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Quispe-Cornejo AA, Alves da Cunha AL, Njimi H, Mongkolpun W, Valle-Martins AL, Arébalo-López M, Creteur J, Vincent JL. Effects of rapid fluid infusion on hemoglobin concentration: a systematic review and meta-analysis. Crit Care 2022; 26:324. [PMID: 36274172 PMCID: PMC9588219 DOI: 10.1186/s13054-022-04191-x] [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] [Received: 08/07/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Background Rapid fluid administration may decrease hemoglobin concentration (Hb) by a diluting effect, which could limit the increase in oxygen delivery (DO2) expected with a positive response to fluid challenge in critically ill patients. Our aim was to quantify the decrease in Hb after rapid fluid administration. Methods Our protocol was registered in PROSPERO (CRD42020165146). We searched PubMed, the Cochrane Database, and Embase from inception until February 15, 2022. We selected studies that reported Hb before and after rapid fluid administration (bolus fluid given over less than 120 min) with crystalloids and/or colloids in adults. Exclusion criteria were studies that included bleeding patients, or used transfusions or extracorporeal circulation procedures. Studies were divided according to whether they involved non-acutely ill or acutely ill (surgical/trauma, sepsis, circulatory shock or severe hypovolemia, and mixed conditions) subjects. The mean Hb difference and, where reported, the DO2 difference before and after fluid administration were extracted. Meta-analyses were conducted to assess differences in Hb before and after rapid fluid administration in all subjects and across subgroups. Random-effect models, meta-regressions and subgroup analyses were performed for meta-analyses. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I2 statistic. Results Sixty-five studies met our inclusion criteria (40 in non-acutely ill and 25 in acutely ill subjects), with a total of 2794 participants. Risk of bias was assessed as “low” for randomized controlled trials (RCTs) and ‘low to moderate’ for non-RCTs. Across 63 studies suitable for meta-analysis, the Hb decreased significantly by a mean of 1.33 g/dL [95% CI − 1.45 to − 1.12; p < 0.001; I2 = 96.88] after fluid administration: in non-acutely ill subjects, the mean decrease was 1.56 g/dL [95% CI − 1.69 to − 1.42; p < 0.001; I2 = 96.71] and in acutely ill patients 0.84 g/dL [95% CI − 1.03 to − 0.64; p = 0.033; I2 = 92.91]. The decrease in Hb was less marked in patients with sepsis than in other acutely ill patients. The DO2 decreased significantly in fluid non-responders with a significant decrease in Hb. Conclusions Hb decreased consistently after rapid fluid administration with moderate certainty of evidence. This effect may limit the positive effects of fluid challenges on DO2 and thus on tissue oxygenation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04191-x.
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Affiliation(s)
- Armin A. Quispe-Cornejo
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium ,Instituto Académico Científico Quispe Cornejo, La Paz, Bolivia
| | - Ana L. Alves da Cunha
- grid.465290.cDepartment of Intensive Care, Hospital da Senhora da Oliveira, Guimarães, Portugal ,Instituto Académico Científico Quispe Cornejo, La Paz, Bolivia
| | - Hassane Njimi
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Wasineenart Mongkolpun
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Ana L. Valle-Martins
- grid.414826.d0000 0004 0496 9134Department of Intensive Care, Hospital Mater Dei, Belo Horizonte, Brazil
| | - Mónica Arébalo-López
- Department of Intensive Care, Hospital Univalle Norte, Cochabamba, Bolivia ,Instituto Académico Científico Quispe Cornejo, La Paz, Bolivia
| | - Jacques Creteur
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
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Schumann R, Zaimi I, Shebaclo K, Gupta A. Blood Products, Crystalloids, and Rapid Infusion: An Experimental Study With Magnesium. J Cardiothorac Vasc Anesth 2021; 36:1040-1046. [PMID: 34330574 DOI: 10.1053/j.jvca.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Calcium and magnesium are concentration-dependent pro- and anticoagulant cofactors, and magnesium behaves similarly to calcium in the presence of citrate. The authors hypothesized that magnesium can cause clot formation (primary objective) when mixed with coagulation factor-containing blood products diluted with different crystalloids in a rapid- infuser reservoir. A secondary objective was the observation of any infuser alarms and stops in the event of clotting. DESIGN An experimental in vitro study with blood products, crystalloids, magnesium, and calcium in a rapid infuser with a reservoir using a closed-loop system. SETTING Anesthesia research laboratory at an urban academic tertiary medical center PARTICIPANTS: Not applicable. INTERVENTIONS Exposure of fresh frozen plasma (FFP) and packed red blood cells alone (control) or in combination with either normal saline (NS), lactated Ringer's solution (LR), or Plasma-Lyte A (PL) to increasing concentrations of magnesium sulphate (MgSO4) up to 1 g. After each incremental MgSO4 change, the authors applied a specific pump-flow sequence in a closed-loop system with a rapid-infuser reservoir, and if no clot was observed, the authors incrementally added calcium chloride (CaCl2) up to 1 g. MEASUREMENTS AND MAIN RESULTS Observation of macroscopic clot and time to event, as well as occurrence and type of any pump alarms or stops. LR experiments resulted in clot observation in the reservoir by a dedicated observer after MgSO4 275 ± 206 mg (95% confidence interval [CI], 9-541). Adding MgSO4 1 g in the NS, PL, or the control experiments did not result in clot observation. Only when CaCl2 166.7 ± 51.64 mg (95% CI, 112.0-22.01) was added to the combination of blood products alone or mixed with NS and PL, clotting occurred. The mean FFP volume was 281 ± 48.6 mL (range, 204-340 mL) and was not different between groups (p = 0.44). Pump alarms and stops were inconsistent. CONCLUSIONS The addition of magnesium to a combination of LR with coagulation factor- containing blood products consistently resulted in a visible blood clot in the rapid-infuser reservoir in the authors' experimental setup. In addition to MgSO4 1 g in the control, NS, and PL experiments, CaCl2 is needed before a clot can be observed.
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Affiliation(s)
- Roman Schumann
- Department of Anesthesiology, VA Boston Healthcare System, West Roxbury, MA; Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA.
| | - Ina Zaimi
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA; Department of Anesthesiology, St. Elizabeth's Medical Center, Brighton, MA
| | - Kareen Shebaclo
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Anupriya Gupta
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
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Humphrey S, Kirby R, Rudloff E. Magnesium physiology and clinical therapy in veterinary critical care. J Vet Emerg Crit Care (San Antonio) 2014; 25:210-25. [PMID: 25427407 DOI: 10.1111/vec.12253] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 09/30/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To review magnesium physiology including absorption, excretion, and function within the body, causes of magnesium abnormalities, and the current applications of magnesium monitoring and therapy in people and animals. ETIOLOGY Magnesium plays a pivotal role in energy production and specific functions in every cell in the body. Disorders of magnesium can be correlated with severity of disease, length of hospital stay, and recovery of the septic patient. Hypermagnesemia is seen infrequently in people and animals with significant consequences reported. Hypomagnesemia is more common in critically ill people and animals, and can be associated with platelet, immune system, neurological, and cardiovascular dysfunction as well as alterations in insulin responsiveness and electrolyte imbalance. DIAGNOSIS Measurement of serum ionized magnesium in critically or chronically ill veterinary patients is practical and provides information necessary for stabilization and treatment. Tissue magnesium concentrations may be assessed using nuclear magnetic resonance spectroscopy as well as through the application of fluorescent dye techniques. THERAPY Magnesium infusions may play a therapeutic role in reperfusion injury, myocardial ischemia, cerebral infarcts, systemic inflammatory response syndromes, tetanus, digitalis toxicity, bronchospasms, hypercoagulable states, and as an adjunct to specific anesthetic or analgesic protocols. Further veterinary studies are needed to establish the frequency and importance of magnesium disorders in animals and the potential benefit of magnesium infusions as a therapeutic adjunct to specific diseases. PROGNOSIS The prognosis for most patients with magnesium disorders is variable and largely dependent on the underlying cause of the disorder.
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Affiliation(s)
- Sarah Humphrey
- From the Animal Emergency Center and Specialty Services, Glendale, WI 52309
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Na HS, Shin HJ, Kang SB, Hwang JW, Do SH. Effects of magnesium sulphate on coagulation after laparoscopic colorectal cancer surgery, measured by rotational thromboelastometry (ROTEM®). Anaesthesia 2014; 69:1314-21. [DOI: 10.1111/anae.12684] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2014] [Indexed: 11/27/2022]
Affiliation(s)
- H. S. Na
- Department of Anaesthesiology and Pain Medicine; Seoul National University Bundang Hospital; Seongnam Gyeonggi South Korea
| | - H. J. Shin
- Department of Anaesthesiology and Pain Medicine; Seoul National University Bundang Hospital; Seongnam Gyeonggi South Korea
| | - S. B. Kang
- Department of Surgery; Seoul National University Bundang Hospital; Seongnam Gyeonggi South Korea
| | - J. W. Hwang
- Department of Anaesthesiology and Pain Medicine; Seoul National University Bundang Hospital; Seongnam Gyeonggi South Korea
| | - S. H. Do
- Department of Anaesthesiology and Pain Medicine; Seoul National University Bundang Hospital; Seongnam Gyeonggi South Korea
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Kaczynski J, Wilczynska M, Hilton J, Fligelstone L. Impact of crystalloids and colloids on coagulation cascade during trauma resuscitation-a literature review. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2052-6229-1-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rioja E, Dzikiti BT, Fosgate G, Goddard A, Stegmann FG, Schoeman JP. Effects of a constant rate infusion of magnesium sulphate in healthy dogs anaesthetized with isoflurane and undergoing ovariohysterectomy. Vet Anaesth Analg 2012; 39:599-610. [DOI: 10.1111/j.1467-2995.2012.00722.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Na HS, Chung YH, Hwang JW, Do SH. Effects of magnesium sulphate on postoperative coagulation, measured by rotational thromboelastometry (ROTEM®)*. Anaesthesia 2012; 67:862-9. [DOI: 10.1111/j.1365-2044.2012.07149.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kang WS, Yun HJ, Han SJ, Kim HY, Kim DK, Lim JA, Woo NS, Kim SH. The effects of magnesium on the course of atrial fibrillation and coagulation in patients with atrial fibrillation undergoing mitral valve annuloplasty. Korean J Anesthesiol 2011; 61:210-5. [PMID: 22025942 PMCID: PMC3198181 DOI: 10.4097/kjae.2011.61.3.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 03/29/2011] [Accepted: 03/30/2011] [Indexed: 11/24/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most common cardiac arrhythmia. Magnesium has been reported to be effective in reducing the incidence or prophylaxis of AF. Magnesium is also an essential constituent of many enzyme systems and plays a physiological role in coagulation regulation. The aim of the present study was to examine the effects of magnesium, whether magnesium infusion might decrease the incidence of AF and induce hypocoagulable state in patients with AF, who were undergoing mitral valve annuloplasty. Methods This prospective laboratory study was performed using blood from patients with AF undergoing mitral valve annuloplasty. The radial artery was punctured with a 20 gauge catheter and used for monitoring continuous arterial pressure and blood sampling. After anesthesia induction, 4 g of magnesium was mixed with 100 ml normal saline and infused for 5 minutes. Magnesium, calcium, activated clotting time (ACT) and thromboelastographic parameters were checked before and 60 minutes after the magnesium infusion. The electrocardiography changes after magnesium infusion were also checked before commencing cardiopulmonary bypass. Results After magnesium infusion, the serum level of magnesium increased significantly but serum calcium did not change significantly. ACT did not change significantly before or after magnesium infusion. The thromboelastographic parameters showed no significant changes before or after magnesium infusion. None of the patients converted to sinus rhythm from AF after the magnesium infusion. Conclusions A magnesium infusion did not influence the course of AF and coagulation in patients during prebypass period with AF undergoing mitral valve annuloplasty.
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Affiliation(s)
- Woon-Seok Kang
- Department of Anaesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
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Ho KM, Leonard A. Risk factors and outcome associated with hypomagnesemia in massive transfusion. Transfusion 2010; 51:270-6. [PMID: 20735766 DOI: 10.1111/j.1537-2995.2010.02855.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Electrolyte disturbances are common in patients with critical bleeding requiring massive transfusion. The risk factors and outcome associated with the occurrence of hypomagnesemia in massive transfusion remain uncertain. STUDY DESIGN AND METHODS A cohort of 353 consecutive patients who required massive transfusion, defined as 10 or more units of allogeneic red blood cells or whole blood transfusion within 24 hours, between 2002 and 2008 in a quaternary health care center in Western Australia was considered. Logistic regression was used to identify risk factors and outcome associated with hypomagnesemia during massive transfusion (<0.7 mmol/L or 1.7 mg/dL). RESULTS Of the 353 patients requiring massive transfusion during the study period, 298 patients (84%) had serum magnesium concentrations available for analysis. Hypomagnesemia was common (172 patients, 58%), and the mean magnesium concentration was 0.68 mmol/L (1.65 mg/dL; standard deviation, 0.15 mmol/L) in these patients. The risk factors for hypomagnesemia were hypocalcemia (odds ratio [OR], 1.67 per 0.1 mmol/L decrement; 95% confidence interval [CI], 1.36-2.01; p = 0.001) and hypofibrinogenemia (OR, 1.05 per 0.1 g/L decrement; 95% CI, 1.01-1.09; p = 0.009). The lowest serum magnesium concentrations were associated with the lowest ionized calcium concentrations (Spearman correlation coefficient, 0.377; p = 0.001). Both magnesium concentrations (OR, 0.91 per 0.1 mmol/L increment; 95% CI 0.31-2.69; p = 0.863) and the interaction term between magnesium and calcium concentrations were not associated with an increased risk of mortality after adjusting for other covariates. CONCLUSIONS Hypomagnesemia was common and associated with hypocalcemia in massive transfusion, but serum magnesium concentrations had no independent effect or interactive effect with hypocalcemia on mortality of patients requiring massive transfusion.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia.
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Piastra M, Di Rocco C, Caresta E, Zorzi G, De Luca D, Caldarelli M, La Torre G, Conti G, Antonelli M, Eaton S, Pietrini D. Blood loss and short-term outcome of infants undergoing brain tumour removal. J Neurooncol 2008; 90:191-200. [DOI: 10.1007/s11060-008-9643-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 06/06/2008] [Indexed: 11/30/2022]
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Srivastava AR, Banerjee A, Misra BB, Minhas H, Virmani S. Does Hemodilution by the Crystalloid Priming Solution Derange the Efficacy of Anticoagulation During Cardiopulmonary Bypass? J Card Surg 2008; 23:239-45. [DOI: 10.1111/j.1540-8191.2007.00535.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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