lactate (sodium lactate, 1,000 mmol/L; concentration, 30 µmol/kg/min) administered 39 hours (26-49 hr) from injury. MEASUREMENTS AND MAIN RESULTS We examined the effect of hypertonic lactate on cerebral perfusion (using transcranial Doppler) and brain energy metabolism (using cerebral microdialysis). The majority of subjects (13/23 = 57%) had reduced brain glucose availability (baseline pretreatment cerebral microdialysis glucose, < 1 mmol/L) despite normal baseline intracranial pressure (10 [7-15] mm Hg). Hypertonic lactate was associated with increased cerebral microdialysis lactate (+55% [31-80%]) that was paralleled by an increase in middle cerebral artery mean cerebral blood flow velocities (+36% [21-66%]) and a decrease in pulsatility index (-21% [13-26%]; all p < 0.001). Cerebral microdialysis glucose increased above normal range during hypertonic lactate (+42% [30-78%]; p < 0.05); reduced brain glucose availability correlated with a greater improvement of cerebral microdialysis glucose (Spearman r = -0.53; p = 0.009). No significant changes in cerebral perfusion pressure, mean arterial pressure, systemic carbon dioxide, and blood glucose were observed during hypertonic lactate (all p > 0.1). CONCLUSIONS This is the first clinical demonstration that hypertonic lactate resuscitation improves both cerebral perfusion and brain glucose availability after brain injury. These cerebral vascular and metabolic effects appeared related to brain lactate supplementation rather than to systemic effects.
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Antequera Martín AM, Barea Mendoza JA, Muriel A, Sáez I, Chico‐Fernández M, Estrada‐Lorenzo JM, Plana MN. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev 2019; 7:CD012247. [PMID: 31334842 PMCID: PMC6647932 DOI: 10.1002/14651858.cd012247.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Fluid therapy is one of the main interventions provided for critically ill patients, although there is no general consensus regarding the type of solution. Among crystalloid solutions, 0.9% saline is the most commonly administered. Buffered solutions may offer some theoretical advantages (less metabolic acidosis, less electrolyte disturbance), but the clinical relevance of these remains unknown. OBJECTIVES To assess the effects of buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. SEARCH METHODS We searched the following databases to July 2018: CENTRAL, MEDLINE, Embase, CINAHL, and four trials registers. We checked references, conducted backward and forward citation searching of relevant articles, and contacted study authors to identify additional studies. We imposed no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) with parallel or cross-over design examining buffered solutions versus intravenous 0.9% saline in a critical care setting (resuscitation or maintenance). We included studies on participants with critical illness (including trauma and burns) or undergoing emergency surgery during critical illness who required intravenous fluid therapy. We included studies of adults and children. We included studies with more than two arms if they fulfilled all of our inclusion criteria. We excluded studies performed in persons undergoing elective surgery and studies with multiple interventions in the same arm. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. We assessed our intervention effects using random-effects models, but when one or two trials contributed to 75% of randomized participants, we used fixed-effect models. We reported outcomes with 95% confidence intervals (CIs). MAIN RESULTS We included 21 RCTs (20,213 participants) and identified three ongoing studies. Three RCTs contributed 19,054 participants (94.2%). Four RCTs (402 participants) were conducted among children with severe dehydration and dengue shock syndrome. Fourteen trials reported results on mortality, and nine reported on acute renal injury. Sixteen included trials were conducted in adults, four in the paediatric population, and one trial limited neither minimum or maximum age as an inclusion criterion. Eight studies involving 19,218 participants were rated as high methodological quality (trials with overall low risk of bias according to the domains: allocation concealment, blinding of participants/assessors, incomplete outcome data, and selective reporting), and in the remaining trials, some form of bias was introduced or could not be ruled out.We found no evidence of an effect of buffered solutions on in-hospital mortality (odds ratio (OR) 0.91, 95% CI 0.83 to 1.01; 19,664 participants; 14 studies; high-certainty evidence). Based on a mortality rate of 119 per 1000, buffered solutions could reduce mortality by 21 per 1000 or could increase mortality by 1 per 1000. Similarly, we found no evidence of an effect of buffered solutions on acute renal injury (OR 0.92, 95% CI 0.84 to 1.00; 18,701 participants; 9 studies; low-certainty evidence). Based on a rate of 121 per 1000, buffered solutions could reduce the rate of acute renal injury by 19 per 1000, or result in no difference in the rate of acute renal injury. Buffered solutions did not show an effect on organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; 266 participants; 5 studies; very low-certainty evidence). Evidence on the effects of buffered solutions on electrolyte disturbances varied: potassium (mean difference (MD) 0.09, 95% CI -0.10 to 0.27; 158 participants; 4 studies; very low-certainty evidence); chloride (MD -3.02, 95% CI -5.24 to -0.80; 351 participants; 7 studies; very low-certainty evidence); pH (MD 0.04, 95% CI 0.02 to 0.06; 200 participants; 3 studies; very low-certainty evidence); and bicarbonate (MD 2.26, 95% CI 1.25 to 3.27; 344 participants; 6 studies; very low-certainty evidence). AUTHORS' CONCLUSIONS We found no effect of buffered solutions on preventing in-hospital mortality compared to 0.9% saline solutions in critically ill patients. The certainty of evidence for this finding was high, indicating that further research would detect little or no difference in mortality. The effects of buffered solutions and 0.9% saline solutions on preventing acute kidney injury were similar in this setting. The certainty of evidence for this finding was low, and further research could change this conclusion. Patients treated with buffered solutions showed lower chloride levels, higher levels of bicarbonate, and higher pH. The certainty of evidence for these findings was very low. Future research should further examine patient-centred outcomes such as quality of life. The three ongoing studies once published and assessed may alter the conclusions of the review.
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Affiliation(s)
- Alba M Antequera Martín
- La Princesa HospitalInternal Medicine DepartmentDiego de León, 62MadridSpain28006
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP)BarcelonaSpain
| | - Jesus A Barea Mendoza
- 12 de Octubre HospitalIntensive Care DepartmentAvda de Cordoba, s/n, 28041MadridSpain
| | - Alfonso Muriel
- Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP)Clinical Biostatistics UnitCarretera de Colmenar Km 9.100MadridSpain28034
| | - Ignacio Sáez
- 12 de Octubre HospitalIntensive Care DepartmentAvda de Cordoba, s/n, 28041MadridSpain
| | - Mario Chico‐Fernández
- 12 de Octubre HospitalIntensive Care DepartmentAvda de Cordoba, s/n, 28041MadridSpain
| | | | - Maria N Plana
- Hospital Universitario Príncipe de Asturias. CIBER Epidemiology and Public Health (CIBERESP)Department of Preventive Medicine and Public HealthCtra. Alcalá‐Meco s/nAlcalá de HenaresMadridMadridSpain28805
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Lima MF, Neville IS, Cavalheiro S, Bourguignon DC, Pelosi P, Malbouisson LMS. Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children Undergoing Neurosurgery: A Randomized Clinical Trial. J Neurosurg Anesthesiol 2019; 31:30-35. [PMID: 29912723 DOI: 10.1097/ana.0000000000000515] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. METHODS In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. RESULTS Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [-1.0; 3.0] mmol/L; P<0.001). Saline use also resulted in increased post-preopΔBE (-4.4 [-5.0; -2.3] vs. -0.4 [-2.7; 1.3] mmol/L; P<0.001) and hyperchloremic acidosis incidence (6/25 [24%] vs. 0; P=0.022) compared with balanced crystalloid. Brain relaxation score was comparable between groups. CONCLUSIONS In children undergoing brain tumor resection, saline infusion increased variation in serum chloride compared with balanced crystalloid. These findings support the use of balanced crystalloid solutions in children undergoing brain tumor resection.
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Affiliation(s)
- Mariana F Lima
- Departments of Anesthesiology.,Department of Anesthesiology
| | - Iuri S Neville
- Neurosurgery, Hospital das Clínicas, University of São Paulo
| | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy
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Harrois A, Soyer B, Gauss T, Hamada S, Raux M, Duranteau J. Response to "Are fluids resuscitation the "Keyser Soze" of acute kidney injury in trauma patients?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:59. [PMID: 30782185 PMCID: PMC6381689 DOI: 10.1186/s13054-019-2344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/05/2019] [Indexed: 12/04/2022]
Affiliation(s)
- Anatole Harrois
- Department of Anesthesiology and Critical Care, Bicêtre Hôpitaux Universitaires Paris Sud, Université Paris Saclay, AP-HP, 78 Rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
| | - Benjamin Soyer
- Department of Anesthesiology and Critical Care, Bicêtre Hôpitaux Universitaires Paris Sud, Université Paris Saclay, AP-HP, 78 Rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, AP-HP, Beaujon, Hôpitaux Universitaires Paris Nord Val de Seine, 100 Avenue du Général Leclerc, 92110, Clichy, France
| | - Sophie Hamada
- Department of Anesthesiology and Critical Care, Bicêtre Hôpitaux Universitaires Paris Sud, Université Paris Saclay, AP-HP, 78 Rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Mathieu Raux
- Department of Anesthesiology and Critical Care, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, AP-HP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Jacques Duranteau
- Department of Anesthesiology and Critical Care, Bicêtre Hôpitaux Universitaires Paris Sud, Université Paris Saclay, AP-HP, 78 Rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
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Utagawa A. Fluid Management for Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Background Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia. Main text Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions. Conclusions The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma). Electronic supplementary material The online version of this article (10.1186/s12871-018-0669-3) contains supplementary material, which is available to authorized users.
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Cinotti R, Putegnat JB, Lakhal K, Desal H, Chenet A, Buffenoir K, Frasca D, Allaouchiche B, Asehnoune K, Rozec B. Evolution of neurological recovery during the first year after subarachnoid haemorrhage in a French university centre. Anaesth Crit Care Pain Med 2018; 38:251-257. [PMID: 31079704 DOI: 10.1016/j.accpm.2018.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 10/03/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The evolution of neurological recovery during the first year after aneurysmal Subarachnoid Haemorrhage (SAH) is poorly described. PATIENTS Patients with SAH in one university hospital from March the 1st 2010, to December 31st 2012, with a one-year follow-up. METHOD Evaluation was performed via phone call at 3, 6 and 12 months. Primary endpoint was poor neurological recovery (modified Rankin Scale 3-4-5-6), one year after SAH. Secondary endpoints were the incidence of lack of self-perceived previous health status recovery and incidence of cognitive disorders, one year after SAH. Risk factors of poor neurological recovery were retrieved with multivariable logistic regression. RESULTS Two hundred and eleven patients were included and 208 had a complete follow-up. One hundred and twenty (57.7%) patients were female, 112 (53.8%) had a WFNS grade I-II-III. Seventy (33.6%) patients displayed one-year poor neurological outcome and risk factors of poor outcome were age, baseline Glasgow Coma Score ≤ 8, external ventricular drainage, intra-cranial hypertension and angiographic vasospasm. We observed an improvement in good outcome at 3 months [112 (53.8%) patients], 6 months [127 (61.1%) patients] and one-year [138 (66.3%) patients]. Fifty-nine (35.3%) patients recovered previous health status, 96 (57.5%) had persistent behaviour disorders, and 71 (42.5%) suffered from memory losses at one year. DISCUSSION Neurological recovery seems to improve over time. The same key complications should be targeted worldwide in SAH patients. CONCLUSION Neurological complications in the following of SAH should be actively treated in order to improve outcome. The early neuro-ICU phase remains a key determinant of long-term recovery.
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Affiliation(s)
- Raphaël Cinotti
- Anaesthesia and critical care department, Hôtel Dieu, 1, place Alexis-Ricordeau 44093 Nantes, university hospital of Nantes, France.
| | - Jean-Baptiste Putegnat
- Anaesthesia and critical care department, centre régional hospitalier universitaire, route de Chauvel, Les Abymes, BP 465, 97159, Pointe-à-Pitre cedex, Guadeloupe, France.
| | - Karim Lakhal
- Anaesthesia and critical care department, hôpital Guillaume et René-Laennec, university hospital of Nantes, boulevard Jacques-Monod, 44800 Saint-Herblain, France.
| | - Hubert Desal
- Department of neuroradiology, hôpital Guillaume et René-Laennec, university hospital of Nantes boulevard Jacques-Monod, 44800 Saint-Herblain, France.
| | - Amandine Chenet
- Service de médecine physique et de réadaptation, hôpital Saint-Jacques, university hospital of Nantes, 85, rue Saint-Jacques, 44200 Nantes, France.
| | - Kévin Buffenoir
- Department of neurotraumatology, university hospital of Nantes Hôtel Dieu, 1, place Alexis-Ricordeau 44093 Nantes, France.
| | - Denis Frasca
- Anaesthesia and critical care department, centre hospitalo-universitaire, university hospital of Poitiers 2, rue de la Milétrie 86021, Poitiers, France; Inserm SPHERE U1246 "Methods for Patients-centered outcomes and Health Research", UFR des sciences pharmaceutiques, university of Nantes, university of Tours, 22, boulevard Benoni-Goullin, 44200 Nantes, France.
| | - Bernard Allaouchiche
- Intensive care unit, anaesthesia and critical care department, centre hospitalier Lyon-Sud, Pierre-Bénite France Hospice Civils de Lyon 165, chemin du Grand Revoyet, 69310, France; Université Claude Bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69100, Villeurbanne, France; Université de Lyon, VetAgroSup, APCSé, 1, avenue Bourgelat, 69280, Marcy-l'Etoile, France.
| | - Karim Asehnoune
- Anaesthesia and critical care department, Hôtel Dieu, 1, place Alexis-Ricordeau 44093 Nantes, university hospital of Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections" university hospital of Nantes. 22, boulevard Benoni-Goullin, 44200 Nantes, France.
| | - Bertrand Rozec
- Anaesthesia and critical care department, hôpital Guillaume et René-Laennec, university hospital of Nantes, boulevard Jacques-Monod, 44800 Saint-Herblain, France; Institut du thorax, Inserm UMR1087 IRT, UN 8 quai Moncousu, University hospital of Nantes, BP 7072 44007 Nantes cedex 1, France.
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Impaired Cerebral Metabolism in Injured Brain. Crit Care Med 2018; 46:1705-1706. [DOI: 10.1097/ccm.0000000000003332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu C, Mao Z, Hu P, Hu X, Kang H, Hu J, Yang Z, Ma P, Zhou F. Fluid resuscitation in critically ill patients: a systematic review and network meta-analysis. Ther Clin Risk Manag 2018; 14:1701-1709. [PMID: 30254452 PMCID: PMC6143126 DOI: 10.2147/tcrm.s175080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective The aim of this study was to compare the effectiveness of different fluids on critically ill patients who need fluid resuscitation through a systematic review and network meta-analysis (NMA). Data sources Electronic databases were searched up to March 2018 for randomized controlled trials comparing the effectiveness of different fluids in critically ill patients. The primary outcome was mortality, and the secondary outcomes were the incident of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). A Bayesian NMA was conducted, and the quality of evidence contributing to each network estimate was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria. Results We deemed 49 trials eligible, including 40,910 participants. The quality of evidence was rated as moderate in most comparisons. There was no significant difference among resuscitation fluids in mortality. NMA at the 9-node level showed the most effective fluid was balanced crystalloid (BC) (80.79%, the ranking of resuscitation fluid based on cumulative probability plots and surface under the cumulative ranking curves [SUCRAs]). NMA at the 10-node level showed that the most effective fluid was Plasma-Lyte (77.52%). Results of sensitivity analyses in mortality did not reveal any significant changes in the findings for primary outcomes. High-molecular-weight hetastarch (H-HES) was associated with an increased incidence of AKI when compared with gelatin (odds ratio [OR], 0.43; 95% credibility interval [CrI], 0.19–0.94), low-molecular-weight hetastarch (L-HES; OR, 0.50; 95% CrI, 0.30–0.87), BC (OR, 0.55; 95% CrI, 0.34–0.88), and normal saline (OR, 0.56; 95% CrI, 0.34–0.93). Meanwhile, H-HES was also associated with an increased risk of receiving RRT when compared with BC (OR, 0.51; 95% CrI, 0.27–0.93) and normal saline (OR, 0.52; 95% CrI, 0.24–0.96). Conclusion BCs, especially the Plasma-Lyte, are presumably the best choice for most critically ill patients who need fluid resuscitation. Meanwhile, the use of H-HES was associated with an increased incidence of AKI and risk of receiving RRT. Registration PROSPERO (CRD42017072728).
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Affiliation(s)
- Chao Liu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Pan Hu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Xin Hu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Hongjun Kang
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Jie Hu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Zhifang Yang
- Beijing Institute of Pharmacology and Toxicology, Beijing, People's Republic of China
| | - Penglin Ma
- Department of Critical Care Medicine, the 309th Hospital of Chinese People's Liberation Army, Beijing, People's Republic of China,
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China, .,National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
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Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, Zarychanski R, Archambault P, Lamontagne F, Léger C, Turgeon AF. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials 2018; 15:398-412. [PMID: 29865897 DOI: 10.1177/1740774518771233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most deaths following severe traumatic brain injury follow decisions to withdraw life-sustaining therapies. However, the incidence of the withdrawal of life-sustaining therapies and its potential impact on research data interpretation have been poorly characterized. The aim of this systematic review was to assess the reporting and the impact of withdrawal of life-sustaining therapies in randomized clinical trials of patients with severe traumatic brain injury. Methods We searched Medline, Embase, Cochrane Central, BIOSIS, and CINAHL databases and references of included trials. All randomized controlled trials published between January 2002 and August 2015 in the six highest impact journals in general medicine, critical care medicine, and neurocritical care (total of 18 journals) were considered for eligibility. Randomized controlled trials were included if they enrolled adult patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) and reported data on mortality. Our primary objective was to assess the proportion of trials reporting the withdrawal of life-sustaining therapies in a publication. Our secondary objectives were to describe the overall mortality rate, the proportion of deaths following the withdrawal of life-sustaining therapies, and to assess the impact of the withdrawal of life-sustaining therapies on trial results. Results From 5987 citations retrieved, we included 41 randomized trials (n = 16,364, ranging from 11 to 10,008 patients). Overall mortality was 23% (range = 3%-57%). Withdrawal of life-sustaining therapies was reported in 20% of trials (8/41, 932 patients in trials) and the crude number of deaths due to the withdrawal of life-sustaining therapies was reported in 17% of trials (7/41, 884 patients in trials). In these trials, 63% of deaths were associated with the withdrawal of life-sustaining therapies (105/168). An analysis carried out by imputing a 4% differential rate in instances of withdrawal of life-sustaining therapies between study groups yielded different results and conclusions in one third of the trials. Conclusion Data on the withdrawal of life-sustaining therapies are incompletely reported in randomized controlled trials of patients with severe traumatic brain injury. Given the high proportion of deaths due to the withdrawal of life-sustaining therapies in severe traumatic brain injury patients, and the potential of this medical decision to influence the results of clinical trials, instances of withdrawal of life-sustaining therapies should be systematically reported in clinical trials in this group of patients.
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Affiliation(s)
- Guillaume Leblanc
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- 3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Lauzier
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,4 Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Véronique Potvin
- 2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- 5 Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick Archambault
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,6 Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - François Lamontagne
- 7 Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada.,8 Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Caroline Léger
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
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Kwak HJ, Lim OK, Baik JM, Jo YY. Acid/base alterations during major abdominal surgery: 6% hydroxyethyl starch infusion versus 5% albumin. Korean J Anesthesiol 2018; 71:459-466. [PMID: 29684990 PMCID: PMC6283709 DOI: 10.4097/kja.d.18.27195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the effects of intraoperative infusions of balanced electrolyte solution (BES)-based hydroxyethyl starch (HES) and saline-based albumin on metabolic acidosis and acid/base changes during major abdominal surgery conducted using Stewart's approach. METHODS Forty patients, aged 20-65 years, undergoing major abdominal surgery, were randomly assigned to the HES group (n = 20; received 500 ml of BES-based 6% HES 130/0.4) or the albumin group (n = 20; received 500 ml of normal saline-based 5% albumin). Acid-base parameters were measured and calculated using results obtained from arterial blood samples taken after anesthesia induction (T1), 2 hours after surgery commencement (T2), immediately after surgery (T3), and 1 hour after arriving at a postanesthetic care unit (T4). RESULTS Arterial pH in the HES group was significantly higher than that in the albumin group at T3 (7.40 ± 0.04 vs. 7.38 ± 0.04, P = 0.043), and pH values exhibited significant intergroup difference over time (P = 0.002). Arterial pH was significantly lower at T3 and T4 in the HES group and at T2, T3, and T4 in the albumin group than at T1. Apparent strong ion difference (SIDa) was significantly lower at T2, T3, and T4 than at T1 in both groups. Total plasma weak nonvolatile acid (ATOT) was significantly lower in the HES group than in the albumin group at T2, T3 and T4 and exhibited a significant intergroup difference over time (P < 0.001). CONCLUSIONS BES-based 6% HES infusion was associated with lower arterial pH values at the end of surgery than saline-based 5% albumin infusion, but neither colloid caused clinically significant metabolic acidosis (defined as an arterial pH < 7.35).
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Affiliation(s)
- Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Oh Kyung Lim
- Department of Rehabilitation Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Myung Baik
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Ekbal NJ, Hennis P, Dyson A, Mythen M, James MFM, Singer M. The anion study: effect of different crystalloid solutions on acid base balance, physiology, and survival in a rodent model of acute isovolaemic haemodilution. Br J Anaesth 2018; 120:1412-1419. [PMID: 29793606 PMCID: PMC6200115 DOI: 10.1016/j.bja.2018.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/05/2018] [Accepted: 01/31/2018] [Indexed: 01/16/2023] Open
Abstract
Background Commercially available crystalloid solutions used for volume replacement do not exactly match the balance of electrolytes found in plasma. Large volume administration may lead to electrolyte imbalance and potential harm. We hypothesised that haemodilution using solutions containing different anions would result in diverse biochemical effects, particularly on acid-base status, and different outcomes. Methods Anaesthetised, fluid-resuscitated, male Wistar rats underwent isovolaemic haemodilution by removal of 10% blood volume every 15 min, followed by replacement with one of three crystalloid solutions based on acetate, lactate, or chloride. Fluids were administered in a protocolised manner to achieve euvolaemia based on echocardiography-derived left ventrical volumetric measures. Removed blood was sampled for plasma ions, acid-base status, haemoglobin, and glucose. This cycle was repeated at 15-min intervals until death. The primary endpoint was change in plasma bicarbonate within each fluid group. Secondary endpoints included time to death and cardiac function. Results During haemodilution, chloride-treated rats showed significantly greater decreases in plasma bicarbonate and strong ion difference levels compared with acetate- and lactate-treated rats. Time to death, total volume of fluid administered: chloride group 56 (3) ml, lactate group 62 (3) ml, and acetate group 65 (3) ml; haemodynamic and tissue oxygenation changes were, however, similar between groups. Conclusions With progressive haemodilution, resuscitation with a chloride-based solution induced more acidosis compared with lactate- and acetate-based solutions, but outcomes were similar. No short-term impact was seen from hyperchloraemia in this model.
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Affiliation(s)
- N J Ekbal
- University College London, Bloomsbury Institute of Intensive Care Medicine, London, UK
| | - P Hennis
- UCL Centre for Anaesthesia, Critical Care and Pain Medicine, University College London, UK
| | - A Dyson
- University College London, Bloomsbury Institute of Intensive Care Medicine, London, UK
| | - M Mythen
- UCL Centre for Anaesthesia, Critical Care and Pain Medicine, University College London, UK
| | - M F M James
- University of Cape Town, Department of Anaesthesia, Cape Town, South Africa
| | - M Singer
- University College London, Bloomsbury Institute of Intensive Care Medicine, London, UK.
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Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations. Intensive Care Med 2018; 44:449-463. [DOI: 10.1007/s00134-018-5086-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/03/2018] [Indexed: 01/03/2023]
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Abstract
The use of fluid bolus infusion is the cornerstone for hemodynamic resuscitation of critically ill patients. Recently, the clinical use of colloids has lost strength with the publication of several trials suggesting no benefit, and possible harm of its use.On the other hand, the so-called balanced solutions, with low chloride concentrations, have emerged as an alternative with potential physiological benefits over traditional saline solution. Normal saline carries a high amount of chloride which has been associated with an increased incidence of metabolic acidosis, renal vasoconstriction, and reduced urine output. Recent observational studies associated the use of saline with acute kidney injury, which was not observed in a single prospective randomized controlled trial.The present review summarizes available literature regarding the potential clinical and laboratorial benefits of balanced solutions in septic patients.
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Affiliation(s)
- Pedro Vitale Mendes
- Intensive Care Unit , Emergency Department, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
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Hahn RG. In response: fluids in neurosurgery. Acta Anaesthesiol Scand 2018; 62:140-141. [PMID: 29143305 DOI: 10.1111/aas.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- R. G. Hahn
- Research Unit; Södertälje Hospital; Södertälje Sweden
- Department of Clinical Sciences (KIDS); Karolinska Institutet; Stockholm Sweden
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Kanda H, Hirasaki Y, Iida T, Kanao-Kanda M, Toyama Y, Chiba T, Kunisawa T. Perioperative Management of Patients With End-Stage Renal Disease. J Cardiothorac Vasc Anesth 2017; 31:2251-2267. [DOI: 10.1053/j.jvca.2017.04.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Indexed: 12/17/2022]
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Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg 2017; 106:509-528. [PMID: 28712906 DOI: 10.1016/j.wneu.2017.07.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In neurotrauma care, a better understanding of treatments after traumatic brain injury (TBI) has led to a significant decrease in morbidity and mortality in this population. TBI represents a significant medical problem, and complications after TBI are associated with the initial injury and postevent intracranial processes such as increased intracranial pressure and brain edema. Consequently, appropriate therapeutic interventions are required to reduce brain tissue damage and improve cerebral perfusion. We present a contemporary review of literature on the use of pharmacologic therapies to reduce intracranial pressure after TBI and a comparison of their efficacy. METHODS This review was conducted by PubMed query. Only studies discussing pharmacologic management of patients after TBI were included. This review includes prospective and retrospective studies and includes randomized controlled trials as well as cohort, case-control, observational, and database studies. Systematic literature reviews, meta-analyses, and studies that considered conditions other than TBI or pediatric populations were not included. RESULTS Review of the literature describing the current pharmacologic treatment for intracranial hypertension after TBI most often discussed the use of hyperosmolar agents such as hypertonic saline and mannitol, sedatives such as fentanyl and propofol, benzodiazepines, and barbiturates. Hypertonic saline is associated with faster resolution of intracranial hypertension and restoration of optimal cerebral hemodynamics, although these advantages did not translate into long-term benefits in morbidity or mortality. In patients refractory to treatment with hyperosmolar therapy, induction of a barbiturate coma can reduce intracranial pressure, although requires close monitoring to prevent adverse events. CONCLUSIONS Current research suggests that the use of hypertonic saline after TBI is the best option for immediate decrease in intracranial pressure. A better understanding of the efficacy of each treatment option can help to direct treatment algorithms during the critical early hours of trauma care and continue to improve morbidity and mortality after TBI.
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Affiliation(s)
- Ahmed M Alnemari
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Brianna M Krafcik
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Tarek R Mansour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Daniel Gaudin
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA.
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Patrick AL, Grin PM, Kraus N, Gold M, Berardocco M, Liaw PC, Fox-Robichaud AE. Resuscitation fluid composition affects hepatic inflammation in a murine model of early sepsis. Intensive Care Med Exp 2017; 5:5. [PMID: 28105603 PMCID: PMC5247397 DOI: 10.1186/s40635-017-0118-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/13/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fluid resuscitation is a crucial therapy for sepsis, and the use of balanced fluids and/or isotonic albumin may improve patient survival. We have previously demonstrated that resuscitation with normal saline results in increased hepatic leukocyte recruitment in a murine model of sepsis. Given that clinical formulations of albumin are in saline, our objectives were to develop a novel balanced electrolyte solution specifically for sepsis and to determine if supplementing this solution with albumin would improve the inflammatory response in sepsis. METHODS We developed two novel buffered electrolyte solutions that contain different concentrations of acetate and gluconate, named Seplyte L and Seplyte H, and administered these solutions with or without 5% albumin. Normal saline with or without albumin and Ringer's lactate served as controls. Sepsis was induced by cecal ligation and puncture (CLP), and the liver microvasculature was imaged in vivo at 6 h after CLP to quantify leukocyte recruitment. Hepatic cytokine expression and plasma cell-free DNA (cfDNA) concentrations were also measured. RESULTS Septic mice receiving either Seplyte fluid showed significant reductions in hepatic post-sinusoidal leukocyte rolling and adhesion compared to normal saline. Hepatic cytokine concentrations varied in response to different concentrations of acetate and gluconate in the novel resuscitation fluids but were unaffected by albumin. All Seplyte fluids significantly increased hepatic TNF-α levels at 6 h compared to control fluids. However, Seplyte H exhibited a similar cytokine profile to the control fluids for all other cytokines, whereas mice given Seplyte L had significantly elevated IL-6, IL-10, KC (CXCL1), and MCP-1 (CCL2). Plasma cfDNA was generally increased during sepsis, but resuscitation fluid composition did not significantly affect cfDNA concentrations. CONCLUSIONS Electrolyte concentrations and buffer constituents of resuscitation fluids can modulate hepatic cytokine production and leukocyte recruitment in septic mice, while the effects of albumin are modest during early sepsis. Therefore, crystalloid fluid choice should be an important consideration for resuscitation in sepsis, and the effects of fluid composition on inflammation in other organ systems should be studied to better understand the physiological impact of this vital sepsis therapy.
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Affiliation(s)
- Amanda L Patrick
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter M Grin
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, McMaster University, DBRI C5-106, 237 Barton St. East, Hamilton, ON, L8L 2X2, Canada
| | - Nicole Kraus
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Gold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Patricia C Liaw
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, McMaster University, DBRI C5-106, 237 Barton St. East, Hamilton, ON, L8L 2X2, Canada
| | - Alison E Fox-Robichaud
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada. .,Thrombosis and Atherosclerosis Research Institute, McMaster University, DBRI C5-106, 237 Barton St. East, Hamilton, ON, L8L 2X2, Canada.
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Abstract
PURPOSE OF REVIEW Evidence-based fluid therapy is complicated by blurred boundaries toward other fields of therapy and the majority of trials not focusing on patient-relevant outcomes. Additionally, recent trials unsettled the faith in traditional concepts on fluid therapy. The article reviews the evidence on diagnosis and treatment of hypovolemia and discusses the use of balanced solutions and early goal-directed therapy (EGDT) in septic shock resuscitation. RECENT FINDINGS Hypovolemia should be diagnosed and its treatment guided by a multifaceted approach, including medical history, physical examination, volume responsiveness, and technical parameters - dynamic indicators, volumetric indicators, sonography, and metabolic indicators. Central venous pressure and pulmonary artery occlusion pressure should be avoided. In ICU patients, balanced crystalloids should primarily be used, because unbalanced infusions (especially saline) cause hyperchloremic acidosis which is associated with renal impairment and infections. Colloids are beneficial to restore blood volume rapidly. Hydroxyethyl starch may be harmful although the validity of the respective recent studies is limited by methodological flaws. Early aggressive fluid therapy is still beneficial in septic shock resuscitation, despite recent trials challenging the EGDT concept. Today, 10 years after Rivers, 'usual care' includes aggressive fluid resuscitation that is as effective as formal EGDT. SUMMARY Evidence-based fluid therapy includes a multifaceted diagnostic approach, the primary use of balanced crystalloids and early aggressive (septic) shock resuscitation.
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Romagnoli S, Ricci Z. The good receipt for the kidneys: salty…but not too much. J Thorac Dis 2016; 8:2403-2406. [PMID: 27746988 DOI: 10.21037/jtd.2016.08.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Department of Health Science, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Zaccaria Ricci
- Depatment of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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Soussi S, Ferry A, Chaussard M, Legrand M. Chloride toxicity in critically ill patients: What's the evidence? Anaesth Crit Care Pain Med 2016; 36:125-130. [PMID: 27476827 DOI: 10.1016/j.accpm.2016.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 11/03/2015] [Accepted: 03/21/2016] [Indexed: 01/16/2023]
Abstract
Crystalloids have become the fluid of choice in critically ill patients and in the operating room both for fluid resuscitation and fluid maintenance. Among crystalloids, NaCl 0.9% has been the most widely used fluid. However, emerging evidence suggests that administration of 0.9% saline could be harmful mainly through high chloride content and that the use of fluid with low chloride content may be preferable in major surgery and intensive care patients. Administration of NaCl 0.9% is the leading cause of metabolic hyperchloraemic acidosis in critically ill patients and side effects might target coagulation, renal function, and ultimately increase mortality. More balanced solutions therefore may be used especially when large amount of fluids are administered in high-risk patients. In this review, we discuss physiological background favouring the use of balanced solutions as well as the most recent clinical data regarding the use of crystalloid solutions in critically ill patients and patients undergoing major surgery.
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Affiliation(s)
- Sabri Soussi
- Department of Anaesthesiology and Critical Care, Smur, Burn Unit, AP-HP, groupe hospitalier Saint-Louis-Lariboisière, 75010 Paris, France.
| | - Axelle Ferry
- Department of Anaesthesiology and Critical Care, Smur, Burn Unit, AP-HP, groupe hospitalier Saint-Louis-Lariboisière, 75010 Paris, France.
| | - Maité Chaussard
- Department of Anaesthesiology and Critical Care, Smur, Burn Unit, AP-HP, groupe hospitalier Saint-Louis-Lariboisière, 75010 Paris, France.
| | - Matthieu Legrand
- Department of Anaesthesiology and Critical Care, Smur, Burn Unit, AP-HP, groupe hospitalier Saint-Louis-Lariboisière, 75010 Paris, France; Institut national de la santé et de la recherche médicale (Inserm), UMR Inserm 942, Lariboisière hospital, 75010 Paris, France; Université Paris Diderot, 75475 Paris, France.
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Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
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49
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Barea Mendoza JA, Antequera AM, Plana MN, Chico-Fernández M, Muriel A, Sáez I, Estrada-Lorenzo JM. Buffered solutions versus isotonic saline for resuscitation in non-surgical critically ill adults and children. Hippokratia 2016. [DOI: 10.1002/14651858.cd012247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jesus A Barea Mendoza
- 12 de Octubre Hospital; Intensive Care Department; Avda de Cordoba, s/n, 28041 Madrid Spain
| | - Alba M Antequera
- La Princesa Hospital; Internal Medicine Department; Diego de León, 62 Madrid Spain 28006
| | - Maria N Plana
- Universidad Francisco de Vitoria (UFV) Madrid; Ctra. Pozuelo-Majadahonda km. 1.800 Pozuelo de Alarcón Madrid Spain 28223
| | - Mario Chico-Fernández
- 12 de Octubre Hospital; Intensive Care Department; Avda de Cordoba, s/n, 28041 Madrid Spain
| | - Alfonso Muriel
- Ramón y Cajal Hospital (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP); Clinical Biostatistics Unit; Carretera de Colmenar Km 9.100 Madrid Spain 28034
| | - Ignacio Sáez
- 12 de Octubre Hospital; Intensive Care Department; Avda de Cordoba, s/n, 28041 Madrid Spain
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50
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Abstract
PURPOSE OF REVIEW Monitoring and therapy of patients in neurocritical care are areas of intensive research and the current evidence needs further confirmation. RECENT FINDINGS A consensus statement of the Neurocritical Care Society and the European Society of Intensive Care Medicine provided pragmatic guidance and recommendations for multimodal monitoring in neurocritical care patients. Only a minority of these recommendations have strong evidence. In addition, recent multicenter randomized controlled trials concerning the therapy of subarachnoidal hemorrhage and traumatic brain injury could not show decreased mortality or improved functional neurologic outcome after the interventions. The current evidence for monitoring and medical therapy in patients after traumatic brain injury and aneurysmal subarachnoid hemorrhage is highlighted in this review. SUMMARY Although strong evidence is lacking, multimodal monitoring is of great value in neurocritical care patients and may help to provide patients with the optimal therapy based on the individual pathophysiological changes.
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