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Amouzandeh M, Sundström A, Wahlin S, Wernerman J, Rooyackers O, Norberg Å. Albumin and fibrinogen synthesis rates in advanced chronic liver disease. Am J Physiol Gastrointest Liver Physiol 2023; 325:G391-G397. [PMID: 37605837 DOI: 10.1152/ajpgi.00072.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 08/23/2023]
Abstract
Synthesis of plasma proteins is an important function of the liver that has sparsely been investigated by modern techniques in patients with advanced chronic liver disease (CLD). Twenty-eight well-characterized patients with CLD under evaluation for liver transplantation were included. Albumin and fibrinogen synthesis rates were measured by the flooding dose technique using stable isotope-labeled phenylalanine. Transcapillary escape rate of albumin and plasma volume were assessed by radioiodinated human serum albumin. The absolute albumin synthesis rates were low (65 mg/kg/day, range: 32-203) and were associated with impaired liver function, as reflected by the risk-scores Child-Pugh (P = 0.025) and model for end-stage liver disease (rs = -0.62, P = 0.0005). The fibrinogen synthesis rate (12.8 mg/kg/day, range: 2.4-52.9) was also negatively associated with liver function. The synthesis rates of albumin and fibrinogen were positively correlated. Plasma volume was high (51 ± 9 mL/kg body wt), which contributed to an almost normal intravascular albumin mass despite low plasma concentration. Autoimmune inflammatory etiologies to CLD were associated with higher fibrinogen synthesis. De novo synthesis rates of albumin and fibrinogen in advanced chronic liver failure were negatively correlated to prognostic scores of liver disease. Albumin synthesis rate was low and associated with both liver failure and autoimmune inflammation, whereas fibrinogen synthesis was often normal and positively associated with chronic inflammation. This is different from acute inflammatory states in which both albumin and fibrinogen synthesis rates are high.NEW & NOTEWORTHY Albumin and fibrinogen synthesis were positively correlated, but the high variation indicates that these are probably influenced by different mechanisms. There might be a limited metabolic reserve for the liver to increase both albumin and fibrinogen synthesis in response to longstanding inflammation in CLD and fibrinogen seems to be prioritized.
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Affiliation(s)
- Mariam Amouzandeh
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sundström
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Wahlin
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Lorente JV, Hahn RG, Jover JL, Del Cojo E, Hervías M, Jiménez I, Uña R, Clau-Terré F, Monge MI, Llau JV, Colomina MJ, Ripollés-Melchor J. Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols. J Clin Med 2023; 12:5930. [PMID: 37762871 PMCID: PMC10531658 DOI: 10.3390/jcm12185930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.
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Affiliation(s)
- Juan V. Lorente
- Department of Anesthesiology and Critical Care, Juan Ramón Jiménez University Hospital, 21005 Huelva, Spain
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Robert G. Hahn
- Karolinska Institute, Danderyds Hospital (KIDS), 171 77 Stockholm, Sweden
| | - José L. Jover
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Verge del Lliris Hospital, 03802 Alcoy, Spain
| | - Enrique Del Cojo
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Don Benito-Villanueva de la Serena Health District, 06400 Don Benito, Spain
| | - Mónica Hervías
- Department of Anesthesiology and Critical Care, Gregorio Marañón General University Hospital, 28007 Madrid, Spain
- Paediatric Anaesthesiology Section, Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Ignacio Jiménez
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Virgen del Rocío University Hospital, 41013 Seville, Spain
| | - Rafael Uña
- Department of Anesthesiology and Critical Care, La Paz University General Hospital, 28046 Madrid, Spain
| | - Fernando Clau-Terré
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Vall d’Hebron Institut Recerca, Vall d’Hebrón University Hospital, 08035 Barcelona, Spain
| | - Manuel I. Monge
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Juan V. Llau
- Department of Anesthesiology and Critical Care, Doctor Peset Hospital, 46017 Valencia, Spain
| | - Maria J. Colomina
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Bellvitge University Hospital, University of Barcelona, 08907 Barcelona, Spain
| | - Javier Ripollés-Melchor
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Infanta Leonor Hospital, 28031 Madrid, Spain
- Department of Toxicology, Universidad Complutense de Madrid, 28040 Madrid, Spain
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3
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Xiong K, Li G, Zhang Y, Bao T, Li P, Yang X, Chen J. Effects of glutamine on plasma protein and inflammation in postoperative patients with colorectal cancer: a meta-analysis of randomized controlled trials. Int J Colorectal Dis 2023; 38:212. [PMID: 37566134 PMCID: PMC10421765 DOI: 10.1007/s00384-023-04504-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE To evaluate the effects of glutamine on the plasma protein and inflammatory responses in colorectal cancer (CRC) patients following radical surgery. METHODS We thoroughly retrieved online databases (EMBASE, MEDLINE, PubMed, and others) and selected the randomized controlled trials (RCTs) with glutamine vs. conventional nutrition or blank treatment up until March 2023. The plasma protein associated markers indicators (consisting of albumin (ALB), prealbumin (PA), nitrogen balance (NB), total protein (TP)), inflammatory indicators (including TNF-α, CRP, infectious complications (ICs)), and matching 95% confidence intervals (CIs) were evaluated utilizing the pooled analysis. Subsequently, meta-regression analysis, contour-enhanced funnel plot, Egger's test, and sensitivity analysis were carried out. RESULTS We discovered 26 RCTs, included an aggregate of 1678 patients, out of which 844 were classified into the glutamine group whereas 834 were classified into the control group. The findings recorded from pooled analysis illustrated that glutamine substantially enhanced the plasma protein markers (ALB [SMD[random-effect] = 0.79, 95% CI: 0.55 to 1.03, I2 = 79.4%], PA [SMD[random-effect] = 0.94, 95% CI: 0.69 to 1.20, I2 = 75.1%], NB [SMD[random-effect] = 1.11, 95% CI: 0.46 to 1.75, I2 = 86.9%). However, the content of TP was subjected to comparison across the 2 groups, and no statistical significance was found (SMD[random-effect] = - 0.02, 95% CI: - 0.60 to 0.57, P = 0.959, I2 = 89.7%). Meanwhile, the inflammatory indicators (including TNF-α [SMD[random-effect] = - 1.86, 95% CI: - 2.21 to - 1.59, I2 = 56.7%], CRP [SMD[random-effect] = - 1.94, 95% CI: - 2.41 to - 1.48, I2 = 79.9%], ICs [RR[fixed-effect] = 0.31, 95% CI: 0.21 to 0.46, I2 = 0.00%]) were decreased significantly followed by the treatment of glutamine. CONCLUSIONS The current study's findings illustrated that glutamine was an effective pharmaco-nutrient agent in treating CRC patients following a radical surgical operation. PROSPERO registration number: CRD42021243327.
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Affiliation(s)
- Kai Xiong
- College of Clinical Medicine, Guizhou University of Traditional Chinese Medicine, Guiyang, No. 50 Shi East Road, Nanming District Guiyang, 550002 China
| | - Guangsong Li
- Department of Pharmacy, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, 550002 China
| | - Yu Zhang
- Colorectal and Anal Surgery, Chengdu Anorectal Hospital, Chengdu, 610015 China
| | - Tiantian Bao
- Colorectal and Anal Surgery, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, 550002 China
| | - Ping Li
- Colorectal and Anal Surgery, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, 550002 China
| | - Xiangdong Yang
- Colorectal and Anal Surgery, Chengdu Anorectal Hospital, Chengdu, 610015 China
| | - Jiang Chen
- Colorectal and Anal Surgery, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, 550002 China
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Dull RO, Hahn RG. Hypovolemia with peripheral edema: What is wrong? Crit Care 2023; 27:206. [PMID: 37245039 DOI: 10.1186/s13054-023-04496-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023] Open
Abstract
Fluid normally exchanges freely between the plasma and interstitial space and is returned primarily via the lymphatic system. This balance can be disturbed by diseases and medications. In inflammatory disease states, such as sepsis, the return flow of fluid from the interstitial space to the plasma seems to be very slow, which promotes the well-known triad of hypovolemia, hypoalbuminemia, and peripheral edema. Similarly, general anesthesia, for example, even without mechanical ventilation, increases accumulation of infused crystalloid fluid in a slowly equilibrating fraction of the extravascular compartment. Herein, we have combined data from fluid kinetic trials with previously unconnected mechanisms of inflammation, interstitial fluid physiology and lymphatic pathology to synthesize a novel explanation for common and clinically relevant examples of circulatory dysregulation. Experimental studies suggest that two key mechanisms contribute to the combination of hypovolemia, hypoalbuminemia and edema; (1) acute lowering of the interstitial pressure by inflammatory mediators such as TNFα, IL-1β, and IL-6 and, (2) nitric oxide-induced inhibition of intrinsic lymphatic pumping.
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Affiliation(s)
- Randal O Dull
- Department of Anesthesiology, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Suite 4401, PO Box 245114, Tucson, AZ, 85724-5114, USA.
- Department of Pathology, University of Arizona College of Medicine, Tucson, AZ, USA.
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Robert G Hahn
- Karolinska Institute at Danderyds Hospital (KIDS), 171 77, Stockholm, Sweden
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Lazzareschi DV, Fong N, Pirracchio R, Mathis MR, Legrand M. Leveraging observational data to identify targeted patient populations for future randomized trials. RESEARCH SQUARE 2023:rs.3.rs-2641628. [PMID: 37205590 PMCID: PMC10187375 DOI: 10.21203/rs.3.rs-2641628/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Randomized controlled trials reported in the literature are often affected by poor generalizability, and pragmatic trials have become an increasingly utilized workaround approach to overcome logistical limitations and explore routine interventions demonstrating equipoise in clinical practice. Intravenous albumin, for example, is commonly administered in the perioperative setting despite lacking supportive evidence. Given concerns for cost, safety, and efficacy, randomized trials are needed to explore the clinical equipoise of albumin therapy in this setting, and we therefore present an approach to identifying populations exposed to perioperative albumin to encourage clinical equipoise in patient selection and optimize study design for clinical trials.
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Petch-in P, Saokaew S, Phisalprapa P, Dilokthornsakul P. The Association of Pre-operative Serum Albumin Levels and Post-operative In-Hospital Death in Patients Undergoing Gastrointestinal Surgeries in Thailand: A Retrospective Cohort Study. Drugs Real World Outcomes 2023:10.1007/s40801-023-00364-4. [DOI: 10.1007/s40801-023-00364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/29/2023] Open
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7
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Huang J, Xie L, Yang Y, Xie H, Liu C. Hypoalbuminemia within One Hour After Surgery as a Predictor of Post-Operative Urosepsis in Patients Undergoing Flexible Ureteroscopy Lithotripsy: A Retrospective Study. Surg Infect (Larchmt) 2023; 24:75-81. [PMID: 36579922 DOI: 10.1089/sur.2022.290] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract Background: To investigate retrospectively whether changes in serum albumin levels within one hour of flexible ureteroscopy (fURS) lithotripsy can be used as a predictor of post-operative urosepsis. Patients and Methods: Eligible patients with unilateral upper urinary calculi who underwent fRUS lithotripsy performed by a single surgeon at our center were included in the analysis. The patients were divided into sepsis and non-sepsis groups. The change ratio of albumin and white blood cell (WBC) count was calculated by post-operative/pre-operative index*100%. Univariable and multivariable logistic regression analyses were used to assess whether there was a correlation between risk factors and post-operative urosepsis. The receiver operating characteristic (ROC) curve was used to analyze factors that showed significant differences in multivariable logistic regression analysis. Results: A total of 314 patients were included in the analysis, 20 of whom had post-operative urosepsis and five developed septic shock; no deaths occurred. Multivariable logistic regression analysis showed that urine culture results, WBC counts within one hour after surgery, post-operative albumin levels, and the degree of albumin changes after surgery were independent predictors of post-operative urosepsis. Receiver operating characteristic curve analysis showed that noteworthy hypoalbuminemia after surgery and positive pre-operative urine culture could help screen high-risk patients for post-operative urosepsis effectively. Conclusions: Hypoalbuminemia shortly after operation can be utilized as a predictor for early diagnosis of post-operative urosepsis in patients undergoing fURS lithotripsy.
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Affiliation(s)
- Junkai Huang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Linguo Xie
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Yu Yang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Haijie Xie
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Chunyu Liu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
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Dumitrescu G, Januszkiewicz A, Ågren A, Magnusson M, Sparrelid E, Rooyackers O, Wernerman J. Fibrinogen and albumin synthesis rates in major upper abdominal surgery. PLoS One 2022; 17:e0276775. [PMID: 36301906 PMCID: PMC9612515 DOI: 10.1371/journal.pone.0276775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/13/2022] [Indexed: 11/22/2022] Open
Abstract
Plasma fibrinogen and albumin concentrations initially decrease after abdominal surgery. On postoperative days 3-5 fibrinogen concentration returns to the preoperative level or even higher, while albumin stays low. It is not known if these altered plasma concentrations reflect changes in synthesis rate, utilization, or both. In particular a low albumin plasma concentration has often been attributed to a low synthesis rate, which is not always the case. The objective of this study was to determine fibrinogen and albumin quantitative synthesis rates in patients undergoing major upper abdominal surgery with and without intact liver size. Patients undergoing liver or pancreatic resection (n = 9+6) were studied preoperatively, on postoperative days 1 and 3-5. De novo synthesis of fibrinogen and albumin was determined; in addition, several biomarkers indicative of fibrinogen utilization were monitored. After hemihepatectomy, fibrinogen synthesis was 2-3-fold higher on postoperative day 1 than preoperatively. On postoperative days 3-5 the synthesis level was still higher than preoperatively. Following major liver resections albumin synthesis was not altered postoperatively compared to preoperative values. After pancreatic resection, on postoperative day 1 fibrinogen synthesis was 5-6-fold higher than preoperatively and albumin synthesis 1.5-fold higher. On postoperative days 3-5, synthesis levels returned to preoperative levels. Despite decreases in plasma concentrations, de novo synthesis of fibrinogen was markedly stimulated on postoperative day 1 after both hemihepatectomies and pancreatectomies, while de novo albumin synthesis remained grossly unchanged. The less pronounced changes seen following hepatectomies were possibly related to the loss of liver tissue.
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Affiliation(s)
- Gabriel Dumitrescu
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Anna Januszkiewicz
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Ågren
- Department of Molecular Medicine and Surgery, MMK, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
| | - Maria Magnusson
- Department of Molecular Medicine and Surgery, MMK, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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9
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Dull RO, Hahn RG. The glycocalyx as a permeability barrier: basic science and clinical evidence. Crit Care 2022; 26:273. [PMID: 36096866 PMCID: PMC9469578 DOI: 10.1186/s13054-022-04154-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/15/2022] [Indexed: 11/11/2022] Open
Abstract
Preclinical studies in animals and human clinical trials question whether the endothelial glycocalyx layer is a clinically important permeability barrier. Glycocalyx breakdown products in plasma mostly originate from 99.6–99.8% of the endothelial surface not involved in transendothelial passage of water and proteins. Fragment concentrations correlate poorly with in vivo imaging of glycocalyx thickness, and calculations of expected glycocalyx resistance are incompatible with measured hydraulic conductivity values. Increases in plasma breakdown products in rats did not correlate with vascular permeability. Clinically, three studies in humans show inverse correlations between glycocalyx degradation products and the capillary leakage of albumin and fluid.
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10
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Zdolsek M, Hahn RG. Kinetics of 5% and 20% albumin: A controlled crossover trial in volunteers. Acta Anaesthesiol Scand 2022; 66:847-858. [PMID: 35491239 PMCID: PMC9541965 DOI: 10.1111/aas.14074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/27/2022]
Abstract
Background Albumin for intravenous infusion is marketed in two concentrations, 20% and 5%, but how they compare with regard to plasma volume expansion over time is unclear. Methods In a prospective crossover study, 12 volunteers received 3 ml kg−1 of 20% albumin and, on another occasion, 12 ml kg−1 of 5% albumin over 30 min. Hence, equivalent amounts of albumin were given. Blood was collected on 15 occasions over 6 h. Mass balance and volume kinetics were used to estimate the plasma volume expansion and the capillary leakage of albumin and fluid based on measurements of blood hemoglobin, plasma albumin, and the colloid osmotic pressure. Results The greatest plasma volume expansion was 16.0 ± 6.4% (mean ± SD) with 20% albumin and 19.0 ± 5.2% with 5% albumin (p < .03). The volume expansion with 20% albumin corresponded to twice the infused volume. One third of the 5% albumin volume quickly leaked out of the plasma, probably because of the higher colloid osmotic pressure of the volunteer plasma (mean, 24.5 mmHg) than the albumin solution (19.1 mmHg). At 6 h, the capillary leakage amounted to 42 ± 15% and 47 ± 11% of the administered albumin with the 20% and 5% preparations, respectively (p = .28). The corresponding urine outputs were 547 (316–780) ml and 687 (626–1080) ml (median and interquartile range; p = .24). Conclusion The most important difference between the fluids was a dehydrating effect of 20% albumin when the same albumin mass was administered.
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Affiliation(s)
- Markus Zdolsek
- Department of Biomedical and Clinical Sciences (BKV) Linköping University Linköping Sweden
| | - Robert G. Hahn
- Research Unit Södertälje Hospital, Södertälje, Sweden, and Karolinska Institutet at Danderyds Hospital (KIDS) Danderyd Sweden
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11
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Zdolsek M, Wuethrich PY, Gunnström M, Zdolsek JH, Hasselgren E, Beilstein CM, Engel D, Hahn RG. Plasma disappearance rate of albumin when infused as a 20% solution. Crit Care 2022; 26:104. [PMID: 35410365 PMCID: PMC9003982 DOI: 10.1186/s13054-022-03979-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022] Open
Abstract
Background The transcapillary leakage of albumin is increased by inflammation and major surgery, but whether exogenous albumin also disappears faster is unclear. Methods An intravenous infusion of 3 mL/kg of 20% albumin was given over 30 min to 70 subjects consisting of 15 healthy volunteers, 15 post-burn patients, 15 patients who underwent surgery with minor bleeding, 10 who underwent surgery with major bleeding (mean, 1.1 L) and 15 postoperative patients. Blood Hb and plasma albumin were measured on 15 occasions over 5 h. The rate of albumin disappearance from the plasma was quantitated with population kinetic methodology and reported as the half-life (T1/2). Results No differences were observed for T1/2 between volunteers, post-burn patients, patients who underwent surgery with minor bleeding and postoperative patients. The T1/2 averaged 16.2 h, which corresponds to 3.8% of the amount infused per h. Two groups showed plasma concentrations of C-reactive protein of approximately 60 mg/L and still had a similarly long T1/2 for albumin. By contrast, patients undergoing surgery associated with major hemorrhage had a shorter T1/2, corresponding to 15% of the infused albumin per h. In addition, our analyses show that the T1/2 differ greatly depending on whether the calculations consider plasma volume changes and blood losses. Conclusion The disappearance rate of the albumin in 20% preparations was low in volunteers, in patients with moderately severe inflammation, and in postoperative patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03979-1.
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Affiliation(s)
- Markus Zdolsek
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michaela Gunnström
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Joachim H Zdolsek
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Emma Hasselgren
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert G Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden. .,Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden.
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12
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Motamed C, Mariani L, Suria S, Weil G. Serum Albumin Kinetics in Major Ovarian, Gastrointestinal, and Cervico Facial Cancer Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063394. [PMID: 35329082 PMCID: PMC8955132 DOI: 10.3390/ijerph19063394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023]
Abstract
Hypoalbuminemia in major cancer surgery can lead to postoperative short and long-term complications. Our study was designed to detect albumin variations in three major cancer surgeries: ovarian debulking (DBK), major abdominal gastrointestinal surgery (ABD), and major cervico-facial, or ear, nose and throat cancer surgery (ENT). Single-center prospective study inclusion criteria were non-emergency procedures scheduled to last at least five hours. We performed hourly perioperative monitoring of the patients’ albuminemia and hemoglobinemia. Electronic charts were followed for at least five years for survival analysis. Sixty-three patients were analyzed: 30 in the DBK group, 13 in the ABD group, and 20 in the ENT group. There was a significant difference in albumin decrease between the ENT group and the two others (−19% at six hours in the ENT group versus -49% in the debulking group and −31% in the ABD group (p < 0.05). There was no significant difference between the DBK and ABD groups. The decrease in hemoglobin was not significantly different between the groups, and no significant difference was observed in long-term survival. DBK and ABD surgery yielded significant hypoalbuminemia. Therefore, the extent of decrease in serum albumin is probably not the only etiology of the specific postoperative complications of these major surgeries. No significant difference was noticed in five-year mortality, and no correlation was found in relation to the degree of intraoperative albumin kinetics.
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Affiliation(s)
- Cyrus Motamed
- Department of Anesthesia, Institut de Cancerologie Gustave Roussy, 94080 Paris, France;
- Correspondence:
| | - Lucie Mariani
- Department of Anesthesia and Intensive Care, APHP Hopital Pitié Salpétrière, 75013 Paris, France;
| | - Stéphanie Suria
- Department of Anesthesia, Institut de Cancerologie Gustave Roussy, 94080 Paris, France;
| | - Gregoire Weil
- Anesthesia Department, Centre Hospitalier d’Orleans, 45100 Orléans, France;
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Muzaffar SN, Patnaik R, Siddiqui SS, Azim A. Letter to the Editor: "Impact of hypoalbuminemia on mortality in critically ill patients requiring continuous renal replacement therapy". J Crit Care 2022; 69:154017. [PMID: 35272099 DOI: 10.1016/j.jcrc.2022.154017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| | - Rupali Patnaik
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneshwar 751003, Odisha, India.
| | - Suhail Sarwar Siddiqui
- Department of Critical Care Medicine, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, Uttar Pradesh, India
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Abstract
Hypoalbuminemia has been associated with poor outcome in critically ill population including sepsis and COVID-19. The observational study by Su et al showed a favorable albumin kinetics, with an initial downwards trend followed by recovery back to the predicted albumin levels, in survivors of COVID-19 and sepsis-induced acute respiratory distress syndrome (ARDS). However, nonsurvivors in COVID-19 group did not have an upwards recovery slope, while those in sepsis group did not follow any sort of albumin kinetics. Thus, authors concluded that the pattern of albumin kinetics may be predictive of outcome in COVID-19 and sepsis-induced ARDS. Here, we would like to highlight a few more points in this letter.
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Joliat GR, Schoor A, Schäfer M, Demartines N, Hübner M, Labgaa I. Postoperative decrease of albumin (ΔAlb) as early predictor of complications after gastrointestinal surgery: a systematic review. Perioper Med (Lond) 2022; 11:7. [PMID: 35164873 PMCID: PMC8845214 DOI: 10.1186/s13741-022-00238-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022] Open
Abstract
Background Postoperative complications are frequent after gastrointestinal surgery and early prediction remains an unmet need. Serum albumin shows a rapid decrease after surgery, and this decline (ΔAlb) may reflect the intensity of the surgical stress response and thereby be a predictor of postoperative complications. This study aimed to comprehensively review the available data on ΔAlb in gastrointestinal surgery. Methods PRISMA guidelines were followed to conduct a systematic review of the literature in MEDLINE and Embase. Studies assessing the role of ΔAlb to predict complications after gastrointestinal surgery were included. Results A total of 1256 articles were screened, and 16 studies were included in the final analysis: 7 prospective and 9 retrospective trials. Sensitivity of ΔAlb to predict postoperative complications ranged from 63 to 84%, whereas specificity ranged from 61 to 86%. Nine out of the 16 included studies established a threshold of ΔAlb to predict morbidity (range: 5–11 g/l or 14–27%). Conclusion ΔAlb appeared as a valuable and promising biomarker to anticipate complications after gastrointestinal surgery. Future efforts are needed to determine whether and how ΔAlb may be integrated in clinical practice to guide clinicians in the perioperative management of patients.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland. .,Graduate School of Health Sciences, University of Bern, Bern, Switzerland.
| | - Arnaud Schoor
- Department of General and Visceral Surgery, HIB Hospital, Payerne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
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Gunnström M, Zdolsek JH, Hahn RG. Plasma Volume Expansion and Fluid Kinetics of 20% Albumin During General Anesthesia and Surgery Lasting for More Than 5 Hours. Anesth Analg 2021; 134:1270-1279. [PMID: 34797221 DOI: 10.1213/ane.0000000000005802] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative administration of crystalloid for plasma volume expansion may be reduced by use of hyperoncotic albumin. However, the degree of plasma volume expansion with administration of 20% albumin is poorly quantitated. We estimated the amount of volume expansion attributable to 20% albumin administration in patients undergoing surgery for more than 5 hours. METHODS Twenty percent albumin was delivered at 3 mL/kg by intravenous infusion during 30 minutes to 15 patients (mean ± standard deviation [SD] age; 46 ± 15 years) undergoing surgery. Blood samples and urine were collected for 5 hours. Mass balance calculations and volume kinetics were used to estimate plasma volume expansion and capillary leakage of albumin and fluid. RESULTS Administration of 20% albumin was associated with an increase in plasma volume amounting to 1.7 times the infused volume. After correction for hemorrhage, the median (and 25th to 75th percentiles) intravascular half-life for the administered albumin mass was 20.4 (14.2-34.7) hours. The plasma volume decreased with a half-life of 21.7 (16.1-26.8) hours. Urinary excretion was 3 times greater than the infused volume of albumin, but kinetic analysis suggested that other flows of fluid to and from the plasma occurred more slowly than previously found in volunteers. Hemodynamic support with norepinephrine increased urinary excretion and contracted the plasma volume. CONCLUSIONS Albumin (20%) increased the plasma volume by 1.7 times the infused volume. Our results do not support that the transcapillary leakage of albumin is accelerated by anesthesia and surgery.
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Affiliation(s)
- Michaela Gunnström
- From the Department of Anesthesia, Operation, and Intensive Care (ANOPIVA), and Department of Medical and Health Sciences (IMH), Linköping University, Linköping, Sweden
| | - Joachim H Zdolsek
- From the Department of Anesthesia, Operation, and Intensive Care (ANOPIVA), and Department of Medical and Health Sciences (IMH), Linköping University, Linköping, Sweden
| | - Robert G Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden.,Karolinska Institutet at Danderyds Hospital (KIDS), Karolinska Institutet, Stockholm, Sweden
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Sabbatini G, Caccioppola A, Lusardi AC, Pozzi T, Bianco C, Baio S, Chiumello D. Electrolytes, albumin and acid base equilibrium during laparoscopic surgery. Minerva Anestesiol 2021; 87:1300-1308. [PMID: 34633165 DOI: 10.23736/s0375-9393.21.15465-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgery, causing inflammation, disrupts endothelial permeability leading to movement of fluids and albumin across the vascular barrier. Fluid therapy for restoring circulatory homeostasis may lead to positive fluid balance which has been shown to increase morbidity and mortality in surgical patients. The current investigation aims to describe physio-pathological changes in circulating albumin, fluid and electrolyte balance, and acidbase equilibrium in a cohort of patients undergoing laparoscopic surgery under general anesthesia. METHODS Single-center prospective observational study. Patients undergoing laparoscopic colorectal surgery were screened for eligibility.. Before surgery the baseline fasting conditions were homogenized. Hemoglobin, urinary and plasmatic were collected before surgery and then at pre-defined timepoints. Albumin/Creatinine ratio was measured before and after surgery. Expected and actual circulating Sodium concentrations were compared according to a physiological theoretical model. Assessment and quantification of changes in major electrolytes, albumin and acid-base balance was defined as the primary outcome of the study. RESULTS 38 patients were enrolled in the protocol. Patients had a positive electrolytes (Na+ 295 [244-375] mmol, Cl- 234 [195-295] mmol, K+ 16.8 [12.0-21.4] mmol) and fluid balance (2165 [1727-2728] ml). The positive fluid balance was associated with stable chloride (105 [103-107], end study vs 103 [102-106] mmol/L, baseline, p=ns) and potassium (4.2 [3.8-4.4], end study vs 4.1 [3.6-4.4] mmol/L, baseline, p=ns) levels, but sodium concentrations decreased over time (138 [137-140], end study vs 139 [138-141] mmol/L, baseline, p<0.05). The Albumin/Creatinine ratio was higher at the end of surgery 134 [61-267] vs 7 [4-14], p<0.001). CONCLUSIONS Data from patients undergoing colorectal laparoscopic surgery showed a positive fluid balance, decreased circulating albumin and increased albuminuria. A positive sodium balance was not always associated with an increase in sodium plasma concentration.
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Affiliation(s)
- Giovanni Sabbatini
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Alessio Caccioppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Andrea C Lusardi
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Tommaso Pozzi
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Claudia Bianco
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Serena Baio
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy - .,Department of Health Sciences, University of Milan, Milan, Italy.,Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy
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Adamik KN, Yozova ID. Colloids Yes or No? - a "Gretchen Question" Answered. Front Vet Sci 2021; 8:624049. [PMID: 34277747 PMCID: PMC8282815 DOI: 10.3389/fvets.2021.624049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/05/2021] [Indexed: 12/13/2022] Open
Abstract
Colloid solutions, both natural and synthetic, had been widely accepted as having superior volume expanding effects than crystalloids. Synthetic colloid solutions were previously considered at least as effective as natural colloids, as well as being cheaper and easily available. As a result, synthetic colloids (and HES in particular) were the preferred resuscitation fluid in many countries. In the past decade, several cascading events have called into question their efficacy and revealed their harmful effects. In 2013, the medicines authorities placed substantial restrictions on HES administration in people which has resulted in an overall decrease in their use. Whether natural colloids (such as albumin-containing solutions) should replace synthetic colloids remains inconclusive based on the current evidence. Albumin seems to be safer than synthetic colloids in people, but clear evidence of a positive effect on survival is still lacking. Furthermore, species-specific albumin is not widely available, while xenotransfusions with human serum albumin have known side effects. Veterinary data on the safety and efficacy of synthetic and natural colloids is limited to mostly retrospective evaluations or experimental studies with small numbers of patients (mainly dogs). Large, prospective, randomized, long-term outcome-oriented studies are lacking. This review focuses on advantages and disadvantages of synthetic and natural colloids in veterinary medicine. Adopting human guidelines is weighed against the particularities of our specific patient populations, including the risk-benefit ratio and lack of alternatives available in human medicine.
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Affiliation(s)
- Katja-Nicole Adamik
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Science, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ivayla D. Yozova
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
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Transcapillary escape rate of 125I-albumin in relation to timing of blood sampling: the need for standardization. EJNMMI Radiopharm Chem 2021; 6:9. [PMID: 33591459 PMCID: PMC7886925 DOI: 10.1186/s41181-021-00125-0] [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: 10/29/2020] [Accepted: 02/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Increased vascular permeability is an early sign of vascular damage and can be measured with the transcapillary escape rate of albumin (TERalb). Although TERalb has a multi-exponential kinetic model, most published TERalb data are based on mono-exponential kinetic models with variation in blood sampling schemes. Aim of this posthoc study was to evaluate the influence of variation in blood sampling schemes and the impact of mono- or bi-exponential analyses on the calculation of TERalb. Study participants were part of a cross-over intervention study protocol, investigating effects of sodium loading on blood pressure, endothelial surface layer and microcirculation. Multiple blood samples were drawn between 3 and 60 min after injection of radioactive iodide labeled human serum albumin (rHSA). Results In total 27 male participants with 54 measurements were included. For all participants the maximum serum radioactivity was reached within 20 min, while 85% of the participants had their maximum serum activity within 10 min. The TERalb calculated with the subsequently chosen T20–60 min reference scheme (6.19 ± 0.49%/h) was significantly lower compared to the TERalb of the T3–60 min, T5–60 min, and Tmax – 60 min schemes. There was no significant difference between the T20–60 min reference scheme and the T10–60 min and T15–60 min schemes. Bi-exponential kinetic modeling did not result in significant different observations compared to the mono-exponential kinetic analysis. Conclusions As there is variation in the timing of the maximum serum radioactivity of rHSA, blood sampling schemes starting before 10 min after administration of rHSA will result in a significant overestimation of TERalb. In addition, variation in kinetic modeling did not result in significant changes in TERalb. Therefore, we emphasize the need to standardize TERalb and for practical and logistical reasons advocate the use of a mono-exponential model with blood sampling starting 20 min after rHSA administration.
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Liu Q, Gao K, Zheng C, Guo C. The Risk Factors for Perioperative Serum Albumin Variation in Pediatric Patients Undergoing Major Gastroenterology Surgery. Front Surg 2021; 7:627174. [PMID: 33585551 PMCID: PMC7873733 DOI: 10.3389/fsurg.2020.627174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background: The albumin, a negative acute-phase protein, is important for perioperative morbidity, even in patients with normal preoperative levels. This study intend to determine the perioperative factors related with the postoperative reduction in serum albumin (ΔALB) and its influence on perioperative outcome in a pediatric general surgical cohort. Methods: This single-center retrospective review included 939 pediatric patients who underwent major gastroenterology surgery from August 2010 to August 2019. The patients were dichotomized into a high ΔALB group (≥14.6%) and a low ΔALB group (<14.6%) based on the mean value of ΔALB (14.6%). the independent risk factors for ΔALB, were explored using the propensity score matching to minimize potential selection bias and subjected to method multivariable logistic regression model. Furthermore, in 366 matched patients, the influences of operating time on perioperative outcomes were analyzed. Results: Among the 996 patients reviewed, 939 patient records were enrolled in the final analysis. Controlling for other factors, multivariable analysis showed that a high CRP on POD 3 or 4 [odds ratio (OR) = 2.36 (95% CI, 1.51–3.86); p = 0.007], a longer operating time [OR = 1.18 (95% CI, 1.00–1.53); p = 0.014), and the presence of Charcot's triad [OR = 1.73 (95% CI, 1.05–2.83); p = 0.031] were factors that predicted a high ΔALB level. A high ΔALB level was also related with gastrointestinal functional recovery delay, reflected by the postoperative defecation (p = 0.013) and bowel movement (p = 0.019) delay and the high occurrence of postoperative complications (16.1 vs. 10.9%, OR, 1.57; 95% CI, 1.02–2.41, P = 0.0026). Conclusions: The high ΔALB level was correlated with postoperative outcome. To obtain a safe recovery and discharge after a major abdominal operation, the above risk factors for ΔALB could be addressed in the perioperative period.
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Affiliation(s)
- Qingshuang Liu
- Department of Pediatric General and Neonatal Surgery, Children's Hospital, Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Kai Gao
- Department of Pediatric General and Neonatal Surgery, Children's Hospital, Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chao Zheng
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Orthopedics, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Chunbao Guo
- Department of Pediatric General and Neonatal Surgery, Children's Hospital, Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
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De Waele E, Jakubowski JR, Stocker R, Wischmeyer PE. Review of evolution and current status of protein requirements and provision in acute illness and critical care. Clin Nutr 2020; 40:2958-2973. [PMID: 33451860 DOI: 10.1016/j.clnu.2020.12.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/20/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.
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Affiliation(s)
- Elisabeth De Waele
- Department of Intensive Care Medicine and Department of Nutrition, UZ Brussel, Vrije Unversiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Julie Roth Jakubowski
- Medical Affairs, Baxter Healthcare Corporation, One Baxter Parkway, Deerfield, IL 60015, USA.
| | - Reto Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, 8032, Zurich, Switzerland.
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery Duke University School of Medicine, 200 Morris Street, #7600-H, P.O. Box 17969, Durham, NC 27701, USA.
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Wu JM, Ho TW, Lai IR, Chen CN, Lin MT. Parenteral glutamine supplementation improves serum albumin values in surgical cancer patients. Clin Nutr 2020; 40:645-650. [PMID: 32713723 DOI: 10.1016/j.clnu.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 05/29/2020] [Accepted: 06/14/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Patients with gastric adenocarcinoma (GA) often develop malnutrition, which deteriorates after cancer surgery and negatively affects surgical outcomes. Despite being an abundant and versatile amino acid involved in the immune system and metabolic functions, glutamine levels are significantly depleted among patients who are critically ill or hypercatabolic. Therefore, this study aimed to investigate whether parenteral glutamine supplementation may improve nutritional status and surgical outcomes. METHODS This retrospective, single-center cohort study included patients with GA who underwent gastrectomy between January 2007 and June 2019. Patients were classified into either the non-glutamine or glutamine group. Propensity score matching was used to minimize the bias in patient demographics. Furthermore, the average parenteral glutamine dose from the day of surgery to postoperative day four was calculated in g/kg/day. Surgical outcomes (length of hospitalization, major complication, and mortality) and changes in lymphocyte count and serum albumin levels 7 days post-surgery were assessed in both matched groups using adjusted models. RESULTS A total of 1950 patients were reviewed, among whom 522 (26.8%) received parenteral glutamine supplementation (glutamine dose ranging from 0.05 to 0.49 g/kg/day). Among the included patients, 57.2% were males, and the median age was 64.9 years. After matching, there were 478 cases in each group. No differences in surgical outcomes and changes in lymphocyte count were observed between both matched groups. The glutamine group exhibited a smaller decrease in serum albumin levels compared to the non-glutamine group (-0.6 vs. -1.1 g/dL; P < 0.001). The adjusted matched model showed that glutamine dose contributed significantly toward increasing serum albumin levels (coefficient = 0.08 per 0.1 g/day/kg increment in glutamine; 95% confidence interval: 0.04 to 0.10; P < 0.001). CONCLUSIONS Perioperative parenteral glutamine supplementation had a positive dose-dependent impact on the recovery of serum albumin levels among patients with GA undergoing gastrectomy, implying that glutamine supplementation improved postoperative nutritional suppression and ameliorated stress-associated inflammation. Although glutamine supplementation was not associated with surgical outcomes, further studies should be conducted to evaluate the clinical significance of serum albumin restoration.
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Affiliation(s)
- Jin-Ming Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, National Taiwan University Hospital Hsin-Chu Biomedical Science Park Branch, Hsin-Chu County, Taiwan
| | - Te-Wei Ho
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Rue Lai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chiung-Nien Chen
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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Increased neutrophil percentage-to-albumin ratio is associated with all-cause mortality in patients with severe sepsis or septic shock. Epidemiol Infect 2020; 148:e87. [PMID: 32238212 PMCID: PMC7189348 DOI: 10.1017/s0950268820000771] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
There has been no study exploring the prognostic values of neutrophil percentage-to-albumin ratio (NPAR). We hypothesised that NPAR is a novel marker of inflammation and is associated with all-cause mortality in patients with severe sepsis or septic shock. Patient data were extracted from the MIMIC-III V1.4 database. Only the data for the first intensive care unit (ICU) admission of each patient were used and baseline data were extracted within 24 h after ICU admission. The clinical endpoints were 30-, 90- and 365-day all-cause mortality in critically ill patients with severe sepsis or septic shock. Cox proportional hazards models and subgroup analyses were used to determine the relationship between NPAR and these clinical endpoints. A total of 2166 patients were eligible for this analysis. In multivariate analysis, after adjustments for age, ethnicity and gender, higher NPAR was associated with increased risk of 30-, 90- and 365-day all-cause mortality in critically ill patients with severe sepsis or septic shock. Furthermore, after adjusting for more confounding factors, higher NPAR remained a significant predictor of all-cause mortality (tertile 3 vs. tertile 1: HR, 95% CI: 1.29, 1.04–1.61; 1.41, 1.16–1.72; 1.44, 1.21–1.71). A similar trend was observed in NPAR levels stratified by quartiles. Higher NPAR was associated with increased risk of all-cause mortality in critically ill patients with severe sepsis or septic shock.
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Tailakh MA, Yahia A, Polischuck I, Liel Y. INCREASED SERUM CALCIUM IS NOT COMMON IN HOSPITALIZED PATIENTS WITH PRIMARY HYPERPARATHYROIDISM: A RETROSPECTIVE, OBSERVATIONAL STUDY. Endocr Pract 2019; 26:285-290. [PMID: 31859546 DOI: 10.4158/ep-2019-0349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Serum calcium levels often decrease during acute illness in patients with an intact calcium-regulating system. However, the dynamics of serum calcium levels in hospitalized patients with primary hyperparathyroidism (PHPT) have not yet been described. Methods: Clinical and laboratory data were retrospectively retrieved from the electronic medical records of patients with PHPT before, during, and after hospitalization for various reasons (excluding parathyroid surgery). Results: There were 99 nonselected patients with asymptomatic, hypercalcemic PHPT, hospitalized for various reasons; 42% were admitted for apparent infectious or septic conditions, and 58% were admitted for noninfectious conditions. Total serum calcium increased >0.5 mg/dL in 7.4% of the patients: 10.9% and 2.5% of the patients with noninfectious and infectious conditions, respectively. In 65.7% of the patients, the mean total serum calcium (TsCa), but not albumin-corrected calcium (corrCa), decreased significantly during hospitalization, down to below the upper limit of the reference range. Although prehospitalization TsCa and corrCa were similar in patients with infectious and noninfectious conditions, during hospitalization, TsCa was lower in patients with infectious conditions (P = .02). Both TsCa and albumin returned to prehospitalization levels after recovery. Conclusion: TsCa increases in a minority of hospitalized PHPT patients. In the majority of hospitalized patients with PHPT, TsCa, but not corrCa, decreases to within the normal reference range, more so in patients with infectious conditions, obscuring the major characteristic of PHPT. Therefore, it is prudent to follow calcium and corrCa during hospitalization in patients with PHPT. Abbreviations: corrCa = albumin-corrected serum calcium; IQR = interquartile range; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; TsCa = total serum calcium.
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Satoh M, Taira K, Hara T, Siba J, Takeuchi M. High mobility group box 1 can be used to monitor perioperative course in patients with liver cancer. Surg Oncol 2019; 33:216-221. [PMID: 31443921 DOI: 10.1016/j.suronc.2019.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/09/2019] [Accepted: 08/01/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE High mobility group box 1 (HMGB1) is produced by inflammation. Regarding liver injuries, HMGB1 is reportedly involved in liver regeneration. The present study investigated the use of HMGB1 as a postoperative marker of surgical course in patients with liver cancer. METHODS Patients were enrolled if they had liver cancer, had undergone liver surgery, and did not develop postsurgical complications. Patients who received emergency surgery or patients with unresectable cancerous lesions were excluded. Blood samples were preoperatively obtained as well as at 1 day, 1 week, and 4 weeks following surgery; white blood cell count, serum C-reactive protein, serum albumin, and serum HMGB1 levels were measured. RESULTS A total of 36 patients were included in this study. HMGB1 levels significantly changed over time, increasing from a median of 7.1 ng/ml (preoperatively) to 13.9 ng/ml at 1 week postoperatively, and then decreased to 6.3 ng/ml at 4 weeks postoperatively. Peak HMGB1 levels were delayed, and elevated HMGB1 levels persisted as compared with the changes in conventional markers. CONCLUSIONS HMGB1 indicates a unique perioperative inflammatory state in patients with liver cancer. Serum HMGB1 may serve as a marker for monitoring surgical course in patients undergoing surgery for liver cancer.
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Affiliation(s)
- Masaaki Satoh
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, 329-0498, Japan.
| | - Koki Taira
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, 329-0498, Japan.
| | - Tetsuhito Hara
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, 329-0498, Japan.
| | - Juntaro Siba
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, 329-0498, Japan.
| | - Mamoru Takeuchi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, 329-0498, Japan.
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Ai S, Sun F, Liu Z, Yang Z, Wang J, Zhu Z, Du S, Guan W. Change in serum albumin level predicts short-term complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer. ANZ J Surg 2019; 89:E297-E301. [PMID: 31297940 DOI: 10.1111/ans.15363] [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: 01/15/2019] [Revised: 05/28/2019] [Accepted: 06/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the correlation between serum albumin level change (ΔALB) and post-operative complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer. METHODS A total of 193 patients undergoing curative (R0) gastrectomy from September 2015 to May 2017 were enrolled in this study. The risk factors for predicting post-operative complications were identified by univariate and multivariate analysis. The cut-off value and diagnostic accuracy of ΔALB were measured by receiver operating characteristic curves. ΔALB was defined as: (albumin level before surgery - albumin on post-operative day (POD) 1)/albumin level before surgery × 100%. RESULTS A total of 60 patients (31.0%) had post-operative complications. Our results showed that the cut-off value of ΔALB was 19.0%. Using a cut-off value of 19.0%, multivariate analysis identified that ΔALB was able to predict post-operative complications as an independent factor (odds ratio 13.98, 95% confidence interval 6.048-32.32, P < 0.001). In addition, the area under the curve of ΔALB is higher than C-reactive protein on POD 3 (0.773 versus 0633). Compared with patients with ΔALB <19.0%, patients with ΔALB ≥19.0% have higher risk of post-operative complications suffered (62.3 versus 13.7%, P < 0.001) and longer post-operative stay (22.1 ± 13.5 versus 17.5 ± 4.2, P < 0.001). CONCLUSION ΔALB acted as an independent predictor in short-term complications for patients with normal preoperative serum albumin and its diagnostic accuracy was higher than C-reactive protein on POD 3. It is promising to be a precise and straight predictor for incidence of post-operative complications to patients with normal preoperative serum albumin.
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Affiliation(s)
- Shichao Ai
- Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Sun
- Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of General Surgery, Drum Tower Medical College of Nanjing Medical University, Nanjing, China
| | - Zhijian Liu
- Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of General Surgery, Drum Tower Medical College of Nanjing Medical University, Nanjing, China
| | - Zhengyang Yang
- Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiafeng Wang
- Department of General Surgery, Drum Tower Medical College of Nanjing Medical University, Nanjing, China
| | - Zhouting Zhu
- Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Shangce Du
- Department of General Surgery, Drum Tower Medical College of Nanjing Medical University, Nanjing, China
| | - Wenxian Guan
- Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of General Surgery, Drum Tower Medical College of Nanjing Medical University, Nanjing, China
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Tanda N, Hoshikawa Y, Sato T, Takahashi N, Koseki T. Exhaled acetone and isoprene in perioperative lung cancer patients under intensive oral care: possible indicators of inflammatory responses and metabolic changes. Biomed Res 2019; 40:29-36. [PMID: 30787261 DOI: 10.2220/biomedres.40.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
One of the most severe complications of lung resection is postoperative pneumonia, and its prevention and prediction are critical. Exhaled acetone and isoprene are thought to be related to metabolism; however, little is known on their relationship with bacteria living in the oral cavity or their meaning in the acute phase in perioperative lung cancer patients. We measured acetone and isoprene in exhaled breath of 13 Japanese patients with lung cancer (3 women and 10 men, age range 62-82 years, mean 72.4 years) before breakfast during hospitalization, and compared with two acute-phase proteins, C-reactive protein (CRP) and albumin in blood serum, as well as the total number of bacteria in saliva and their activity to produce acetone and isoprene. Before operation, intensive oral care was carried out for each patient to prevent postoperative pneumonia, and swallowing and cough reflexes were measured for 12 of 13 patients to assess risk of postoperative pneumonia. Breath and saliva were sampled before intensive oral care (T1), after oral care but before operation (T2), and after operation (T3) during hospitalization. The total number of oral bacteria in saliva decreased significantly from T1 to T2 among 13 patients. No acetone or isoprene was detected from saliva after in vitro incubation under anaerobic or aerobic conditions, but both acetone and isoprene were detected in breath. After operation, breath acetone correlated significantly with CRP (Spearman's ρ = 0.559, P = 0.03), but not with albumin. Breath isoprene correlated significantly with albumin (Spearman's ρ = 0.659, P = 0.008), but not with CRP after operation. Although the number of subjects was small, our results support the hypothesis that breath acetone and isoprene may be related with these acute-phase proteins, which reflect inflammatory reactions and subsequent changes in metabolism in the early postoperative phase of lung resection.
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Affiliation(s)
- Naoko Tanda
- Department of Preventive Dentistry, Tohoku University Hospital
| | - Yasushi Hoshikawa
- Department of Thoracic Surgery, Fujita Health University School of Medicine
| | - Takuichi Sato
- Division of Clinical Chemistry, Department of Medical Technology, Niigata University Graduate School of Health Sciences
| | - Nobuhiro Takahashi
- Division of Oral Ecology and Biochemistry, Department of Oral Biology, Tohoku University Graduate School of Dentistry
| | - Takeyoshi Koseki
- Division of Preventive Dentistry, Department of Oral Health and Development Sciences, Tohoku University Graduate School of Dentistry
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Statkevicius S, Bonnevier J, Fisher J, Bark BP, Larsson E, Öberg CM, Kannisto P, Tingstedt B, Bentzer P. Albumin infusion rate and plasma volume expansion: a randomized clinical trial in postoperative patients after major surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:191. [PMID: 31138247 PMCID: PMC6537197 DOI: 10.1186/s13054-019-2477-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/14/2019] [Indexed: 01/22/2023]
Abstract
Background Optimal infusion rate of colloids in patients with suspected hypovolemia is unknown, and the primary objective of the present study was to test if plasma volume expansion by 5% albumin is greater if fluid is administered slowly rather than rapidly. Methods Patients with signs of hypoperfusion after major abdominal surgery were randomized to intravenous infusion of 5% albumin at a dose of 10 ml/kg (ideal body weight) either rapidly (30 min) or slowly (180 min). Plasma volume was measured using radiolabeled albumin at baseline, at 30 min, and at 180 min after the start of infusion. Primary outcome was change in plasma volume from the start of infusion to 180 min after the start of infusion. Secondary outcomes included the change in the area under the plasma volume curve and transcapillary escape rate (TER) for albumin from 180 to 240 min after the start of albumin infusion. Results A total of 33 and 31 patients were included in the analysis in the slow and rapid groups, respectively. The change in plasma volume from the start of infusion to 180 min did not differ between the slow and rapid infusion groups (7.4 ± 2.6 vs. 6.5 ± 4.1 ml/kg; absolute difference, 0.9 ml/kg [95%CI, − 0.8 to 2.6], P = 0.301). Change in the area under the plasma volume curve was smaller in the slow than in the rapid infusion group and was 866 ± 341 and 1226 ± 419 min ml/kg, respectively, P < 0.001. TER for albumin did not differ and was 5.3 ± 3.1%/h and 5.4 ± 3%/h in the slow and in the rapid infusion groups, respectively, P = 0.931. Conclusions This study does not support our hypothesis that a slow infusion of colloid results in a greater plasma volume expansion than a rapid infusion. Instead, our result of a smaller change in the area under the plasma volume curve indicates that a slow infusion results in a less efficient plasma volume expansion, but further studies are required to confirm this finding. A rapid infusion has no effect on vascular leak as measured after completion of the infusion. Trial registration EudraCT2013-004446-42 registered December 23, 2014. Electronic supplementary material The online version of this article (10.1186/s13054-019-2477-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Johan Bonnevier
- Department of Anesthesia & Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Jane Fisher
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Björn P Bark
- Department of Anesthesia & Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Erik Larsson
- Department of Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Carl M Öberg
- Department of Nephrology, Skåne University Hospital, Lund, Sweden
| | - Päivi Kannisto
- Department of Gynecology and Obstetrics, Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Peter Bentzer
- Department of Anesthesia and Intensive Care, Helsingborg Hospital, Helsingborg and Lund University, 251 87, Helsingborg, Sweden. .,Department of Clinical Sciences, Anesthesiology, Lund University, Lund, Sweden.
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Müller C, Stift A, Argeny S, Bergmann M, Gnant M, Marolt S, Unger L, Riss S. Delta albumin is a better prognostic marker for complications following laparoscopic intestinal resection for Crohn's disease than albumin alone - A retrospective cohort study. PLoS One 2018; 13:e0206911. [PMID: 30422980 PMCID: PMC6233913 DOI: 10.1371/journal.pone.0206911] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 10/22/2018] [Indexed: 12/11/2022] Open
Abstract
Purpose Little is known about the perioperative dynamic of albumin and its effect on surgical outcome in Crohn’s disease. Thus, we aimed to assess postoperative changes of albumin levels and their potentially predictive role for complications after laparoscopic intestinal resections. Methods We identified 182 patients who underwent laparoscopic intestinal resection for symptomatic Crohn´s disease between 2000 and 2014 for this retrospective cohort study. Pre- and postoperative serum albumin levels (within 4 days) were recorded retrospectively and proportional postoperative reduction (delta (Δ) albumin) was calculated. Complications were defined according to the Clavien-Dindo classification. Univariate and multivariate analysis describing an eventful postoperative course were conducted. Results Complications were found in 22.5% (n = 41), 6% (n = 11) developed major complications defined as Clavien Dindo III-V and 16.5% (n = 30) had minor complications (Clavien Dindo I-II). The median Δ albumin was 22.75% (range: -18.46–47.14%). Delta albumin was found to be significantly higher in patients who developed complications after surgery (p = 0.03). Notably, neither preoperative (p = 0.28) nor postoperative albumin levels (p = 0.41) taken as absolute numerical values correlated with an eventful course following intestinal resection. In the multivariate analysis, based on a cut-off of 24.27%, Δ albumin remained an independent factor for surgical complications (p = 0.04, OR 2.232) next to conversion rate (p<0.001, OR 5.577) and the presence of an inflammatory mass (p = 0.003, OR 0.280). Conclusion Δ albumin is a better prognostic marker for an eventful postoperative course after laparoscopic surgery in patients with Crohn’s disease in comparison to albumin alone.
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Affiliation(s)
- Catharina Müller
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Anton Stift
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Stanislaus Argeny
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Bergmann
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Gnant
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Sebastian Marolt
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Lukas Unger
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Riss
- Department of Surgery, Division of General Surgery and Comprehensive Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
- * E-mail:
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van Beek DEC, Königs MHH, Kuijpers YAM, van der Horst ICC, Scheeren TWL. Predictive value of serum albumin levels on noradrenaline and fluid requirements in the first 24 h after admission to the Intensive Care Unit - A prospective observational study. J Crit Care 2018; 47:99-103. [PMID: 29940406 DOI: 10.1016/j.jcrc.2018.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 01/04/2023]
Abstract
PURPOSE To determine the predictive value of serum albumin (SA) at admission to the intensive care unit (ICU) on the cumulative dose of noradrenaline, the fluids administered, the lactate level, and mortality during the first 24 h of ICU admission. METHODS A total of 100 ICU patients were included. The association between SA and the cumulative dose of noradrenaline was analyzed using logistic regression. For the total amount of fluids administered linear regression, for the lactate level and for 24 h mortality logistic regression was used. Age, gender, patient category, type of surgery, severe sepsis, lactate level, estimated glomerular filtration rate, c-reactive protein level, and the target mean arterial pressure were considered effect modifiers. RESULTS SA was significantly associated with the dose of noradrenaline (OR 0.92, 95% CI 0.84–0.99, p = 0.028), lower lactate levels (OR 1.14, 95% CI 1.00–1.30, p = 0.049), and with the amount of fluids administered (B -0.02, 95% CI −0.03/−0.00, p = 0.016), but not with mortality (OR 0.95, 95% CI 0.85–1.07, p = 0.41). CONCLUSIONS SA significantly predicts noradrenaline and fluid requirements as well as the change in lactate level during the first 24 h of ICU admission. Our observations have to be validated in another large cohort.
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Affiliation(s)
- Dianne E C van Beek
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Intensive Care, Maxima Medical Center, Veldhoven, The Netherlands.
| | - Marc H H Königs
- Department of Intensive Care, Maxima Medical Center, Veldhoven, The Netherlands
| | - Yvette A M Kuijpers
- Department of Intensive Care, Maxima Medical Center, Veldhoven, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Amouzandeh M, Nowak G, Januszkiewicz A, Wernerman J, Rooyackers O, Norberg Å. Albumin mass balance and kinetics in liver transplantation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:152. [PMID: 29880012 PMCID: PMC5992699 DOI: 10.1186/s13054-018-2053-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
Background In major abdominal surgery albumin is shifted from the circulation, presumably leaking into the interstitial space, contributing to a 30–40% decrease in plasma albumin concentration. During and after liver transplantation exogenous albumin is infused for volume substitution and to maintain plasma albumin concentration. Here we used liver transplantation as a model procedure for the study of albumin mass balance and kinetics during major abdominal surgery with albumin substitution. Methods Patients were studied during liver transplantation (n = 16), and until postoperative day 3 (POD 3) (n = 11). Cumulative perioperative albumin shift was assessed by mass balance of albumin and hemoglobin. Synthesis rates of albumin and fibrinogen were estimated by the flooding technique using deuterium-labeled phenylalanine. Albumin distribution was assessed by radioiodinated human serum albumin. Results At the end of surgery, 37 ± 17 g of albumin (p < 0.0001) had shifted from plasma, and this amount was stable until POD 3 (48 ± 33 g, p = 0.0017 versus baseline). There was 91 ± 37 g exogenous albumin infused peroperatively and another 47 ± 35 g was infused postoperatively until POD 3. Absolute synthesis rates of albumin and fibrinogen on POD 3 were 239 ± 84 mg/kg body weight/day and 33 mg/kg body weight/day (range 5–161), respectively. Conclusions Albumin net leakage from plasma progressed until the end of surgery, and was then unaltered until POD 3. This is in contrast with the normalization of the cumulative albumin shift identified at day 3 after non-transplant major abdominal surgery. Liver synthesis of export proteins was high compared to reference values at the third postoperative day, suggesting rapid recovery of synthesis capacity. Trial registration Swedish Medical Product Agency, EudraCT 2015-002568-18. Registered on 15 July 2015.
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Affiliation(s)
- Mariam Amouzandeh
- Perioperative Medicine and Intensive Care, B31, Karolinska University Hospital, Huddinge, SE-141 86, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, Stockholm, Sweden
| | - Greg Nowak
- Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, Stockholm, Sweden.,Trauma and Reparative Medicine, Transplantation Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Anna Januszkiewicz
- Perioperative Medicine and Intensive Care, B31, Karolinska University Hospital, Huddinge, SE-141 86, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, Stockholm, Sweden
| | - Jan Wernerman
- Perioperative Medicine and Intensive Care, B31, Karolinska University Hospital, Huddinge, SE-141 86, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, Stockholm, Sweden
| | - Olav Rooyackers
- Perioperative Medicine and Intensive Care, B31, Karolinska University Hospital, Huddinge, SE-141 86, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, Stockholm, Sweden
| | - Åke Norberg
- Perioperative Medicine and Intensive Care, B31, Karolinska University Hospital, Huddinge, SE-141 86, Stockholm, Sweden. .,Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, Stockholm, Sweden.
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Goulart A, Ferreira C, Estrada A, Nogueira F, Martins S, Mesquita-Rodrigues A, Sousa N, Leão P. Early Inflammatory Biomarkers as Predictive Factors for Freedom from Infection after Colorectal Cancer Surgery: A Prospective Cohort Study. Surg Infect (Larchmt) 2018; 19:446-450. [PMID: 29624484 DOI: 10.1089/sur.2017.294] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Different biomarkers are useful in diagnosing infections. The aim of this work was to clarify the relation between different inflammatory biomarkers (white blood cell [WBC] count, C-reactive protein [CRP], procalcitonin [PCT], and C-reactive protein-to-albumin ratio [CAR]) and early infectious complications after colorectal surgery. METHODS This prospective single-center cohort study included 130 patients undergoing elective colorectal surgery. The WBC count, CRP, and PCT were measured at post-operative day one (POD1) and POD3 and albumin on POD3. RESULTS Patients with surgical site infections (SSI) exhibited significantly higher CRP concentrations on POD1 and CRP and CAR on POD3 than did patients without SSI. According to receiver operating characteristic analysis, the CRP concentration on POD1 and the CRP and CAR on POD3 showed the highest area under the curve (AUC) for predicting SSI (AUC 0.639, 0.736, and 0.729, respectively). Multivariable logistic regression analysis showed that CRP on POD1 and CRP and CAR on POD3 were independent predictors of SSI (odds ratio 7.355, 7.605, and 8.337, respectively). CONCLUSIONS The CRP concentration on PO1 and CRP and CAR on POD3 can positively identify patients at low risk of SSI. They can be used as a prognostic tool to predict an uneventful post-operative period and therefore have been incorporate into our discharge criteria after elective colorectal resection, improving clinical decision-making.
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Affiliation(s)
- André Goulart
- 1 Departments of General Surgery, Hospital de Braga , Braga, Portugal .,2 Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho , Braga, Portugal
| | - Carla Ferreira
- 2 Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho , Braga, Portugal
| | | | - Fernanda Nogueira
- 1 Departments of General Surgery, Hospital de Braga , Braga, Portugal
| | - Sandra Martins
- 1 Departments of General Surgery, Hospital de Braga , Braga, Portugal .,2 Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho , Braga, Portugal
| | | | - Nuno Sousa
- 2 Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho , Braga, Portugal
| | - Pedro Leão
- 1 Departments of General Surgery, Hospital de Braga , Braga, Portugal .,2 Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho , Braga, Portugal
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Liu ZJ, Ge XL, Ai SC, Wang HK, Sun F, Chen L, Guan WX. Postoperative decrease of serum albumin predicts short-term complications in patients undergoing gastric cancer resection. World J Gastroenterol 2017; 23:4978-4985. [PMID: 28785152 PMCID: PMC5526768 DOI: 10.3748/wjg.v23.i27.4978] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/12/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To find an accurate and simple predictor for postoperative short-term complications after gastrectomy.
METHODS Two hundred and twenty-three patients undergoing gastric cancer resection between October 1, 2015 and September 30, 2016 were enrolled in this study. Univariate and multivariate analyses were used to identify risk factors for complications after gastrectomy. The cutoff values and diagnostic accuracy were examined by receiver operating characteristic curves.
RESULTS Sixty-two (27.8%) patients had short-term complications after gastric cancer resection. The postoperative decrease in serum albumin (∆ALB) was an independent risk factor for complications (OR = 17.957, 95%CI: 6.073-53.095, P < 0.001). The cutoff value was 14.0% and the area under the curve was higher than that of C-reactive protein on postoperative day 3 (area under the curve: 0.806 vs 0.709). Patients with ∆ALB ≥ 14.0% were more likely to have short-term complications after gastrectomy (46.7% vs 5.0%, P < 0.001), prolonged hospital stay (17.2 ± 10.8 d vs 14.1 ± 4.2 d, P = 0.007) and higher comprehensive complication index (P < 0.001) than those with ∆ALB < 14.0%.
CONCLUSION Postoperative ∆ALB with a cutoff of 14.0% can be used to recognize patients who have high risk of short-term complications following gastric cancer resection.
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Dumitrescu G, Komaromi A, Rooyackers O, Klaude M, Hebert C, Wernerman J, Norberg Å. Repeated quantitative measurements of De Novo synthesis of albumin and fibrinogen. PLoS One 2017; 12:e0174611. [PMID: 28350862 PMCID: PMC5370154 DOI: 10.1371/journal.pone.0174611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/13/2017] [Indexed: 11/18/2022] Open
Abstract
The possibility of using two different isotopomers, for the incorporation of isotopically labeled amino acids, was explored to enable longitudinal studies of de novo synthesis of two export liver proteins, albumin and fibrinogen. The agreement of the synthesis rates between the two different labels was evaluated along with the reproducibility of repeated experiments using different time intervals. Healthy volunteers were studied in a standardized fed state. Protocol A (n = 10) involved two measurements 48 hours apart. Protocol B (n = 6) involved three measurements at baseline and five hours and then seven days after the initial measurement. De novo synthesis of albumin and fibrinogen by the incorporation of D5-phenylalanine or D8-phenylalanine were measured using the flooding dose technique. Albumin and fibrinogen were isolated from plasma using standard techniques. Fractional and absolute synthesis rates were calculated. Repeated measurements employing the two isotoptomers showed good agreement for albumin fractional synthesis rate after 48 hours (p = 0.92) and after 7 days (p = 0.99), with a coefficient of variation of 5.9% when using the same isotopic label. For fibrinogen, the coefficient of variation for the fractional synthesis rate employing the same isotopic label was 16.6%. Repeated measurements after 48 hours and seven days showed less agreement although there was no statistical difference (P = 0.32 and P = 0.30 respectively). Repeated measurement after five hours showed a statistical significant difference for the fractional synthesis rate of fibrinogen (p = 0.008) but not for albumin (p = 0.12). Repeated measurements of albumin de novo synthesis more than 48 hours apart show acceptable agreement using either one or two different isotopic labels. For fibrinogen the larger intra-individual scatter necessitates larger study groups to detect changes in longitudinal studies. Repeated measurements within 48 hours need to be validated further.
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Affiliation(s)
- Gabriel Dumitrescu
- Department of Anesthesia and Intensive Care Medicine at Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Andras Komaromi
- Department of Anesthesia and Intensive Care Medicine at Karolinska University Hospital, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Anesthesia and Intensive Care Medicine at Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Maria Klaude
- Department of Clinical Science, Intervention and Technology CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Christina Hebert
- Department of Clinical Science, Intervention and Technology CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Department of Anesthesia and Intensive Care Medicine at Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Department of Anesthesia and Intensive Care Medicine at Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology CLINTEC, Karolinska Institutet, Stockholm, Sweden
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Early Postoperative Decrease of Serum Albumin Predicts Surgical Outcome in Patients Undergoing Colorectal Resection. Dis Colon Rectum 2017; 60:326-334. [PMID: 28177996 DOI: 10.1097/dcr.0000000000000750] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A simple and accurate predictor of postoperative complications is needed for early and safe discharge after surgery. A decrease in serum albumin is commonly observed early after surgery, even in patients with normal preoperative levels. However, whether it predicts patient postoperative outcome is unknown. OBJECTIVE The purpose of this study was to evaluate whether the reduction in serum albumin within 2 postoperative days compared with the preoperative level could serve as an independent predictor of postoperative complications after colorectal surgery. DESIGN This was a retrospective study from a single institution. SETTINGS The study was conducted in a tertiary referral hospital. PATIENTS A total of 626 patients undergoing major colorectal surgery between December 2012 and January 2016 were eligible for this study. MAIN OUTCOME MEASURES Univariate and multivariate analyses were performed to identify risk factors for postoperative complications and to identify the factors associated with Δalbumin. Receiver operating characteristic curves were developed to examine the cutoff value of the change in albumin in predicting postoperative complications. RESULTS Among all of the patients, the median Δalbumin after surgery was 15%. ΔAlbumin was an independent risk factor for overall complications (p < 0.01). The cutoff value was 15%, and an increased area under the curve compared with C-reactive protein occurred on postoperative day 3 or 4. Patients with a Δalbumin ≥15% experienced more postoperative major complications, a higher comprehensive complication index, a longer postoperative stay, and increased surgical site infections (p < 0.05) than those <15%. ΔAlbumin correlated with sex, type of surgery, stoma creation, C-reactive protein on postoperative day 3 or 4, and intraoperative blood transfusion. Postoperative C-reactive protein remained independently associated with Δalbumin (p < 0.01). LIMITATIONS The study was limited by its retrospective nature. CONCLUSIONS A cutoff value of a 15% reduction in serum albumin within 2 postoperative days could help to identify patients with a high probability of postoperative complications and permit safe and early discharge after colorectal surgery.
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Wernerman J, Morris CR, Paddon-Jones D, Sarav M. Assessment of Protein Turnover in Health and Disease. Nutr Clin Pract 2017; 32:15S-20S. [DOI: 10.1177/0884533617694611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jan Wernerman
- Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | | | - Douglas Paddon-Jones
- Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Menaka Sarav
- Section of Nephrology and Hypertension, NorthShore University HealthSystem, University of Chicago, Evanston, Illinois, USA
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Ge X, Cao Y, Wang H, Ding C, Tian H, Zhang X, Gong J, Zhu W, Li N. Diagnostic accuracy of the postoperative ratio of C-reactive protein to albumin for complications after colorectal surgery. World J Surg Oncol 2017; 15:15. [PMID: 28069031 PMCID: PMC5223565 DOI: 10.1186/s12957-016-1092-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/23/2016] [Indexed: 12/14/2022] Open
Abstract
Background The ratio of C-reactive protein to albumin, as a novel inflammation-based prognostic score, is associated with outcomes in cancer and septic patients. The diagnostic accuracy of the CRP/albumin ratio has not been assessed in colorectal surgery for postoperative complications. Methods A total of 359 patients undergoing major colorectal surgery between 2012 and 2015 were eligible for this study. Uni- and multivariate analyses were performed to identify risk factors for postoperative complications. Receiver operating characteristic curves were developed to examine the cutoff values and diagnostic accuracy of the CRP/albumin ratio and postoperative CRP levels. Results Among all the patients, 139 (38.7%) were reported to have postoperative complications. The CRP/albumin ratio was an independent risk factor for complications (OR 4.413; 95% CI 2.463–7.906; P < 0.001), and the cutoff value was 2.2, which had a higher area under the curve compared to CRP on postoperative day 3 (AUC 0.779 vs 0.756). The CRP/albumin ratio also had a higher positive predictive value than CRP levels on postoperative day 3. Patients with CRP/albumin ≥2.2 suffered more postoperative complications (60.8% vs 18.6%, P < 0.001), longer postoperative stays (10 (4–71) vs 7 (3–78) days, P < 0.001), and increased surgical site infections (SSIs) (21.1% vs 4.8%, P < 0.001) than those with CRP/albumin <2.2. Conclusions The ratio of C-reactive protein to albumin could help to identify patients who have a high probability of postoperative complications, and the ratio has higher diagnostic accuracy than C-reactive protein alone for postoperative complications in colorectal surgery.
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Affiliation(s)
- Xiaolong Ge
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Yu Cao
- Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hongkan Wang
- First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Ding
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Hongliang Tian
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Xueying Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China.
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China.
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Feng C, Feng M, Jiao R, Liu D, Jin Y, Zhao X, Xiao R. Effect of Dezocine on IL-12 and IL-10 secretion and lymphocyte activation by culturing dendritic cells from human umbilical cord blood. Eur J Pharmacol 2016; 796:110-114. [PMID: 28017828 DOI: 10.1016/j.ejphar.2016.12.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 01/06/2023]
Abstract
Dezocine has been generally utilized for pain therapy and auxiliary anesthesia. Although it has some advantages on the prevention of some anesthesia related complications, its effect on immune responses remains unclear. Our study investigated the effects of Dezocine on IL-10 and IL-12 secretion and lymphocytes activation by culturing dendritic cells (DCs), and revealed the underlying mechanism. Mononuclear cells were divided into negative control group (GN), positive control group (GP), experimental group (GD; GD5, D7, D9). DCs morphological structure was performed by microscope and its phenotypes were evaluated by flow cytometry. IL-12 and IL-10 levels were determined by ELISA and lymphocyte proliferation capacity was performed by MTT assay. Results showed that typical morphological characters of DCs were observed in GP and GD. The positive cell percentages of CD83, HLA-DR, CD80, CD86 and CD40 in GD were lower than those in GP, but higher than the GN group (P<0.01). IL-12 level in GD was higher than in GP, however, IL-10 was opposite (P<0.01). The optical density in GD was lower than in GP (P<0.05). There were no dose-dependent relationships correlated with DCs phenotypes, IL-12 and IL-10 secretion and lymphocytes activation (P>0.05). Our conclusion was that Dezocine might play a role in immunity by regulating IL-12 and IL-10 secretion, and affecting lymphocyte activity in process of DCs maturation. Our findings reveal an unexpected immuno-regulatory function of Dezocine in DCs and provide an important insight for investigating the effect of opioid drugs in immunologic responses.
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Affiliation(s)
- Chang Feng
- Department of Anesthesiology, The Second Hospital of Shandong University, 247 Bei Yuan Street, Jinan 250033, China
| | - Man Feng
- Department of Pathology, Affiliated Hospital of Shandong Academy of Medical Sciences, Shandong Academy of Medical Sciences, 38 Wu Yingshan Road, Jinan 250031, China
| | - Ran Jiao
- Department of Operation Room, Ophthalmologic Hospital of Shandong Province, 372 Jing Si Road, Jinan 250021, China
| | - Dongyi Liu
- Department of Anesthesiology, The Second Hospital of Shandong University, 247 Bei Yuan Street, Jinan 250033, China
| | - Yanwu Jin
- Department of Anesthesiology, The Second Hospital of Shandong University, 247 Bei Yuan Street, Jinan 250033, China
| | - Xin Zhao
- Department of Anesthesiology, The Second Hospital of Shandong University, 247 Bei Yuan Street, Jinan 250033, China.
| | - Ruixue Xiao
- Department of Pathology, Affiliated Hospital of Shandong Academy of Medical Sciences, Shandong Academy of Medical Sciences, 38 Wu Yingshan Road, Jinan 250031, China
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Statkevicius S, Bonnevier J, Bark BP, Larsson E, Öberg CM, Kannisto P, Tingstedt B, Bentzer P. The importance of albumin infusion rate for plasma volume expansion following major abdominal surgery - AIR: study protocol for a randomised controlled trial. Trials 2016; 17:578. [PMID: 27923389 PMCID: PMC5142270 DOI: 10.1186/s13063-016-1714-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 11/17/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Administration of fluids to restore normovolaemia is one of the most common therapeutic interventions performed peri-operatively and in the critically ill, but no study has evaluated the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid. The present study is designed to test the hypothesis that a slow infusion of resuscitation fluid results in better plasma volume expansion than a rapid infusion. METHODS/DESIGN The study is a single-centre, assessor-blinded, parallel-group, randomised prospective study. Patients over 40 years of age admitted to the post-operative care unit after a Whipple procedure or major gynaecological surgery and presenting with signs of hypovolaemia are eligible for inclusion. Patients are randomised in a 1:1 fashion with no stratification to either rapid (30 minutes) or slow (180 minutes) infusion of 5% albumin at a dose of 10 ml/kg ideal body weight. Plasma volume is measured using 125I human serum albumin at baseline (prior to albumin infusion) as well as at 30 minutes and 180 minutes after infusion start. The primary endpoint is change in plasma volume from baseline to 180 minutes after the start of 5% albumin infusion. Secondary endpoints include the integral of plasma volume over time from baseline to 180 minutes after the start of the infusion and transcapillary escape rate of albumin (%/h) from 180 minutes to 240 minutes after the start of albumin infusion. In addition, diuresis, change in central venous oxygen saturation, lactate and blood pressure will be evaluated. A total of 70 patients will be included in the study, and the study has 80% power to detect a difference of 4 ml/kg in plasma volume expansion between the two groups. DISCUSSION The present study is the first clinical investigation of the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid. TRIAL REGISTRATION EudraCT identifier: 2013-004446-42 . Registration date: 20 December 2013. ClinicalTrials.gov identifier: NCT02728921 . Registration date: 31 March 2016.
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Affiliation(s)
- Svajunas Statkevicius
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Johan Bonnevier
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Björn P. Bark
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Erik Larsson
- Department of Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Carl M. Öberg
- Department of Nephrology, Skåne University Hospital, Lund, Sweden
| | - Päivi Kannisto
- Department of Gynaecology and Obstetrics, Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Peter Bentzer
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital and Lund University, 251 87 Helsingborg, Sweden
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Komáromi A, Estenberg U, Hammarqvist F, Rooyackers O, Wernerman J, Norberg Å. Simultaneous assessment of the synthesis rate and transcapillary escape rate of albumin in inflammation and surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:370. [PMID: 27846908 PMCID: PMC5111293 DOI: 10.1186/s13054-016-1536-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 10/18/2016] [Indexed: 12/31/2022]
Abstract
Background Better knowledge of albumin kinetics is needed to define the indications for albumin use in clinical practice. This study involved two approaches: the synthesis rate and transcapillary escape rate of albumin were measured simultaneously at different levels of plasma albumin concentration in relation to acute inflammation and surgery; and two different tracers were compared to determine plasma volume and the transcapillary escape rate. Methods Healthy volunteers (n = 10), patients with acute inflammatory abdominal disease (n = 10), and patients undergoing elective pancreatic resection (n = 10) were studied. The albumin synthesis rate was measured by the incorporation of deuterium-labeled phenylalanine. Plasma volume and the transcapillary escape rate were assessed using 123I-labeled and 125I-labeled albumin. Results A 50 % elevated de-novo albumin synthesis rate was seen in patients with acute inflammation and marked hypoalbuminemia, while patients with marginal hypoalbuminemia before the start of surgery had a normal albumin synthesis rate. The transcapillary escape rate was elevated intraoperatively during the reconstructive phase of pancreatic surgery, when plasma albumin was decreased but stable. In acute inflammation with marked hypoalbuminemia, the transcapillary escape rate was no different from normal. 123I-labeled and 125I-labeled albumin were found exchangeable for plasma volume determinations, but could be used only in groups of patients for the transcapillary escape rate. Conclusions This observational study illustrates the limited information contained in albumin plasma concentrations to reflect albumin kinetics. On the contrary, single measurements of the synthesis rate and/or transcapillary escape rate of albumin obviously cannot explain the plasma level of albumin or the changes seen in plasma albumin concentration. Trial registration www.clinicaltrials.gov, study number NCT01686776. Registered 13 September 2012.
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Affiliation(s)
- András Komáromi
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
| | - Ulrika Estenberg
- Department of Nuclear Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Folke Hammarqvist
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Center for Digestive Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Jan Wernerman
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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Máca J, Burša F, Ševčík P, Sklienka P, Burda M, Holub M. Alarmins and Clinical Outcomes After Major Abdominal Surgery-A Prospective Study. J INVEST SURG 2016; 30:152-161. [PMID: 27689623 DOI: 10.1080/08941939.2016.1231855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Tissue injury causing immune response is an integral part of surgical procedure. Evaluation of the degree of surgical trauma could help to improve postoperative management and determine the clinical outcomes. MATERIALS AND METHODS We analyzed serum levels of alarmins, including S100A5, S100A6, S100A8, S100A9, S100A11, and S100A12; high-mobility group box 1; and heat-shock protein 70, after elective major abdominal surgery (n = 82). Blood samples were collected for three consecutive days after surgery. The goals were to evaluate the relationships among the serum levels of alarmins and selected surgical characteristics and to test potential of alarmins to predict the clinical outcomes. RESULTS Significant, positive correlations were found for high-mobility group box 1 with the length of surgery, blood loss, and intraoperative fluid intake for all three days of blood sampling. The protein S100A8 serum levels showed positive correlations with intensive care unit length of stay, 28-day and in-hospital mortality. The protein S100A12 serum levels had significant, positive correlations with intensive care unit length of stay, 28-day mortality, and in-hospital mortality. We did not find significant differences in alarmin levels between cancer and noncancer subjects. CONCLUSION The high-mobility group box 1 serum levels reflect the degree of surgical injury, whereas proteins S100A8 and S100A12 might be considered good predictors of major abdominal surgery morbidity and mortality.
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Affiliation(s)
- Jan Máca
- a University of Ostrava , Ostrava , Czech Republic.,b University Hospital of Ostrava , Ostrava , Czech Republic
| | - Filip Burša
- a University of Ostrava , Ostrava , Czech Republic.,b University Hospital of Ostrava , Ostrava , Czech Republic
| | - Pavel Ševčík
- a University of Ostrava , Ostrava , Czech Republic.,b University Hospital of Ostrava , Ostrava , Czech Republic
| | - Peter Sklienka
- a University of Ostrava , Ostrava , Czech Republic.,b University Hospital of Ostrava , Ostrava , Czech Republic
| | - Michal Burda
- c University of Ostrava , Institute for Research and Applications of Fuzzy Modeling , Ostrava , Czech Republic
| | - Michal Holub
- d Univerzita Karlova v Praze , First Faculty Of Medicine , Praha , Czech Republic.,e Military Hospital of Prague , Prague , Czech Republic
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Norberg Å, Rooyackers O, Segersvärd R, Wernerman J. Leakage of albumin in major abdominal surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:113. [PMID: 27117323 PMCID: PMC4845320 DOI: 10.1186/s13054-016-1283-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/01/2016] [Indexed: 11/29/2022]
Abstract
Background The time course of plasma albumin concentration (P-alb) and cumulative perioperative albumin shift as a measure of albumin extravasation in major abdominal surgery is not well described. Knowledge of these indices of the vascular barrier and vascular content are important for our understanding of fluid physiology during surgery and anesthesia. Methods Patients (n = 10) were studied during esophageal or pancreatic surgery. P-alb was repeatedly measured over 72 h, and the mass balance of albumin and hemoglobin were obtained from measures of P-alb, blood hemoglobin and hematocrit. Results P-alb decreased rapidly from baseline (32.8 ± 4.8 g/L) until the start of surgical reconstruction (18.7 ± 4.8 g/L; p < 0.001), and was thereafter stable until postoperative day 3. Cumulative perioperative albumin shift increased until 1 h after the end of surgery, when 24 ± 17 g (p < 0.001) had been lost from the circulation. Conclusions The rapid fall in P-alb of more than 40 % consistently occurred during the first part of the surgical procedure, but albumin leakage progressed until 1 h after the end of surgery. After the initial drop, P-alb was stable for 72 h. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1283-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Åke Norberg
- Department of Anaesthesia and Intensive Care, Karolinska University Hospital Huddinge, Hälsovägen, SE-141 86, Stockholm, Sweden. .,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, SE-141 86, Stockholm, Sweden.
| | - Olav Rooyackers
- Department of Anaesthesia and Intensive Care, Karolinska University Hospital Huddinge, Hälsovägen, SE-141 86, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, SE-141 86, Stockholm, Sweden
| | - Ralf Segersvärd
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, SE-141 86, Stockholm, Sweden.,Division of Surgery, Karolinska University Hospital Huddinge, Hälsovägen, SE-141 86, Stockholm, Sweden
| | - Jan Wernerman
- Department of Anaesthesia and Intensive Care, Karolinska University Hospital Huddinge, Hälsovägen, SE-141 86, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen, SE-141 86, Stockholm, Sweden
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Sundström Rehal M, Tjäder I, Wernerman J. Nutritional needs for the critically ill in relation to inflammation. Curr Opin Clin Nutr Metab Care 2016; 19:138-43. [PMID: 26808267 DOI: 10.1097/mco.0000000000000260] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This review focuses on nutritional needs in critically ill patients. The inflammation corresponding to acute stress is highlighted. Simultaneously, we try to avoid limiting the perspective to only the acute phase. RECENT FINDINGS During the last year, a number of important studies on nutritional needs in the critically ill have been published, including large randomized controlled trials. In particular studies addressing the needs for energy and proteins in the critically ill have imparted new knowledge in this field. However, there are few studies concerning the rehabilitation phase after critical illness. SUMMARY Although the recent findings and publications contribute to a more nuanced understanding of nutrition during critical illness, the implications for clinical practice are not in discord with the current recommendations of guidelines.
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Affiliation(s)
- Martin Sundström Rehal
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
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Role of albumin in diseases associated with severe systemic inflammation: Pathophysiologic and clinical evidence in sepsis and in decompensated cirrhosis. J Crit Care 2015; 33:62-70. [PMID: 26831575 DOI: 10.1016/j.jcrc.2015.12.019] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/21/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023]
Abstract
The metabolism of albumin in inflammatory states such as sepsis or major surgery is complex and still not well characterized. Nevertheless, in inflammatory states, albumin synthesis has been observed to increase. By contrast, in decompensated cirrhosis, a disease characterized by systemic inflammation, albumin synthesis by the liver may decrease to 30% to 50% of normal values. Furthermore, in these conditions, there are high capillary leakage and altered albumin kinetics. The discussion regarding the effect of exogenous albumin administration on intravascular volume in inflammatory states should therefore address albumin turnover. To add complexity to our understanding of the effects of albumin, there are many data indicating that the therapeutic action of albumin is mediated not only through the impact on plasma volume expansion but also through a modulatory effect on inflammation and oxidative stress. All these characteristics are relevant to diseases associated with systemic inflammation including sepsis and decompensated cirrhosis.
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