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Teixeira-Neto FJ, Valverde A. Clinical Application of the Fluid Challenge Approach in Goal-Directed Fluid Therapy: What Can We Learn From Human Studies? Front Vet Sci 2021; 8:701377. [PMID: 34414228 PMCID: PMC8368984 DOI: 10.3389/fvets.2021.701377] [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: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Resuscitative fluid therapy aims to increase stroke volume (SV) and cardiac output (CO) and restore/improve tissue oxygen delivery in patients with circulatory failure. In individualized goal-directed fluid therapy (GDFT), fluids are titrated based on the assessment of responsiveness status (i.e., the ability of an individual to increase SV and CO in response to volume expansion). Fluid administration may increase venous return, SV and CO, but these effects may not be predictable in the clinical setting. The fluid challenge (FC) approach, which consists on the intravenous administration of small aliquots of fluids, over a relatively short period of time, to test if a patient has a preload reserve (i.e., the relative position on the Frank-Starling curve), has been used to guide fluid administration in critically ill humans. In responders to volume expansion (defined as individuals where SV or CO increases ≥10–15% from pre FC values), FC administration is repeated until the individual no longer presents a preload reserve (i.e., until increases in SV or CO are <10–15% from values preceding each FC) or until other signs of shock are resolved (e.g., hypotension). Even with the most recent technological developments, reliable and practical measurement of the response variable (SV or CO changes induced by a FC) has posed a challenge in GDFT. Among the methods used to evaluate fluid responsiveness in the human medical field, measurement of aortic flow velocity time integral by point-of-care echocardiography has been implemented as a surrogate of SV changes induced by a FC and seems a promising non-invasive tool to guide FC administration in animals with signs of circulatory failure. This narrative review discusses the development of GDFT based on the FC approach and the response variables used to assess fluid responsiveness status in humans and animals, aiming to open new perspectives on the application of this concept to the veterinary field.
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Affiliation(s)
- Francisco José Teixeira-Neto
- Departmento de Cirurgia Veterinária e Reprodução Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, Brazil
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Hall K, Drobatz K. Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications. Front Vet Sci 2021; 8:638104. [PMID: 34395568 PMCID: PMC8357988 DOI: 10.3389/fvets.2021.638104] [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: 12/05/2020] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.
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Affiliation(s)
- Kelly Hall
- Department of Clinical Sciences, Critical Care Services, Colorado State University, Fort Collins, CO, United States
| | - Kenneth Drobatz
- Section of Critical Care, Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA, United States
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Iannucci C, Dirkmann D, Howard J, Adamik KN. A prospective randomized open-label trial on the comparative effects of 6% hydroxyethyl starch 130/0.4 versus polyionic isotonic crystalloids on coagulation parameters in dogs with spontaneous hemoperitoneum. J Vet Emerg Crit Care (San Antonio) 2020; 31:32-42. [PMID: 33108052 DOI: 10.1111/vec.13018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 03/17/2019] [Accepted: 04/23/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the effects of 6% hydroxyethyl starch 130/0.4 (HES) and a polyionic isotonic crystalloid (CRYS) on standard coagulation tests and rotational thromboelastometry (ROTEM) in dogs with spontaneous hemoperitoneum (SHP). DESIGN Prospective randomized open-label clinical study. SETTING University teaching hospital. ANIMALS Forty-two client-owned dogs presented with SHP. INTERVENTIONS Dogs diagnosed with SHP and hypovolemic shock were randomly allocated to receive HES (10 mL/kg, n = 22) or CRYS (30 mL/kg, n = 20) intravenously over 20 minutes for hemodynamic stabilization. MEASUREMENTS AND MAIN RESULTS Parameters measured before (T0 ) and after (T1 ) treatment were HCT, platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen concentrations, and extrinsic activated (EXTEM), intrinsic activated (INTEM), and extrinsic activated with platelet inhibition ROTEM assays. Data were analyzed as absolute values and as the percentage change from T0 to T1 . No significant differences between groups were detected in any variable at T0 , and for HCT, platelet counts, prothrombin time, activated thromboplastin time, and fibrinogen concentrations at T1 . Clot formation time in EXTEM was significantly prolonged (P = 0.037), and maximum clot firmness was significantly decreased (P = 0.038) in the HES group compared to the CRYS group at T1 . The percentage change in EXTEM clotting time (P = 0.012) and INTEM clot formation time (P = 0.031) was greater after HES than CRYS. Lysis indices remained at 100% for all ROTEM assays in both groups. CONCLUSION Compared to a 3-fold volume of CRYS, administration of HES was associated with impairment in ROTEM parameters in dogs with SHP, but no evidence of hyperfibrinolysis was detected.
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Affiliation(s)
- Claudia Iannucci
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Daniel Dirkmann
- Clinic for Anesthesiology and Intensive Care, Essen University Hospital, Essen, Germany
| | - Judith Howard
- Clinical Diagnostic Laboratory, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Katja N Adamik
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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van Galen G, Hallowell G. Hydroxyethyl starches in equine medicine. J Vet Emerg Crit Care (San Antonio) 2019; 29:349-359. [PMID: 31228334 DOI: 10.1111/vec.12854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/11/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review and discuss the use of hydroxyethyl starches (HES) in equine veterinary medicine, and to provide recommendations for its use. DATA SOURCES Veterinary and human peer-reviewed medical literature including scientific reviews, meta-analyses, and original research articles. HUMAN DATA SYNTHESIS Increasing evidences on adverse effects after HES use and decreasing support for beneficial effects with regards to volume expansion and colloid osmotic pressure (COP) support in critically ill subjects have led to a recent guideline to limit the use of HES in critically ill people. EQUINE VETERINARY DATA SYNTHESIS The rationale for HES use in horses is mainly extrapolated from human medicine, and very limited studies in horses are available. There is limited evidence suggesting a superiority of volume expansion effects of HES over crystalloids. The potential for HES to increase and maintain COP is well supported, but there is no evidence that maintaining or increasing plasma COP influences outcome, tissue edema formation, or rates of complications that potentially relate to edema formation. HES induce dose-dependent changes in coagulopathic parameters, but there is no evidence that HES causes clinical coagulopathies. Insufficient data are available on other adverse effects such as acute kidney injury, or mortality in horses. The use of HES should be restricted in septic patients, but may still have some use in cases of hemorrhagic shock resuscitation, hypoalbuminemia, or perioperative fluid replacement. CONCLUSION The evidence supporting the use of HES in horses is weak due to lack of species-specific investigations. Acknowledging species differences, the use of HES should be judicious, yet with some recognition of its benefits in particular cases. More research is necessary to improve knowledge on use of HES in horses and to establish better future recommendations.
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Affiliation(s)
- Gaby van Galen
- Medicine and Surgery, Department of Large Animal Science, University of Copenhagen, Copenhagen, Denmark
| | - Gayle Hallowell
- School of Veterinary Medicine and Surgery, University of Nottingham, Nottingham, UK
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Diniz MS, Teixeira-Neto FJ, Gonçalves DS, Celeita-Rodríguez N, Girotto CH, Fonseca MW, Takahira RK. Effects of 6% tetrastarch or lactated Ringer's solution on blood coagulation in hemorrhaged dogs. J Vet Intern Med 2018; 32:1927-1933. [PMID: 30357915 PMCID: PMC6272039 DOI: 10.1111/jvim.15327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 08/22/2018] [Indexed: 01/08/2023] Open
Abstract
Background Tetrastarch solution (TS) can impair coagulation but the clinical relevance of this impairment is unclear in veterinary medicine. Objective Compare the effects of volume replacement (VR) with lactated Ringer's solution (LRS) or 6% TS on coagulation in hemorrhaged dogs. Animals Six healthy English Pointer dogs (19.7‐35.3 kg). Methods Prospective crossover study. Dogs were anesthetized without hemorrhage and VR (control). Two weeks later, dogs were hemorrhaged under anesthesia on 2 occasions (8‐week washout intervals) and randomly received VR with LRS or TS at 3:1 or 1:1 of shed blood, respectively, aiming to decrease the hematocrit to 33%. Rotational thromboelastometry and other coagulation variables were determined before 0.5, 2, and 4 hours after VR during anesthesia and 24 hours after VR (conscious dogs). Results Buccal mucosal bleeding time did not differ between treatments after VR. Activated partial thromboplastin time increased from controls 4 hours after TS (P = 0.045). Clot formation time (CFT) and alfa‐angle increased from controls from 0.5 to 4 hours after LRS (CFT, P ≤ 0.0001‐0.02; alpha angle, P = 0.0001‐0.02) and from 0.5 to 2 hours after TS (CFT, P = 0.0002‐0.01; alpha angle, P = 0.0005‐0.02). The maximum clot firmness decreased from controls from 0.5 to 4 hours after LRS (P ≤ 0.0001‐0.01) and TS (P ≤ 0.0001‐0.04). Conclusions and Clinical Relevance Tetrastarch does not impair primary hemostasis and induces transient dilutional coagulopathy that is similar to LRS because, when compared to a 3 times higher volume of LRS in hemorrhaged dogs, it does not cause greater interference on the viscoelastic properties of the coagulum.
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Affiliation(s)
- Miriely S Diniz
- From Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Francisco J Teixeira-Neto
- Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Daniele S Gonçalves
- Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | | | - Carolina H Girotto
- From Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Mariana W Fonseca
- From Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Regina K Takahira
- Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
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Gao X, Tao Q, Zhou X, Lei W. Lactated Ringer' Solution may be Superior to Saline-Based 6% Hydroxyethyl Starch 130/0.4 for Early Resuscitation within 12 hours from Hemorrhagic Shock. J INVEST SURG 2018; 32:515-522. [PMID: 29509042 DOI: 10.1080/08941939.2018.1439550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Purpose: To compare the effects of fluid resuscitation with lactated Ringer's solution (LR) and saline-based 6% hydroxyethyl starch 130/0.4 (HES) on the inflammatory response and oxidative stress in the small intestine as well as on bacterial translocation to the liver. Methods: Sprague-Dawley rats were subjected to blood pressure-controlled hemorrhagic shock and then resuscitated with LR or HES. At 1, 3, 6, 12, and 24 hr after resuscitation, liver tissues were collected to count the bacterial colonies, and small intestines were harvested to analyze the levels of inflammatory (TNF-α and HO-1) and oxidative stress (MPO) mediators as well as the intestinal injury by immunohistochemistry, colorimetry and hematoxylin & eosin staining, respectively. Results: The expression level of TNF-α in the LR group was stable from 1 to 6 hr but decreased at 12 hr and then abruptly increased at 24 hr. The expression level of TNF-α in the LR group was significantly lower than that in the HES group, especially during the first 12 hr post-fluid infusion. MPO activity decreased to its lowest level at 3 hr but increased from 6 to 12 hr, with no difference at 24 hr between the two groups. Although a decreasing tendency was observed from 6 hr, HO-1 expression levels remained higher in the LR group than in the HES group at 12 and 24 hr, particularly at 12 hr. During the initial 12 hr, the LR group exhibited significantly lower colony-forming units in the liver tissues than the HES group. Chiu's score in the intestine decreased regardless of which resuscitative fluids were used. Conclusions: During early resuscitation (within 12 hr), LR may be superior to HES in reducing intestinal injuries by suppressing inflammatory and oxidative mediators.
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Affiliation(s)
- Xinyue Gao
- Department of Anesthesiology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Tao
- Department of Anesthesiology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - Xun Zhou
- Department of Anesthesiology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - WeiFu Lei
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong, China
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Yao F, Lu YQ, Jiang JK, Gu LH, Mou HZ. Immune recovery after fluid resuscitation in rats with severe hemorrhagic shock. J Zhejiang Univ Sci B 2018; 18:402-409. [PMID: 28471112 DOI: 10.1631/jzus.b1600370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the effects of resuscitation with normal saline (NS), hypertonic saline (HTS), and hydroxyethyl starch (HES) on regulatory T cells (Tregs), helper T 1 (Th1)/Th2 and cytotoxic T 1 (Tc1)/Tc2 profiles in the treatment of hemorrhagic shock. METHODS Rats subjected to severe hemorrhagic shock were resuscitated for 30 min with NS (n=8), HTS (n=8), or HES (n=8); sham (n=8) and naive control (n=8) groups were used for comparison. Following fluid resuscitation, the whole shed blood was reinfused for 30 min, and the rats were observed with continuous hemodynamic monitoring for 120 min. CD4+CD25+Foxp3+ Treg proportions, Th1/Th2 and Tc1/Tc2 profiles in spleen were analyzed by three-color flow cytometry. RESULTS The proportion of CD4+CD25+Foxp3+ Tregs and ratios of Th1/Th2 and Tc1/Tc2 did not differ among control, sham, and HTS groups, but were significantly lower in NS and HES groups (both P<0.05 vs. sham); NS and HES levels were similar. The level of Tc1 was significantly increased in HTS (P<0.05 vs. sham), and levels of Tc2 were increased in NS, HES, and HTS groups compared to sham (all P<0.05), but did not differ from each other. CONCLUSIONS HTS resuscitation has a greater impact on immune system recovery than NS or HES by preserving the proportion of Tregs and maintaining the balance between Th1/Th2 and Tc1/Tc2 cells in the spleen. Thus, HTS resuscitation provides potential immunomodulatory activity in the early stage after hemorrhagic shock.
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Affiliation(s)
- Feng Yao
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yuan-Qiang Lu
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jiu-Kun Jiang
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Lin-Hui Gu
- Cancer Institute, Zhejiang Tumor Hospital, Hangzhou 310022, China
| | - Han-Zhou Mou
- Cancer Institute, Zhejiang Tumor Hospital, Hangzhou 310022, China
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Diniz MS, Teixeira-Neto FJ, Celeita-Rodríguez N, Girotto CH, Fonseca MW, Oliveira-Garcia AC, López-Castañeda B. Effects of 6% Tetrastarch and Lactated Ringer's Solution on Extravascular Lung Water and Markers of Acute Renal Injury in Hemorrhaged, Isoflurane-Anesthetized Healthy Dogs. J Vet Intern Med 2018; 32:712-721. [PMID: 29377300 PMCID: PMC5866968 DOI: 10.1111/jvim.14853] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/25/2017] [Accepted: 09/13/2017] [Indexed: 12/17/2022] Open
Abstract
Background Tetrastarch can cause acute kidney injury (AKI) in humans with sepsis, but less likely to result in tissue edema than lactated Ringer's solution (LRS). Objectives Compare effects of volume replacement (VR) with LRS and 6% tetrastarch solution (TS) on extravascular lung water (EVLW) and markers of AKI in hemorrhaged dogs. Animals Six healthy English Pointer dogs (19.7–35.3 kg). Methods Prospective crossover study. Animals underwent anesthesia without hemorrhage (Control). Two weeks later, dogs hemorrhaged under anesthesia on 2 occasions (8‐week washout intervals) and randomly received VR with LRS or TS at 3 : 1 or 1 : 1 of shed blood, respectively. Anesthesia was maintained until 4 hour after VR for EVLW measurements derived from transpulmonary thermodilution cardiac output. Neutrophil gelatinase‐associated lipocalin (NGAL) and creatinine concentrations in plasma and urine were measured until 72 hour after VR. Results The EVLW index (mL/kg) was lower at 1 hour after TS (10.0 ± 1.9) in comparison with controls (11.9 ± 3.4, P = 0.04), and at 4 hour after TS (9.7 ± 1.9) in comparison with LRS (11.8 ± 2.7, P = 0.03). Arterial oxygen partial pressure‐to‐inspired oxygen fraction ratio did not differ among treatments from 0.5 to 4 hour after VR. Urine NGAL/creatinine ratio did not differ among treatments and remained below threshold for AKI (120,000 pg/mg). Conclusions and Clinical Importance Although TS causes less EVLW accumulation than LRS, neither fluid produced evidence of lung edema (impaired oxygenation). Both fluids appear not to cause AKI when used for VR after hemorrhage in healthy nonseptic dogs.
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Affiliation(s)
- M S Diniz
- Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - F J Teixeira-Neto
- Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - N Celeita-Rodríguez
- Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - C H Girotto
- Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - M W Fonseca
- Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - A C Oliveira-Garcia
- Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - B López-Castañeda
- Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
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Sigrist NE, Kälin N, Dreyfus A. Effects of Hydroxyethyl Starch 130/0.4 on Serum Creatinine Concentration and Development of Acute Kidney Injury in Nonazotemic Cats. J Vet Intern Med 2017; 31:1749-1756. [PMID: 28862347 PMCID: PMC5697200 DOI: 10.1111/jvim.14813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/23/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022] Open
Abstract
Background Hydroxyethyl‐starch (HES) solutions might have renal adverse effects in humans and dogs. Objective To determine if administration of 6% HES‐130/0.4 is associated with an increase in serum creatinine concentration and development of acute kidney injury (AKI) in nonazotemic cats. Animals A total of 62 critically ill cats; 26 HES exposed and 36 unexposed. Methods Retrospective cohort study (2012–2015). Serum creatinine concentrations were recorded and changes in serum creatinine concentrations before exposure (baseline) and 2–10 and 11–90 days, respectively, were determined. Development of AKI was defined as a > 150% increase or >26 μmol/L increase in serum creatinine concentration from baseline. Risk factors, such as HES administration, cumulative volume of HES (mL/kg) and number of days of HES administration leading to development of AKI, and change in serum creatinine were analyzed. Results Cats in the HES cohort received a mean volume of 98.5 ± 76.2 mL/kg (range, 8–278 mL/kg) HES over a median of 4 (range, 1–11) days, resulting in a median dose of 20.1 (range, 8–40.5) mL/kg per day. Short‐term %change in serum creatinine concentration (P = 0.40) and development of AKI (P = 0.32) were not significantly different between cohorts. Multivariable logistic regression did not identify HES dose in mL/kg (P = 0.33) and number of days of HES application (P = 0.49) as a risk factor for development of AKI. Conclusion and Clinical Importance Hydroxyethyl‐starch administration to critically ill nonazotemic cats seems to be safe. A larger prospective study is required to determine the effect of HES administration at higher dosages and for prolonged time periods.
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Affiliation(s)
- N E Sigrist
- Department for Small Animals, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
| | - N Kälin
- Department for Small Animals, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
| | - A Dreyfus
- Section of Epidemiology (Dreyfus), Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
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McBride D, Raisis AL, Hosgood G, Smart L. Hydroxyethyl starch 130/0.4 compared with 0.9% NaCl administered to greyhounds with haemorrhagic shock. Vet Anaesth Analg 2017; 44:444-451. [DOI: 10.1016/j.vaa.2016.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 05/23/2016] [Accepted: 05/27/2016] [Indexed: 12/16/2022]
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Sigrist NE, Kälin N, Dreyfus A. Changes in Serum Creatinine Concentration and Acute Kidney Injury (AKI) Grade in Dogs Treated with Hydroxyethyl Starch 130/0.4 From 2013 to 2015. J Vet Intern Med 2017; 31:434-441. [PMID: 28109131 PMCID: PMC5354072 DOI: 10.1111/jvim.14645] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 11/16/2016] [Accepted: 11/28/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Hydroxyethyl starch (HES) solutions may cause acute kidney injury (AKI) in humans. OBJECTIVE To compare AKI grades in 94 dogs exposed and 90 dogs that were unexposed to 6% HES-130/0.4. ANIMALS Dogs receiving 6% HES-130/0.4 (HES cohort) or crystalloids (unexposed cohort) between 2013 and 2015. METHODS Historical cohort study. Diagnosis, total cumulative dose and total mL/kg of HES administered, time frame of HES administration and serum creatinine concentrations up to 90 days after initiation of HES treatment were retrospectively reviewed. The AKI grades were retrospectively determined by IRIS guidelines. RESULTS Exposed dogs received a median cumulative dose of 69.4 mL/kg (range, 2-429 mL/kg) HES over a median of 4 (range, 1-16) days, resulting in a median dose of 20.7 (range, 2-87) mL/kg/d. Although the cohorts differed in terms of age and diagnosis, AKI grades were not significantly different at the evaluated short- and long-term time points. Results of ordinal logistic regression identified the number of days of HES administration as significantly associated with an increase in AKI grade within 10 days (P = .038), whereas there was no significant association among HES exposure, HES mL/kg/d, and an increase in AKI grade. CONCLUSIONS AND CLINICAL IMPORTANCE HES-130/0.4-treated dogs were not more prone to develop AKI than HES-untreated, but the number of HES days was significantly associated with an increase in AKI grade within 10 days post-HES administration. The time frame of HES treatment should be kept short. Prospective, randomized clinical trials are required to assess the effect of HES on renal function in dogs.
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Affiliation(s)
- N E Sigrist
- Department of Small Animals, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
| | - N Kälin
- Department of Small Animals, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
| | - A Dreyfus
- Section of Epidemiology, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
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Ortiz AL, Vala H, Venâncio C, Mesquita J, Silva A, Gonzalo-Orden JM, Ferreira D. The influence of Ringer's lactate or HES 130/0.4 administration on the integrity of the small intestinal mucosa in a pig hemorrhagic shock model under general anesthesia. J Vet Emerg Crit Care (San Antonio) 2016; 27:96-107. [PMID: 27984669 DOI: 10.1111/vec.12560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 05/04/2015] [Accepted: 05/21/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effect of fluid resuscitation with 2 different physiological solutions, Ringer's lactate (RL) and hydroxyethyl starch (HES) 130/0.4, on histological lesions of the small intestinal mucosa in anesthetized pigs subjected to severe acute bleeding. DESIGN Prospective experimental study. SETTING University teaching hospital. ANIMALS Twenty-eight healthy Large White pigs, 3 months of age. INTERVENTIONS Pigs were subjected to severe acute bleeding (30 mL/kg) under total intravenous anesthesia with propofol and remifentanil. Pigs were randomly allocated to 3 groups: Group 1 (n = 11) received RL solution (25 mL/kg) after bleeding; Group 2 (n = 11) received HES 130/0.4 solution (20 mL/kg) after bleeding; and Group 3 (n = 6) volume replacement nor induced bleeding. Pigs were euthanized and the small intestine was harvested for histopathological analysis. MEASUREMENTS AND MAIN RESULTS The small intestine was histologically evaluated and the presence of the following lesions were characterized: edema, congestion, hyperemia, hemorrhage, inflammatory infiltration, cellular degeneration, necrosis, and epithelial detachment. Mucosal loss percentage (%ML) and crypt:interstitium ratio (C:I) were also assessed. In the duodenum, jejunum, and ileum, and the entire small intestine, the %ML was significantly higher in Group 1, than in Groups 2 and 3. Hyperemia in the small intestine was significantly higher in pigs resuscitated with HES 130/0.4 compared to pigs resuscitated with RL. CONCLUSIONS AND CLINICAL RELEVANCE In a setting of controlled hemorrhage, resuscitation with HES 130/0.4 was associated with a lower percentage of mucosal loss on the small intestine, compared with resuscitation with RL solution. Our study also suggests that the duodenum may be more sensitive to hypovolemia induced by severe hemorrhage.
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Affiliation(s)
- Ana Liza Ortiz
- School of Veterinary Medicine, University of León, León, Spain.,Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Helena Vala
- Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB) and Centre for Studies in Education and Health Technologies (CI&DETS) Agrarian Superior School of Viseu, Polytechnic Institute of Viseu, Viseu, Portugal
| | - Carlos Venâncio
- Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB), University of Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - João Mesquita
- Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB) and Centre for Studies in Education and Health Technologies (CI&DETS) Agrarian Superior School of Viseu, Polytechnic Institute of Viseu, Viseu, Portugal
| | - Aura Silva
- REQUIMTE, Faculty of Pharmacy, University of Porto, Portugal
| | | | - David Ferreira
- CBIOS- Research Center for Biosciences & Health Technologies, University Lusófonal de Humanidades e Tecnologias, Lisbon, Portugal and Veterinary Medicine Department of University of Évora, Évora, Portugal
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Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Diniz MS, Teixeira-Neto FJ, Cândido TD, Zanuzzo FS, Teixeira LR, Klein AV, do Nascimento P. Effects of dexmedetomidine on pulse pressure variation changes induced by hemorrhage followed by volume replacement in isoflurane-anesthetized dogs. J Vet Emerg Crit Care (San Antonio) 2016; 24:681-92. [PMID: 25471643 DOI: 10.1111/vec.12246] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 05/17/2014] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To evaluate the effects of dexmedetomidine (DEX) on changes in pulse pressure variation (PPV) induced by hemorrhage followed by volume replacement (VR) during isoflurane (ISO) anesthesia. DESIGN Prospective, randomized, crossover study. SETTING Research laboratory at a veterinary teaching hospital. ANIMALS Eight adult dogs. INTERVENTIONS Anesthesia was maintained with 1.3 times the minimum alveolar concentration (MAC) of ISO alone or ISO with DEX (ISO-DEX, 1.6 μg/kg [bolus], followed by 2 μg/kg/h). Atropine was administered 30 minutes prior to hemorrhage in the ISO-DEX treatment. Ventilation was controlled (tidal volume of 12 mL/kg, positive end-expiratory pressure of 7 cm H2 O, respiratory rate of 16-20/min) under neuromuscular blockade. After recording baseline data, progressive withdrawal of 10%, 20%, and 30% of blood volume (HV10 , HV20 , and HV30 , respectively [measurements during hemorrhage, indicating x% of blood volume removed]) was followed by VR with autologous blood. MEASUREMENTS AND MAIN RESULTS In 4 of 8 ISO dogs, hemorrhage decreased mean arterial pressure (MAP) < 60 mm Hg. Based on mean arterial pressure after hemorrhage, dogs were assigned to hypotensive (HG) and normotensive (NG) groups post hoc. During ISO, stroke index and cardiac index decreased with hemorrhage (P < 0.05), while VR normalized or increased these variables. The PPV (%, mean [range]) was increased by hemorrhage from 7 (5-9) to 20 (12-27) and 27 (17-40) at HV20 and HV30 , respectively, only in ISO dogs in the HG; PPV returned to baseline after VR. Dexmedetomidine caused increases in systemic vascular resistance (in dogs in HG and NG), and prevented the increase in PPV with hemorrhage. CONCLUSIONS During ISO anesthesia, PPV increases in individuals prone to developing hypotension from hypovolemia. Because DEX prevents the increase in PPV associated with hypovolemia, PPV should not be used to guide VR in dogs that have been given DEX.
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Adamik KN, Butty E, Howard J. In vitro effects of 3% hypertonic saline and 20% mannitol on canine whole blood coagulation and platelet function. BMC Vet Res 2015; 11:242. [PMID: 26403081 PMCID: PMC4582639 DOI: 10.1186/s12917-015-0555-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 09/17/2015] [Indexed: 12/11/2022] Open
Abstract
Background Hyperosmolar therapy, using either mannitol or hypertonic saline (HTS), is considered the treatment of choice for intracranial hypertension. However, hyperosmolar agents may impair coagulation and platelet function, limiting their use in patients at risk for hemorrhage. Despite this, studies evaluating the effects of mannitol compared to other hyperosmolar agents in dogs are largely lacking. The aim of this study was to compare the in vitro effects on global hemostasis and platelet function of 20 % mannitol and 3 % HTS on canine blood. Methods Citrated whole blood from 15 healthy dogs was diluted with 0.9 % saline, 20 % mannitol and 3 % HTS in ratios of 1:16 and 1:8. Rotational thromboelastometry (ROTEM) was used to assess clotting time (CT), clot formation time (CFT) and maximal clot firmness (MCF) following extrinsic activation (Ex-tem) and after platelet inhibition (Fib-tem). A platelet function analyzer (PFA-100) was used to assess closure time (CtPFA). Results No significant differences were observed between untreated whole blood and samples diluted with saline. Samples diluted with both mannitol and HTS were hypocoagulable compared to untreated whole blood samples. At a dilution of 1:16, no significant differences were found between any measured parameter in samples diluted with saline compared to mannitol or HTS. At a 1:8 dilution, CtPFA was prolonged in samples diluted with mannitol and HTS compared to saline, and CtPFA was prolonged more with mannitol than HTS. Ex-tem CT was increased at a 1:8 dilution with mannitol compared to HTS. Ex-tem CFT was prolonged at a 1:8 dilution with both agents compared to saline, and was prolonged more with mannitol than HTS. Ex-tem MCF was reduced at a 1:8 dilution with both agents compared to saline. Discussion and Conclusions Data in this study indicate that both mannitol and HTS affect canine platelet function and whole blood coagulation in vitro in a dose-dependent fashion. The most pronounced effects were observed after high dilutions with mannitol, which impaired platelet aggregation, clot formation time, clot strength, and fibrin formation significantly more than HTS. Further in vivo studies are necessary before recommendations can be made.
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Affiliation(s)
- Katja-Nicole Adamik
- Division of Emergency and Critical Care, Small Animal Clinic, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland.
| | - Emmanuelle Butty
- Division of Emergency and Critical Care, Small Animal Clinic, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland.
| | - Judith Howard
- Clinical Diagnostic Laboratory, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 124, 3012, Bern, Switzerland.
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Wurlod VA, Howard J, Francey T, Schweighauser A, Adamik KN. Comparison of the in vitro effects of saline, hypertonic hydroxyethyl starch, hypertonic saline, and two forms of hydroxyethyl starch on whole blood coagulation and platelet function in dogs. J Vet Emerg Crit Care (San Antonio) 2015; 25:474-87. [PMID: 26037241 DOI: 10.1111/vec.12320] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 11/22/2013] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To compare the in vitro effects of hypertonic solutions and colloids to saline on coagulation in dogs. DESIGN In vitro experimental study. SETTING Veterinary teaching hospital. ANIMALS Twenty-one adult dogs. INTERVENTIONS Blood samples were diluted with saline, 7.2% hypertonic saline solution with 6% hydroxyethylstarch with an average molecular weight of 200 kDa and a molar substitution of 0.4 (HH), 7.2% hypertonic saline (HTS), hydroxyethyl starch (HES) 130/0.4 or hydroxyethyl starch 600/0.75 at ratios of 1:22 and 1:9, and with saline and HES at a ratio of 1:3. MEASUREMENTS AND MAIN RESULTS Whole blood coagulation was analyzed using rotational thromboelastometry (extrinsic thromboelastometry-cloting time (ExTEM-CT), maximal clot firmness (MCF) and clot formation time (CFT) and fibrinogen function TEM-CT (FibTEM-CT) and MCF) and platelet function was analyzed using a platelet function analyzer (closure time, CTPFA ). All parameters measured were impaired by saline dilution. The CTPFA was prolonged by 7.2% hypertonic saline solution with 6% hydroxyethylstarch with an average molecular weight of 200 kDa and a molar substitution of 0.4 (HH) and HTS but not by HES solutions. At clinical dilutions equivalent to those generally administered for shock (saline 1:3, HES 1:9, and hypertonic solutions 1:22), CTPFA was more prolonged by HH and HTS than other solutions but more by saline than HES. No difference was found between the HES solutions or the hypertonic solutions. ExTEM-CFT and MCF were impaired by HH and HTS but only mildly by HES solutions. At clinically relevant dilutions, no difference was found in ExTEM-CFT between HTS and saline or in ExTEM-MCF between HH and saline. No consistent difference was found between the 2 HES solutions but HH impaired ExTEM-CFT and MCF more than HTS. At high dilutions, FibTEM-CT and -MCF and ExTEM-CT were impaired by HES. CONCLUSIONS Hypertonic solutions affect platelet function and whole blood coagulation to a greater extent than saline and HES. At clinically relevant dilutions, only CTPFA was markedly more affected by hypertonic solutions than by saline. At high dilutions, HES significantly affects coagulation but to no greater extent than saline at clinically relevant dilutions.
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Affiliation(s)
- Virginie A Wurlod
- Division of Small Animal Emergency and Critical Care, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Judith Howard
- the Diagnostic Laboratory, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Thierry Francey
- Small Animal Internal Medicine, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ariane Schweighauser
- Small Animal Internal Medicine, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Katja N Adamik
- Division of Small Animal Emergency and Critical Care, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Raisis AL, Smart L, Drynan E, Hosgood G. Cardiovascular function during maintenance of anaesthesia with isoflurane or alfaxalone infusion in greyhounds experiencing blood loss. Vet Anaesth Analg 2015; 42:133-41. [DOI: 10.1111/vaa.12190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 01/02/2014] [Indexed: 11/30/2022]
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Martin DT, Schreiber MA. Modern resuscitation of hemorrhagic shock: what is on the horizon? Eur J Trauma Emerg Surg 2014; 40:641-56. [PMID: 26814779 DOI: 10.1007/s00068-014-0416-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/23/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE Mortality rates among the severely injured remain high. The successful treatment of hemorrhagic shock relies on expeditious control of bleeding through surgical ligation, packing, or endovascular techniques. An important secondary concern in hemorrhaging patients is how to respond to the lost blood volume. A single method that is able to adequately address all needs of the exsanguinating patient has not yet been agreed upon, despite a large growth of knowledge regarding the causative factors of traumatic shock. METHODS A review of relevent literature was performed. CONCLUSIONS Many different trials are currently underway to discriminate ways to improve outcomes in the severely injured and bleeding patient. This paper will review: (1) recent advances in our understanding of the effects hemorrhagic shock has on the coagulation cascade and vascular endothelium, (2) recent research findings that have changed resuscitation, and (3) resuscitation strategies that are not widely used but under active investigation.
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Affiliation(s)
- D T Martin
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA. .,Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA.
| | - M A Schreiber
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA. .,Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA.
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Roger C, Muller L, Deras P, Louart G, Nouvellon E, Molinari N, Goret L, Gris J, Ripart J, de La Coussaye J, Lefrant J. Does the type of fluid affect rapidity of shock reversal in an anaesthetized-piglet model of near-fatal controlled haemorrhage? A randomized study. Br J Anaesth 2014; 112:1015-23. [DOI: 10.1093/bja/aet375] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Palmer L, Martin L. Traumatic coagulopathy--part 2: Resuscitative strategies. J Vet Emerg Crit Care (San Antonio) 2014; 24:75-92. [PMID: 24393363 DOI: 10.1111/vec.12138] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/10/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC). ETIOLOGY Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models. DIAGNOSIS Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements. SUMMARY Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.
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Affiliation(s)
- Lee Palmer
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL 36849
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Central Venous-to-Arterial CO2 Gap Is a Useful Parameter in Monitoring Hypovolemia-Caused Altered Oxygen Balance: Animal Study. Crit Care Res Pract 2013; 2013:583598. [PMID: 24069537 PMCID: PMC3773396 DOI: 10.1155/2013/583598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 07/10/2013] [Accepted: 07/19/2013] [Indexed: 01/20/2023] Open
Abstract
Monitoring hypovolemia is an everyday challenge in critical care, with no consensus on the best indicator or what is the clinically relevant level of hypovolemia. The aim of this experiment was to determine how central venous oxygen saturation (ScvO2) and central venous-to-arterial carbon dioxide difference (CO2 gap) reflect hypovolemia-caused changes in the balance of oxygen delivery and consumption. Anesthetized, ventilated Vietnamese minipigs (n = 10) were given a bolus followed by a continuous infusion of furosemide. At baseline and then in five stages hemodynamic, microcirculatory measurements and blood gas analysis were performed. Oxygen extraction increased significantly, which was accompanied by a significant drop in ScvO2 and a significant increase in CO2 gap. There was a significant negative correlation between oxygen extraction and ScvO2 and significant positive correlation between oxygen extraction and CO2 gap. Taking ScvO2 < 73% and CO2 gap >6 mmHg values together to predict an oxygen extraction >30%, the positive predictive value is 100%; negative predicted value is 72%. Microcirculatory parameters, capillary perfusion rate and red blood cell velocity, decreased significantly over time. Similar changes were not observed in the sham group. Our data suggest that ScvO2 < 73% and CO2 gap >6 mmHg can be complementary tools in detecting hypovolemia-caused imbalance of oxygen extraction.
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The oxygen supply–demand balance: A monitoring challenge. Best Pract Res Clin Anaesthesiol 2013; 27:201-7. [DOI: 10.1016/j.bpa.2013.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/01/2013] [Accepted: 06/05/2013] [Indexed: 02/08/2023]
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Shao L, Wang B, Wang S, Mu F, Gu K. Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures. Clinics (Sao Paulo) 2013; 68:323-8. [PMID: 23644851 PMCID: PMC3611754 DOI: 10.6061/clinics/2013(03)oa07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/09/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The ideal solution for fluid management during neurosurgical procedures remains controversial. The aim of this study was to compare the effects of a 7.2% hypertonic saline - 6% hydroxyethyl starch (HS-HES) solution and a 6% hydroxyethyl starch (HES) solution on clinical, hemodynamic and laboratory variables during elective neurosurgical procedures. METHODS Forty patients scheduled for elective neurosurgical procedures were randomly assigned to the HS-HES group orthe HES group. Afterthe induction of anesthesia, patients in the HS-HES group received 250 mL of HS-HES (500 mL/h), whereas the patients in the HES group received 1,000 mL of HES (1000 mL/h). The monitored variables included clinical, hemodynamic and laboratory parameters. Chictr.org: ChiCTR-TRC-12002357 RESULTS The patients who received the HS-HES solution had a significant decrease in the intraoperative total fluid input (p<0.01), the volume of Ringer's solution required (p<0.05), the fluid balance (p<0.01) and their dural tension scores (p<0.05). The total urine output, blood loss, bleeding severity scores, operation duration and hemodynamic variables were similar in both groups (p>0.05). Moreover, compared with the HES group, the HS-HES group had significantly higher plasma concentrations of sodium and chloride, increasing the osmolality (p<0.01). CONCLUSION Our results suggest that HS-HES reduced the volume of intraoperative fluid required to maintain the patients undergoing surgery and led to a decrease in the intraoperative fluid balance. Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures.
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Affiliation(s)
- Liujiazi Shao
- Department of Anesthesiology, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, China
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Abstract
PURPOSE OF REVIEW The examination of the recent literature aimed at analysing the most recent data that could affect decisions regarding the use of colloids in trauma resuscitation. RECENT FINDINGS Animal data have generally shown a beneficial effect of colloids in trauma resuscitation, with improvements in capillary leak demonstrated in lung, intestine and brain. In most studies, hydroxyethyl starch resuscitation was more effective than crystalloid and decreased markers of inflammatory processes were observed. Brain injury in animals was attenuated with colloids. In uncontrolled haemorrhage, resuscitation with colloid increased bleeding and mortality.Human studies have also failed to confirm the suggestion that albumin resuscitation may be associated with a worse outcome in head injury. However, there is a strong suggestion that aggressive prehospital resuscitation, particularly with colloid, may be harmful. Studies in burns have consistently shown an improvement in the tendency to fluid overload with the inclusion of colloid in the resuscitation strategy, but so far no outcome benefit has been shown.Two studies of general trauma resuscitation have shown apparent benefit from the use of HES in early resuscitation with reductions in mortality and in renal injury. SUMMARY Recent trauma studies provide ongoing, but not conclusive, evidence of a benefit from colloid resuscitation in trauma.
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Futier E, Teboul J, Vallet B. Tissue carbon dioxide measurement as an index of perfusion: What have we missed? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.tacc.2011.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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