The efficacy and safety of colloid resuscitation in the critically ill

Hydroxyethyl Starch-Bovine Hemoglobin Conjugate as an Effective Oxygen Carrier with the Ability to Expand Plasma

Hemorrhagic shock leads to intravasal volume deficiency, tissue hypoxia, and cellular anaerobic metabolism. Hemoglobin (Hb) could deliver oxygen for hypoxic tissues but is unable to expand plasma. Hydroxyethyl starch (HES) could compensate for the intravasal volume deficiency but cannot deliver oxygen. Thus, bovine Hb (bHb) was conjugated with HES (130 kDa and 200 kDa) to develop an oxygen carrier with the ability to expand plasma. Conjugation with HES increased the hydrodynamic volume, colloidal osmotic pressure, and viscosity of bHb. It slightly perturbed the quaternary structure and heme environment of bHb. The partial oxygen pressures at 50% saturation (P ₅₀) of the two conjugates (bHb-HES130 and bHb-HES200) were 15.1 and 13.9 mmHg, respectively. The two conjugates showed no apparent side effects on the morphology and rigidity, hemolysis, and platelet aggregation of red blood cells of Wistar rats. Thus, bHb-HES130 and bHb-HES200 were expected to function as an effective oxygen carrier with the ability to expand plasma.

Hemostatic effects of a dextran-based priming solution for cardiopulmonary bypass: A secondary analysis of a randomized clinical trial

INTRODUCTION

Intravascular fluids administered to patients may influence hemostasis. In patients undergoing cardiac surgery with cardiopulmonary bypass, the heart-lung machine is primed with 1300 ml of fluid. We assessed postoperative coagulation and platelet function in patients randomized to two different priming solutions, one colloid-based (dextran 40) and one crystalloid-based.

MATERIALS AND METHODS

Eighty-four elective cardiac surgery patients were randomized to either a dextran-based prime or Ringer's acetate with added mannitol. Blood samples were collected before, and 2 and 24 h after cardiopulmonary bypass. Coagulation was assessed by standard coagulation tests and rotational thromboelastometry. Platelet function was assessed with impedance aggregometry. Bleeding volumes and transfusion requirements were recorded.

RESULTS

Comparing the groups 2 h after bypass, the dextran group showed lower hemoglobin concentration, hematocrit, platelet count, and fibrinogen concentration, and higher INR and aPTT, as well as longer clot formation time (+41 ± 21 % vs. +8 ± 18 %, p < 0.001) and a larger reduction in fibrinogen-dependent clot strength (-37 ± 12 % vs. -7 ± 20 %, p < 0.001). Adenosine diphosphate-dependent platelet activation was reduced in the dextran group but not in the crystalloid group 2 h after bypass (-14 ± 29 % vs. -1 ± 41 %, p = 0.041). No significant between-group differences in hemostatic variables remained after 24 h, and no significant differences in perioperative bleeding volumes, re-explorations for bleeding, or transfusion rates were observed.

CONCLUSIONS

Compared to a crystalloid solution, a dextran-based prime had measurable negative impact on hemostatic variables but no detectable increase in bleeding volume or transfusion requirements in cardiac surgery patients.

Effect of a 3% gelatin solution on urinary KIM-1 levels in patients after thyroidectomy: a preliminary randomized controlled trial

Optimal fluid therapy significantly affects the maintenance of proper tissue perfusion and, consequently, kidney function. An adverse effect of colloids on kidney function is related to the incidence of postoperative kidney failure. The study aimed to assess the effect of a 3% gelatin solution on kidney function based on the urinary kidney injury molecule-1 (uKIM-1) level. This study used a parallel design and enrolled 64 adult patients with a mean age of 52.5 ± 13.1 years, all of whom underwent a thyroidectomy procedure under general anesthesia. Patients were randomly assigned to three comparison groups, each receiving a different dose of 3% gelatin solution during the thyroidectomy procedure. The patients from study groups A (n = 21) and B (n = 21) received a 3% gelatin solution at a dose of 30 ml/kg and 15 ml/kg body weight, respectively, during the first hour of the procedure. The patients from the control group C (n = 22) received an isotonic multi-electrolyte solution. Serum creatinine levels were determined, and urine samples were collected to determine levels of uKIM-1 before, 2 h, and 24 h after surgery. The patients' demographic data, type and volume of fluid and hemodynamic status during the surgery were collected from relevant anesthesia protocols and were included in the study data. There were no statistically significant changes between groups in hemodynamic parameters such as systolic and diastolic blood pressure, heart rate, and oxygen saturation values. A statistically significant increase in uKIM-1 level was noted in patients receiving the 3% gelatin solution regardless of the dose. A statistically significant difference in uKIM-1 level was observed between groups A, B, and C measured 24 h after surgery, with the highest uKIM-1 level in group A. Measurement of uKIM-1 level could be an early and sensitive biomarker of kidney injury. Kidney toxicity of a 3% gelatin solution, evaluated based on the level of uKIM-1 in urine, correlates with transfused fluid volume. This study was retrospectively registered in the ISRCTN clinical trials registry (ISRCTN73266049, 08/04/2021: https://www.isrctn.com/ISRCTN73266049 ).

Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis

BACKGROUND

In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement.

METHODS

In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant).

RESULTS

Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02).

CONCLUSIONS

In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.

Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature

BACKGROUND

Over-resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature.

METHODS

A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020.

RESULTS

Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids.

CONCLUSIONS

In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.

Purification of canine albumin by heat denaturation in a plasma bag

OBJECTIVE

To design and evaluate a method to purify canine albumin from fresh frozen plasma (FFP) or stored plasma (SP) in a manner that could be applied clinically.

DESIGN

In vitro experimental study.

SETTING

FDA licensed Blood Bank Laboratory and University biochemistry laboratory.

ANIMALS

None.

INTERVENTIONS

Using equipment that is typically found in veterinary blood banks, plasma bags were thawed, injected with the heat stabilizing agent, sodium caprylate, and then heated and acidified to denature all but albumin proteins. Albumin-rich supernatant was removed, the pH was neutralized, and then pasteurized and refrigerated. Albumin and total plasma protein concentrations were measured and the product was cultured for bacteria at 0, 7, 14, 30, and 60 days post-processing.

MEASUREMENTS AND MAIN RESULTS

Seventeen bags of plasma were analyzed for purity, yield, and sterility of the finished albumin product. Bags were divided into categories based on the age of the frozen plasma. Mean yield of albumin for all bags was 77.3% and mean purity was 91.2%. There was no difference between old stored plasma, new stored plasma, and FFP with regard to yield (P = 0.31) or purity (P = 0.24) based on one-way analysis of variances. Overall 1 of 17 bags of plasma (5.9%) tested positive for bacterial contamination on day 60 after processing.

CONCLUSIONS

Sodium caprylate is able to stabilize canine albumin enabling it to withstand heating that denatures other plasma proteins. The resulting albumin product is of sufficient quality to potentially be used therapeutically as a colloidal resuscitative fluid. Further study is needed into its safety and effect in dogs.

Association of intra-operative hypotension with acute kidney injury, myocardial injury and mortality in non-cardiac surgery: A meta-analysis

BACKGROUND

Intra-operative hypotension might induce poor postoperative outcomes in non-cardiac surgery, and the relationship between the level or duration of Intra-operative hypotension (IOH) and postoperative adverse events is still unclear. In this study, we performed a meta-analysis to determine how IOH could affect acute kidney injury (AKI), myocardial injury and mortality in non-cardiac surgery.

METHODS

We searched PubMed (Medline), Embase, Springer, The Cochrane Library, Ovid and Google Scholar, and retrieved the related clinical trials on intra-operative hypotension and prognosis in non-cardiac surgery.

RESULTS

Fifteen observational studies were included. The meta-analysis showed that in non-cardiac surgery, intra-operative hypotension (mean arterial pressure [MAP]) <60 mm Hg for more than 1 minute was associated with an increased risk of postoperative acute kidney injury(AKI) [1-5 minutes: odds ratio (OR) = 1.13, 95% CI (1.04, 1.23), I²  = 0, P = .003; 5-10 minutes: OR = 1.18, 95% CI (1.07, 1.31), I²  = 0, P = .001; >10 minutes: OR = 1.35, 95% CI (1.1, 1.67), I²  = 52.6%, P = .004] and myocardial injury [1-5 minutes: OR = 1.16, 95% CI (1.01, 1.33), I²  = 30.6%, P = .04; 5-10 minutes: OR = 1.34, 95% CI (1.01, 1.77), I²  = 70.4%, P = .046; >10 minutes: OR = 1.43, 95% CI (1.18, 1.72), I²  = 39.4%, P < .0001]. Intra-operative hypotension (MAP < 60 mm Hg) for 1-5 minutes was not associated with postoperative 30-day mortality [OR = 1.15, 95% CI (0.95, 1.4), I²  = 0, P = .154], but intra-operative hypotension (MAP < 60 mm Hg) for more than 5 min was associated with an increased risk of postoperative 30-day mortality [OR = 1.11, 95% CI (1.06, 1.17), I²  = 51.9%, P < .0001].

CONCLUSION

Intra-operative hypotension was associated with an increased risk of postoperative AKI, myocardial injury and 30-day mortality in non-cardiac surgery. Intra-operative MAP < 60 mm Hg more than 1 minute should be avoided.

Safety and efficacy of peri-operative administration of hydroxyethyl starch in children undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Hydroxyethyl starch (HES) solutions have shown their efficiency for intravascular volume expansion. A safety recommendation limiting their use in adult patients has recently been made.

OBJECTIVE

To assess the efficacy and adverse effects of HES when administered intra-operatively to paediatric patients.

DESIGN

Systematic review with meta-analyses. Data were analysed using classical mean differences [and their 95% confidence intervals (CIs)] and trial sequential analysis. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification was performed for all outcomes. Reviewers extracted valid data, including perioperative total fluid intakes, mortality, renal function, coagulation tests, blood loss and length of hospital and ICU stay.

DATA SOURCES

Searches were performed in databases (Pubmed, Embase, Cochrane central register of controlled trials), clinical trials register, and open access journals not indexed in major databases.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) published before December 2016 involving paediatric patients who received 6% low molecular weight HES.

RESULTS

Nine RCTs involving 530 peri-operative paediatric patients were analysed. Compared with other fluids, HES did not significantly modify the amount of peri-operative fluid administered [mean difference 0.04; 95% CI (-1.76 to 1.84) ml kg], urine output [mean difference -33; 95% CI (-104 to 38) ml kg] or blood loss [mean difference -0.09; (-0.32 to 0.15) ml kg]. Trial sequential analysis determined that the outcomes for peri-operative fluid and urine output were underpowered. All results were graded as very low quality of evidence.

CONCLUSION

Intravascular volume expansion with low molecular weight 6% HES did not appear to modify renal function, blood loss or transfusion when administered to children during the peri-operative period. However, given the lack of statistical power and the very low GRADE quality of evidence, more high-quality RCTs are needed to explore these outcomes.

Substitution of artificial colloids for fresh frozen plasma in pediatric cardiopulmonary bypass surgery

BACKGROUND

In many centers, fresh frozen plasma is generally used as the main component of pump prime in pediatric cardiopulmonary bypass. However, many factors have resulted in stringent control of plasma transfusion and prompted the study of safe and efficient substitutes.

AIMS

The aim of this study was to investigate the feasibility of a priming strategy with gelatin during cardiopulmonary bypass in pediatric patients undergoing cardiac surgery and identify the factors associated with postoperative chest-tube drainage.

METHODS

We reviewed 1164 pediatric patients who underwent cardiac surgery with cardiopulmonary bypass between January 2012 and April 2013 in Fuwai hospital. Infants and children were primed with different types of solution: plasma or gelatin. Clinical data included postoperative coagulation function (pharmacological agents, chest-tube drainage, and transfusion requirements), recovery indicators (mechanical ventilator time, ICU stay and hospital stay), incidence of in-hospital mortality, and morbidity. Multivariate linear regression analysis was used to identify factors correlated with postoperative chest-tube drainage.

RESULTS

No difference in mortality or morbidity was found between the plasma and gelatin groups. In infants, increased chest-tube drainage (postoperation 12 hours, median difference -0.046 ml/kg/hr, 95%CI: -0.105 to -0.007, P = 0.001; postoperation 24 hours, median difference -0.047 ml/kg/hr, 95%CI: -0.081 to -0.025, P < 0.001), and decreased transfusion (red blood cell, median difference 0.00 ml/kg/hr, 95%CI: 0.000-100, P < 0.001; fresh frozen plasma, median difference 5.556 ml/kg/hr, 95%CI: 2.30-8.333, P = 0.001), and recovery time (mechanical ventilator time, median difference 3.00 hours, 95%CI: 1.00-5.500, P < 0.001; ICU stay, median difference 17.00 hours, 95%CI: 1.00-22.000, P = 0.001; hospital stay, median difference 1.00 day, 95%CI: 0.00-2.000, P = 0.038) were demonstrated in the gelatin group. In children, the transfusion requirements (red blood cell, median difference 100 ml, P < 0.001;fresh frozen plasma, median difference 1.11 ml/kg, 95%CI: 0.000-2.42, P = 0.001) were decreased in the gelatin group. Multivariate linear regression analysis revealed that the type of priming solution (β = 1.940,95%CI: 1.057-2.823,P < 0.001), bypass time (β = 0.024, 95%CI: 0.013-0.036, P < 0.001), and age (β = -0.257, 95%CI: -0.422 to -0.09, P = 0.002) were independent variables correlating with chest-tube drainage in infants.

CONCLUSION

In the general pediatric patients undergoing elective cardiac surgery, substitution of gelatin for fresh frozen plasma in cardiopulmonary bypass is feasible.

The Incidence and Risk Factors of Acute Kidney Disease after Total Knee Arthroplasty with Early Postoperative Volume Supplement

Background

Etiology of acute kidney disease (AKD) after total knee arthroplasty (TKA) was considered as multifactorial. However, the role of early postoperative volume supplement in AKD rate has not been investigated. The purpose of this study was to evaluate the incidence and risk factors of AKD in patients with early volume supplement following TKA.

Methods

This was a retrospective study with 458 patients who underwent unilateral TKA. All the patients received 6% tetrastarch, 7.5ml/kg, early in the postoperative period. Postoperative AKD was defined as the postoperative creatinine level ≥ 1.5 times compared with preoperative data. Potential variables associated with AKD were analyzed by multivariate logistic regression model to identify the AKD risk factors in TKA patients after early postoperative volume supplement.

Results

The AKD rate was 3.3% (15 patients) in all patients. Age (OR = 1.09; P = .031) and coronary artery disease (CAD) (OR = 3.63; P = .034) were associated with increased risk of development of postoperative AKD. Other comorbidities as hypertension, diabetes, and CKD were not statistically significant risk factors.

Conclusion

Our study demonstrated that age and CAD were independent risk factors of AKD in TKA patients. However, the common risk factors as hypertension, diabetes, and CKD were not significantly associated with AKD after TKA if early postoperative supplement of tetrastarch is administered.

Perioperative Vision Loss after Non-Ocular Surgery

Perioperative vision loss (POVL) may cause devastating visual morbidity. A prompt anatomical and etiologic diagnosis is paramount to guide management and assess prognosis. Where possible, steps should be undertaken to minimize risk of POVL for vulnerable patients undergoing high-risk procedures. We review the specific risk factors, pathophysiology, and management and prevention strategies for various etiologies of POVL.

Rapid exacerbation of renal function after administration of hydroxyethyl starch in a dog

Hydroxyethyl starches (HES) are commonly used synthetic colloidal solution in veterinary medicine. Despite of possible adverse effect to kidney injury in human, there is no report about nephrotoxic effects of HES in dogs. HES was administered to a Golden retriever (4-year-old, intact male) with ascites in order to increase plasma osmolality. Initially, the dog was mild azotemic, however, kidney function was rapidly deteriorated after several days of HES administration. Finally, histopathological examination revealed remarkable osmotic nephrosis. In the case reported herein, acute kidney injury was remarkably developed after HES administration. Clinical and histopathologic findings of acute kidney injury support nephrotoxic effects of HES to a dog.

The effect of pPolyHb on hemodynamic stability and mesenteric microcirculation in a rat model of hemorrhagic shock

The effects of polymerized porcine hemoglobin (pPolyHb) on hemodynamic stability and maintenance of mesenteric microvascular function were explored in a rat model of hemorrhagic shock (HS). Following controlled hemorrhage, rats were infused with equal volumes of either pPolyHb, hetastarch (HES), or red blood cell (RBC). The results showed that pPolyHb was superior to HES and RBC in restoring hemodynamic stability and reversing anaerobic metabolism. We observed a reduction in the diameter of mesenteric microvasculature after HS. Resuscitation with pPolyHb and RBC was able to restore the diameters of the venules and arterioles, whereas HES failed to restore the diameters during the observation period.

Fluid resuscitation management in patients with burns: update

Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.

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

OBJECTIVES

To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals.

DATA SOURCES

Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present.

HUMAN DATA SYNTHESIS

HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities.

VETERINARY DATA SYNTHESIS

The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations.

CONCLUSIONS

Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.

A rapid-response fluorescent probe for the sensitive and selective detection of human albumin in plasma and cell culture supernatants

A rapid-response fluorescent probeACDMwas developed for selective and sensitive detection of human albumin (HA)viabinding on a non-drug binding site.

Fluid management in abdominal surgery: what, when, and when not to administer

The entire team (including anesthesiologists, surgeons, and intensive care physicians) must work together (before, during, and after abdominal surgery) to determine the optimal amount (quantity) and type (quality) of fluid necessary in the perioperative period. The authors present an overview of the basic principles that underlie fluid management, including evidence-based recommendations (where tenable) and a rational approach for when and what to administer.

Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery

BACKGROUND

Intraoperative hypotension (IOH) may be associated with postoperative acute kidney injury (AKI), but the duration of hypotension for triggering harm is unclear. The authors investigated the association between varying periods of IOH with mean arterial pressure (MAP) less than 55, less than 60, and less than 65 mmHg with AKI.

METHODS

The authors conducted a retrospective cohort study of 5,127 patients undergoing noncardiac surgery (2009 to 2012) with invasive MAP monitoring and length of stay of 1 or more days. Exclusion criteria were preoperative MAP less than 65 mmHg, dialysis dependence, urologic surgery, and surgical duration less than 30 min. The primary exposure was IOH. The primary outcome was AKI (50% or 0.3 mg/dl increase in creatinine) during the first 2 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship.

RESULTS

AKI occurred in 324 (6.3%) patients and was associated with MAP less than 60 mmHg for 11 to 20 min and MAP less than 55 mmHg for more than 10 min in a graded fashion. The adjusted odds ratio of AKI for MAP less than 55 mmHg was 2.34 (1.35 to 4.05) for 11- to 20-min exposure and 3.53 (1.51 to 8.25) for more than 20 min. For MAP less than 60 mmHg, the adjusted odds ratio for AKI was 1.84 (1.11 to 3.06) for 11- to 20-min exposure.

CONCLUSIONS

In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.

[Fluid resuscitation in hemorrhage]

How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.

Safety evaluation on low-molecular-weight hydroxyethyl starch for volume expansion therapy in pediatric patients: a meta-analysis of randomized controlled trials

INTRODUCTION

Hydroxyethyl starch (HES) has been widely used for volume expansion, but its safety in adult patients has been questioned recently. The aim of this meta-analysis is to see whether or not HES has any adverse effect in pediatric patients.

METHODS

Randomized controlled trials (RCTs) involving pediatric patients who received 6% low-molecular-weight HES, published before January 2014, were searched for in Pubmed, Embase database and Cochrane Library. Two reviewers independently extracted the valid data, including the mortality, renal function, coagulation, blood loss, hemodynamic changes, and length of hospital and ICU stay. All data were analyzed by I (2)-test, and the results of statistical analysis were displayed in forest plots. Possible publication bias was tested by funnel plots. Bayesian analysis was performed using WinBUGS with fixed and random effects models.

RESULTS

A total of 13 RCTs involving 1,156 pediatric patients were finally included in this meta-analysis. Compared with other fluids, HES did not significantly decrease the mortality (RR = -0.01; 95%CI: 0.05 to 0.03; P = 0.54; I(2) = 6%), creatinine level (I(2) -test: MD = 1.81; 95%CI: -0.35 to 3.98; P = 0.10;I(2)  = 0%; Bayesian analysis: Fixed effect model MD = 1.77; 95%CI: -0.07 to 3.6; Random effects model MD = 1.78; 95%CI: -1.86 to 5.33), activated partial thromboplastin time (MD = 0.01; 95%CI: -1.05 to 1.07; P = 0.99; I(2) = 42%), and blood loss (MD = 17.72; 95%CI: -41.27 to 5.82; P = 0.10; I(2) = 0%) in pediatric patients. However, HES significantly decreased the blood platelet count (MD = 20.99; 95%CI: -32.08 to -9.90; P = 0.0002; I(2) = 28%) and increased the length of ICU stay (MD = 0.94; 95%CI: 0.18 to 1.70; P = 0.02; I(2) = 46%).

CONCLUSIONS

Volume expansion with 6% HES significantly decreased the platelet count and increased the length of ICU stay, also might have an adverse effect on renal function. Therefore HES is not recommended for pediatric patients, which safety needs more high quality RCTs and studies to confirm in future.

Early resuscitation with fresh frozen plasma for traumatic brain injury combined with hemorrhagic shock improves neurologic recovery

BACKGROUND

We have shown that early administration of fresh frozen plasma (FFP) reduces the size of brain lesions 6 hours after injury in a large animal model of traumatic brain injury (TBI) and hemorrhagic shock (HS). To examine long-term outcomes, we hypothesized that early treatment with FFP would result in faster neurologic recovery and better long-term outcomes in a combined TBI and HS model.

STUDY DESIGN

Anesthetized Yorkshire swine underwent combined TBI and volume-controlled hemorrhage (40% blood volume). After 2 hours of shock, animals were randomized (n = 5/group) to normal saline (3× shed blood) or FFP (1× shed blood) treatment. A neurologic severity score was assessed for 30 days. Magnetic resonance imaging of the brain was performed at days 3, 10, and 24. Cognitive function was tested by training animals to retrieve food from color-coded boxes.

RESULTS

Neurologic impairment was lower and speed of recovery was considerably faster in the FFP-treated animals. There was a trend toward a smaller lesion size in FFP-treated animal at days 3 and 10, but this did not reach statistical significance. Both groups reached baseline performance on the cognitive testing; however, FFP-treated animals were able to participate, on average, 8 days earlier due to quicker recovery.

CONCLUSIONS

This is the first study to demonstrate the beneficial effects of FFP treatment in a long-term survival model of combined TBI and HS. Our data show that early treatment with FFP substantially attenuates the degree of neurologic impairment, improves the rate of recovery, and preserves the cognitive functions.

The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis

Introduction

Recent studies in septic patients showed that adverse effects of hydroxyethyl starches (HESs) possibly outweigh their benefits in severely impaired physiological haemostasis. It remains unclear whether this also applies to patient populations that are less vulnerable. In this meta-analysis, we evaluated the impact of various HES generations on safety and efficacy endpoints in patients undergoing cardiac surgery.

Methods

We searched the PubMed, Embase and Cochrane Central Register of Controlled Trials databases for randomised controlled trials (RCTs) in the English or German language comparing the use of HES to any other colloid or crystalloid during open heart surgery.

Results

Blood loss and transfusion requirements were higher for older starches with mean molecular weights more than 200 kDa compared to other volume substitutes. In contrast, this effect was not observed with latest-generation tetrastarches (130/0.4), which performed even better when compared to albumin (blood loss of tetrastarch versus albumin: standardised mean difference (SMD), −0.34; 95% CI, −0.63, −0.05; P = 0.02; versus gelatin: SMD, −0.06; 95% CI, −0.20, 0.08; P = 0.39; versus crystalloids: SMD, −0.05; 95% CI, −0.20, 0.10; P = 0.54). Similar results were found for transfusion needs. Lengths of stay in the intensive care unit or hospital were significantly shorter with tetrastarches compared to gelatin (intensive care unit: SMD, −0.10; 95% CI, −0.15, −0.05; P = 0.0002) and crystalloids (hospital: SMD, −0.52; 95% CI, −0.90, −0.14; P = 0.007).

Conclusions

In this meta-analysis of RCTs, we could not identify safety issues with tetrastarches compared with other colloid or crystalloid solutions in terms of blood loss, transfusion requirements or hospital length of stay in patients undergoing cardiac surgery. The safety data on coagulation with older starches raise some issues that need to be addressed in future trials.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0656-0) contains supplementary material, which is available to authorized users.

Choices in fluid type and volume during resuscitation: impact on patient outcomes

We summarize the emerging new literature regarding the pathophysiological principles underlying the beneficial and deleterious effects of fluid administration during resuscitation, as well as current recommendations and recent clinical evidence regarding specific colloids and crystalloids. This systematic review allows us to conclude that there is no clear benefit associated with the use of colloids compared to crystalloids and no evidence to support the unique benefit of albumin as a resuscitation fluid. Hydroxyethyl starch use has been associated with increased acute kidney injury (AKI) and use of renal replacement therapy. Other synthetic colloids (dextran and gelatins) though not well studied do not appear superior to crystalloids. Normal saline (NS) use is associated with hyperchloremic metabolic acidosis and increased risk of AKI. This risk is decreased when balanced salt solutions are used. Balanced crystalloid solutions have shown no harmful effects, and there is evidence for benefit over NS. Finally, fluid resuscitation should be applied in a goal-directed manner and targeted to physiologic needs of individual patients. The evidence supports use of fluids in volume-responsive patients whose end-organ perfusion parameters have not been met.

Stroke volume-directed administration of hydroxyethyl starch (HES 130/0.4) and Ringer’s acetate in prone position during neurosurgery: a randomized controlled trial

PURPOSE

General anesthesia in the prone position is associated with hypotension. We studied stroke volume (SV)-directed administration of hydroxyethyl starch (HES 130 kDa/0.4) and Ringer’s acetate (RAC) in neurosurgical patients operated on in a prone position to determine the volumes required for stable hemodynamics and possible coagulatory effects.

METHODS

Thirty elective neurosurgical patients received either HES (n = 15) or RAC (n = 15). Before positioning, SV measured by arterial pressure waveform analysis was maximized by fluid boluses until SV did not increase more than 10 %. SV was maintained by repeated administration of fluid. RAC 3 ml/kg/h was infused in both groups. Thromboelastometry assessed coagulation. Mann–Whitney U test, Wilcoxon signed-rank test, ANOVA on ranks, and a linear mixed model were applied.

RESULTS

Comparable hemodynamics were achieved with the mean cumulative (SD) boluses of HES or RAC 240 (51) or 267 (62) ml (P = 0.207) before positioning, 340 (124) or 453 (160) ml (P = 0.039) 30 min after positioning, and 440 (229) or 653 (368) ml at the end of surgery (P = 0.067). The mean dose of basal RAC infusion was 813 (235) and 868 (354) ml (P = 0.620) in the HES and RAC group, respectively. Formation and maximum strength of the fibrin clot were decreased in the HES group. Intraoperative blood loss was comparable between groups (P = 0.861).

CONCLUSION

The amount of RAC needed in the prone position was 25 % greater. The cumulative dose of 440 ml HES induced a slight disturbance in fibrin formation and clot strength. We suggest cautious administration of HES during neurosurgery.

The physiologic perspective in fluid management in vascular anesthesiology

Vascular surgery patients frequently suffer from atherosclerosis and peripheral arterial occlusive disease generating endothelial dysfunction. Furthermore, ischemia and reperfusion during surgery damage endothelial cells and, especially, the endothelial glycocalix. The damage of the glycocalix promotes an increase in permeability. Not only crystalloids, which freely diffuse between the intravascular and the interstitial compartment, but also colloidal fluids cross from the intravascular space in the interstitial space with the consequence of edema formation. Possible tissue edema may result in an impairment of tissue oxygenation, leading to wound healing disturbances and initiation of inflammatory responses up to tissue apoptosis. Particularly in vascular anesthesia, this possibly means that colloids only should be administered in acute volume resuscitation immediately after unclamping a big vessel for immediate volume restoration. Which colloidal fluid should be administered is still under intense discussion. From a theoretical physiologic point of view, iso-osmolar albumin is the best choice regarding volume effect, antioxidative properties, and protection against destruction of the glycocalix. Nonetheless, albumin experimentally has not lived up to its promise in the clinical setting. Thus, further well-conducted large randomized clinical trials are necessary to ascertain the optimal fluid therapy in vascular surgery patients.

Duration of hemodynamic effects of crystalloids in patients with circulatory shock after initial resuscitation

Background

In the later stages of circulatory shock, monitoring should help to avoid fluid overload. In this setting, volume expansion is ideally indicated only for patients in whom the cardiac index (CI) is expected to increase. Crystalloids are usually the choice for fluid replacement. As previous studies evaluating the hemodynamic effect of crystalloids have not distinguished responders from non-responders, the present study was designed to evaluate the duration of the hemodynamic effects of crystalloids according to the fluid responsiveness status.

Methods

This is a prospective observational study conducted after the initial resuscitation phase of circulatory shock (>6 h vasopressor use). Critically ill, sedated adult patients monitored with a pulmonary artery catheter who received a fluid challenge with crystalloids (500 mL infused over 30 min) were included. Hemodynamic variables were measured at baseline (T0) and at 30 min (T1), 60 min (T2), and 90 min (T3) after a fluid bolus, totaling 90 min of observation. The patients were analyzed according to their fluid responsiveness status (responders with CI increase >15% and non-responders ≤15% at T1). The data were analyzed by repeated measures of analysis of variance.

Results

Twenty patients were included, 14 of whom had septic shock. Overall, volume expansion significantly increased the CI: 3.03 ± 0.64 L/min/m² to 3.58 ± 0.66 L/min/m² (p < 0.05). From this period, there was a progressive decrease: 3.23 ± 0.65 L/min/m² (p < 0.05, T2 versus T1) and 3.12 ± 0.64 L/min/m² (p < 0.05, period T3 versus T1). Similar behavior was observed in responders (13 patients), 2.84 ± 0.61 L/min/m² to 3.57 ± 0.65 L/min/m² (p < 0.05) with volume expansion, followed by a decrease, 3.19 ± 0.69 L/min/m² (p < 0.05, T2 versus T1) and 3.06 ± 0.70 L/min/m² (p < 0.05, T3 versus T1). Blood pressure and cardiac filling pressures also decreased significantly after T1 with similar findings in both responders and non-responders.

Conclusions

The results suggest that volume expansion with crystalloids in patients with circulatory shock after the initial resuscitation has limited success, even in responders.

Role of colloids in traumatic brain injury: Use or not to be used?

Trauma is a leading cause of death worldwide and traumatic brain injury is one of the commonest injuries associated with it. The need for urgent resuscitation is warranted for prevention of secondary insult to brain. However, the choice of fluid in such cases is still a matter of conflict. The literature does not provide enough data pertaining to role of colloids in head injury patients. In this article, we have tried to explore the present role of colloid resuscitation in patient with head injury.

Pros and cons of tetrastarch solution for critically ill patients

Proper fluid management is crucial for the management of critically ill patients. However, there is a continuing debate about the choice of the fluid, i.e., crystalloid vs. colloid. Colloid solution is theoretically advantageous to the crystalloid because of larger volume effect and less interstitial fluid accumulation, and hydroxyethyl starch (HES) is most frequently used for perioperative setting. Nevertheless, application of HES solution is relatively limited due to its side effects including renal toxicity and coagulopathy. Since prolonged presence of large HES molecule is responsible for these side effects, rapidly degradable HES solution with low degree of substitution (tetrastarch) supposedly has less potential for negative effects. Thus, tetrastarch may be more frequently used in the ICU setting. However, several large-scale randomized trials reported that administration of tetrastarch solution to the patients with severe sepsis has negative effects on mortality and renal function. These results triggered further debate and regulatory responses around the world. This narrative review intended to describe the currently available evidence about the advantages and disadvantages of tetrastarch in the ICU setting.

Comparison of low molecular weight hydroxyethyl starch and human albumin as priming solutions in children undergoing cardiac surgery

Human albumin is the conventional cardiopulmonary bypass circuit primer. However, it has high manufacturing costs. Crystalloid and colloid solutions have been developed as alternatives, including a new generation of non-ionic hydroxyethyl starch (HES). The efficacy of hydroxyethyl starch with a 130 molecular weight and substitution degree of 0.4 (hydroxyethyl starch 130/0.4) was compared with human albumin for use in cardiopulmonary bypass surgery in American Society of Anesthesiologists’ grade I-II pediatric congenital heart disease patients. Efficacy was evaluated by comparing perioperative hemodynamic parameters, including plasma colloid osmotic pressure, renal function, blood loss, allogeneic blood volumes and plasma volume substitution. The hydroxyethyl starch group exhibited significantly higher preoperative colloid osmotic pressure (p <0.01) and significantly lower operative renal function and postoperative allogeneic blood volumes than the human albumin group. No significant differences were observed in serum creatinine, glucose, hematocrit or lactic acid levels (p>0.05). Our results indicate that hydroxyethyl starch may be a viable alternative to human albumin in pediatric patients undergoing relatively simple cardiopulmonary bypass surgeries.

Traumatic coagulopathy--part 1: Pathophysiology and diagnosis

OBJECTIVE

To review the current literature in reference to the pathophysiology and diagnostic modalities available for acute traumatic coagulopathy (ATC) in relationship to traumatic hemorrhagic shock.

ETIOLOGY

Posttraumatic hemorrhage is responsible for one of the leading causes of preventable human deaths worldwide. Acute traumatic coagulopathy is an endogenous hypocoagulable condition that has been observed during the immediate (< 1 hour) posttraumatic period. Phenotypically, ATC manifests as a state of systemic hypocoagulability and hyperfibrinolysis. Although different functional mechanisms have been proposed for causing ATC, it is universally thought to be a manifestation of severe tissue injury, shock-induced hypoperfusion, systemic inflammation, and endothelial damage. Excessive activation of the thrombin-thrombomodulin activated Protein C pathway, catecholamine-induced endothelial damage as well as disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype are all hypotheses that have been proposed in attempts to explain the functional mechanism of ATC.

DIAGNOSIS

An accurate and reliable test remains to be validated for ATC. Traditional coagulation assays (activated partial thromboplastin times and prothrombin times) along with platelet count and fibrinogen concentrations have been used more commonly. Viscoelastic tests (thromboelastography and rotational thromboelastometry) are currently being investigated as a more predictive modality for identifying and guiding therapy for ATC.

THERAPY

Damage control resuscitation and hemostatic resuscitation are gaining favor as the optimal resuscitative strategies for hemorrhagic shock and ATC. Antifibrinolytics may also play a role when hyperfibrinolysis is present.

PROGNOSIS

Massive hemorrhage accounts for 30-56% of prehospital posttraumatic deaths in people, with coagulopathic hemorrhage remaining one of the major causes of preventable deaths within the first 24 hours posttrauma. Ten to twenty-five percent of human trauma patients experience ATC, which has been shown to prolong hemorrhage, deter resuscitative efforts, promote sepsis, and increase mortality by at least 4-fold. Prognosis in veterinary patients is not currently known.

Perioperative intravascular volume replacement and kidney insufficiency

Perioperative acute kidney injury (AKI) occurrence is probably increased in recent years due to the increased level of complexity of surgical procedures and severity of illness of surgical patients. Perioperative AKI has a multifactorial aetiology (preoperative co-morbidities such as diabetes, heart failure and chronic kidney disease, emergent surgery, exposure to nephrotoxic drugs, haemodynamic instability, hypothermia, inflammatory response to surgery, hospital-acquired infections and abdominal compartment syndrome). However, fluid choice for perioperative volume replacement might have a major role in perioperative AKI, as administration of crystalloid solutions, colloids or haemoderivates has the potential for kidney injury. This review focusses on the issue of fluid replacement quality and quantity and their association with renal dysfunction.

Colloids in sepsis: evenly distributed molecules surrounded by uneven questions

Colloids are frequently used for fluid expansion in the intensive care unit, although its use on several clinical scenarios remains unproven of any relevant clinical benefit. The purpose of this article was to carry out a narrative review regarding the safety and efficacy of colloids in patients with sepsis and septic shock, with emphasis on the most commonly used colloids, albumin and starches. Colloids are effective fluid expanders and are able to restore the hemodynamic profile with less total volume than crystalloids. These properties appear to be preserved even in patients with sepsis with increased capillary permeability. However, some colloids are associated with renal impairment and coagulation abnormalities. Starch use was associated with increased mortality in two large clinical trials. Also, starches probably have significant renal adverse effects and may be related to more need for renal replacement therapy in severe sepsis. Albumin is the only colloid that has been shown safe in patients with sepsis and that may be associated with improved outcomes on specific subpopulations. No trial so far found any robust clinical end point favoring colloid use in patients with sepsis. Because there is no proven benefit of the use of most colloids in patients with sepsis, its use should not be encouraged outside clinical trials. Albumin is the only colloid solution that has proven to be safe, and its use may be considered on hypoalbuminemic patients with sepsis. Nevertheless, there are no robust data to recommend routine albumin administration in sepsis. Starch use should be avoided in patients with sepsis because of the recent findings of a multicenter randomized study until further evidence is available.

Low molecular weight pentastarch is more effective than crystalloid solution in goal-directed fluid management in patients undergoing major gastrointestinal surgery

BACKGROUND

This prospective observational study compared the volume effect between hydroxyethyl starch (HES) and crystalloid solution and its context dependency in intraoperative goal-directed fluid management.

METHODS

With institutional review board (IRB) approval, 35 patients undergoing major gastrointestinal surgery were enrolled. Fluid challenge consisting of 250 ml of either bicarbonate Ringer solution (BRS) or low molecular weight pentastarch (HES 70/0.5) was given to maintain stroke volume index >35 ml/m2. The context of fluid challenge was classified as related to either epidural block (EB) or blood loss (BL) or as nonspecific. The primary end point was the interval between index fluid challenge and the next fluid challenge, and the secondary end point was the hemodynamic parameter at the end of fluid challenge. Differences in these parameters in each clinical context were compared between BRS and HES 70/0.5. A p value <0.05 was considered statistically significant.

RESULTS

Eighty-eight, 77, and 127 fluid challenges were classified as related to EB and BL and as nonspecific, respectively. In the nonspecific condition, the median (range) interval after fluid challenge with HES 70/0.5 and BRS was 45 (11-162) min and 18 (8-44) min, respectively, and the difference was statistically significant. Also, mean arterial pressure and stroke volume index significantly increased, whereas stroke volume variation significantly decreased after fluid challenge with HES 70/0.5 compared with BRS. Such differences were not observed in the other situations.

CONCLUSIONS

HES 70/0.5 exerted larger volume effects than did crystalloid under nonspecific conditions. However, similar volume effects were observed during volume loss and extensive sympathetic blockade.

Volume replacement therapy during hip arthroplasty using hydroxyethyl starch (130/0.4) compared to lactated Ringer decreases allogeneic blood transfusion and postoperative infection

BACKGROUND AND OBJECTIVES

Hydroxyethyl starch (HES) 130/0.4 is considered an effective plasma expander when compared to crystalloids. There is controversy around its superiority regarding hemodynamic optimization and about possible detrimental effects on coagulation. The aim of this study was to compare the effects of HES 130/0.4 to lactated Ringer solution during hip arthroplasty in adult patients under spinal anesthesia regarding intraoperative bleeding, hemodynamic parameters, coagulation profile, transfusion requirements and clinical outcomes.

METHODS

In this randomized, controlled trial, 48 patients scheduled for hip arthroplasty with spinal anesthesia were randomized into two groups: 24 patients were allocated to receive a preload of 15 mL.kg(-1) of HES 130/0.4 and 24 patients received a preload of 30 mL.kg(-1) lactated Ringer solution before surgery. Hemodynamic measurements, hemoglobin concentrations, biochemical parameters and coagulation tests were evaluated in three periods during surgical procedure. Patients received medical follow-up during their hospital stay and up to postoperative 30 days. Primary outcome was the requirement of red blood cell transfusion between groups during hospital stay. Secondary outcome were hemodynamic parameters, length of hospital stay, mortality and occurrence of clinical postoperative complications.

RESULTS

Red blood cell transfusion was required in 17% of patients in the HES group and in 46% in the Ringer group (p = .029). Postoperative infections were more frequently observed in the Ringer group (17%) compared to the HES group (0), p = .037. There were no significant differences between groups in mortality, hospital length of stay and clinical complications other than infection.

CONCLUSIONS

During hip arthroplasty, patients treated with hypervolemic hemodilution with hydroxyethyl starch 130/0.4 required less transfusion and presented lower infection rate compared to patients who received lactated Ringer.

Stroke volume-directed administration of hydroxyethyl starch or Ringer's acetate in sitting position during craniotomy

BACKGROUND

To determine the volumes required for stable haemodynamics and possible effects on the coagulation, we studied stroke volume (SV)-directed administration of hydroxyethyl starch (HES 130 kDa/0.4) and Ringer's acetate (RAC) in neurosurgical patients operated on in a sitting position.

METHODS

Thirty craniotomy patients were randomised to receive either HES or RAC. Before positioning, SV, measured by arterial pressure waveform analysis, was maximised by boluses of fluid until SV did not increase more than 10%. SV was maintained by repeated administration of fluid. RAC 3 ml/kg/h was infused in both groups during surgery.

RESULTS

Comparable haemodynamics were achieved with the mean [standard deviation (SD)] cumulative doses of HES or RAC 271 (47) or 264 (50) ml (P = 0.699) before the sitting position. Mean (SD) doses of HES or RAC at 30 min after the positioning were 343 (94) or 450 (156) ml (P = 0.036), and at the end of surgery 464 (284) or 707 (425) ml, respectively (P = 0.087). The intraoperative fluid balance was more positive in the RAC than in the HES group [P = 0.044, 95% confidence interval (CI) -978 to -14]. Cardiac and stroke volume indexes [CI and stroke volume index (SVI)] increased in the HES group (P < 0.05) but not in the RAC group [non significant (N.S.)]. Neither coagulation profile nor blood loss differed between the groups.

CONCLUSION

Fluid filling with HES boluses resulted in a positive response in CI and SVI during the sitting position. The 34% smaller volume of HES than crystalloid and less positive fluid balance in the HES group might be important in craniotomy patients with decreased brain compliance.

Rational fluid management in today's ICU practice

Intravenous fluid therapy has evolved significantly over time. From the initial report of the first intravenous administration of sodium-chloride-based solution to the development of goal-directed fluid therapy using novel dynamic indices, efforts have focused on improving patient outcomes. The goal of this review is to provide a brief overview of current concepts for intravenous fluid administration in the ICU. Results of recently published clinical trials suggesting harmful effects of starch-based solutions on critically ill patients are discussed. Concepts for goal-directed fluid therapy and new modalities for the assessment of fluid status as well as for the prediction of responsiveness to different interventions will continue to emerge. Advances in technology will have to be critically evaluated for their ability to improve outcomes in different clinical scenarios.