Colloids Yes or No? - a "Gretchen Question" Answered

Albumin: a comprehensive review and practical guideline for clinical use

PURPOSE

Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration.

METHODS

Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication.

RESULTS

A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation.

CONCLUSION

Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.

2024 AAHA Fluid Therapy Guidelines for Dogs and Cats

Fluids are drugs used in veterinary patients capable of producing beneficial therapeutic or inadvertent harmful effects within the body's intravascular, interstitial, and intracellular fluid spaces. The individualized design of a fluid therapy plan requires careful patient assessment and targeted selection of proper fluid types, administration routes, and rates, along with adjustments during therapy tailored specifically as per the individual patient's fluid requirement and therapeutic response. Personalized fluid prescriptions and vigilant patient monitoring help avoid patient morbidity from body fluid deficiencies, fluid excess, and electrolyte derangements and support better patient outcomes. These guidelines provide an overview of fluid dynamics within the fluid spaces of the body, describe various types of fluids and their uses, and outline recommendations for fluid administration for resuscitation, rehydration, and maintenance purposes. The guidelines also outline approaches to fluid therapy for anesthetized patients and reiterate the recommendations of reduced fluid rates in this population of patients. Additionally, the guidelines include practical fluid therapy strategies for patients with various common disorders. The goal of these guidelines is to help veterinary professionals safely and effectively prescribe and administer fluid therapy for canine and feline patients.

Retrospective evaluation of indications, transfusion protocols, and acute transfusion reactions associated with the administration of lyophilized canine albumin: 53 cases (2009-2020)

OBJECTIVES

To describe the administration of lyophilized canine albumin (LCA) and determine the increase in serum albumin concentrations post-LCA transfusion. To describe the incidence and types of acute transfusion reactions (TRs) and associated outcome in dogs presenting to a veterinary teaching hospital.

DESIGN

Retrospective and descriptive study from 2009 to 2020.

SETTING

University teaching hospital.

ANIMALS

Fifty-three client-owned dogs included in the study if they received an LCA transfusion and had vital sign monitoring recorded for at least for 4 hours after starting the LCA transfusion.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The 53 dogs available for study inclusion received 64 LCA transfusions. Signalment; underlying disease; indications for LCA transfusion; pre- and posttransfusion serum albumin concentration; volume, concentration, and dose of LCA; duration of transfusion; administration of other blood products or synthetic colloids; occurrence, timing, and type of TR; length of hospitalization; and outcome were recorded. Serum albumin concentrations increased post-LCA transfusion, with a median dose of 0.56 g/kg and a median posttransfusion serum albumin increase of 3 g/L (0.3 g/dL) (P = 0.008). TRs occurred in 13 of 64 (20.3%) transfusion events. Volume per kilogram, dose (g/kg), concentration, duration of transfusion, and additional administration of synthetic colloids were not associated with TRs. Three (23%) TRs were classified as febrile nonhemolytic transfusion reaction, 5 (38.5%) as transfusion-associated dyspnea (development of respiratory distress and limited diagnostics), and 5 (38.5%) had clinical signs that could not be defined by any 1 TR category. Six (46.1%) of 13 events were nonsevere, 5 (38.5%) were severe, and 2 (15.4%) were life-threatening.

CONCLUSIONS

Administration of LCA can be used to increase serum albumin concentrations, although the clinical implications of this increase are unknown. Acute TRs associated with LCA are relatively frequent and can be life-threatening. Careful monitoring is vital.

ENGINEERED INTRAVENOUS THERAPIES FOR TRAUMA

Trauma leading to severe hemorrhage and shock on average kills patients within 3 to 6 hours after injury. With average prehospital transport times reaching 1-6 hours in low- to middle-income countries, stopping the bleeding and reversing hemorrhagic shock is vital. First-generation intravenous hemostats rely on traditional drug delivery platforms, such as self-assembling systems, fabricated nanoparticles, and soluble polymers due to their active targeting, biodistribution, and safety. We discuss some challenges translating these therapies to patients, as very few have successfully made it through preclinical evaluation in large-animals, and none have translated to the clinic. Finally, we discuss the physiology of hemorrhagic shock, highlight a new low volume resuscitant (LVR) PEG-20k, and end with considerations for the rational design of LVRs.

A Comparison of Dobutamine, Norepinephrine, Vasopressin, and Hetastarch for the Treatment of Isoflurane-Induced Hypotension in Healthy, Normovolemic Dogs

Isoflurane is a commonly used inhalation anesthetic in species undergoing veterinary care that induces hypotension, impacting organ perfusion, making it imperative to minimize its occurrence or identify effective strategies for treating it. This study evaluated and compared the hemodynamic effects of DOB, NEP, VAS, and HES in twelve isoflurane-anesthetized Beagle dogs. The order of the first three treatments was randomized. HES was administered last. Data were collected before treatments (baseline) and after 10 min of a sustained MAP of <45 mmHg induced by a high end-tidal isoflurane concentration (T0). Once treatment was initiated and the target MAP was achieved (65 to 80 mmHg) or the maximum dose reached, data were collected after 15 min of stabilization (T1) and 15 min after (T2). A 15 min washout period with a MAP of ≥65 mmHg was allowed between treatments. The intravenous dosage regimens started and were increased by 50% every five minutes until the target MAP or maximum dose was reached. The dosages were as follows: DOB, 5-15 μg/kg/min; NEP, 0.1-2 μg/kg/min; VAS, 0.5-5 mU/kg/min; and HET, 6% 1-20 mL/kg/min. DOB improved CO, DO2, and VO2, but reduced SVR. VAS elevated SVR, but decreased CO, DO2, and VO2. HES minimally changed BP and mildly augmented CO, DO2, and VO2. These treatments failed to reach the target MAP. NEP increased the arterial BP, CO, MPAP, and PAWP, but reduced HR. Norepinephrine infusion at 0.44 ± 0.19 μg/kg/min was the most efficient therapy for correcting isoflurane-induced hypotension.

Fluid Therapy in Exotic Animal Emergency and Critical Care

Many new concepts are emerging in the understanding of fluid therapy in human and mammalian medicine, including the role of the glycocalyx, increased understanding of fluid, sodium, and chloride overload, and the advantages of colloid administration in the form of albumin. None of these concepts, however, appear to be directly applicable to non-mammalian exotic patients, and careful consideration of their alternate physiology is required when formulating fluid plans for these patients.

Recent advances in bacteriophage-based therapeutics: Insight into the post-antibiotic era

Antibiotic resistance is one of the biggest threats to global health, as it can make the treatment of bacterial infections in humans difficult owing to their high incidence rate, mortality, and treatment costs. Bacteriophage, which constitutes a type of virus that can kill bacteria, is a promising alternative strategy against antibiotic-resistant bacterial infections. Although bacteriophage therapy was first used nearly a century ago, its development came to a standstill after introducing the antibiotics. Nowadays, with the rise in antibiotic resistance, bacteriophage therapy is in the spotlight again. As bacteriophage therapy is safe and has significant anti-bacterial activity, some specific types of bacteriophages (such as bacteriophage phiX174 and Pyo bacteriophage complex liquid) entered into phase III clinical trials. Herein, we review the key points of the antibiotic resistance crisis and illustrate the factors that support the renewal of bacteriophage applications. By summarizing recent state-of-the-art studies and clinical data on bacteriophage treatment, we introduced (i) the pharmacological mechanisms and advantages of antibacterial bacteriophages, (ii) bacteriophage preparations with clinical potential and bacteriophage-derived anti-bacterial treatment strategies, and (iii) bacteriophage therapeutics aimed at multiple infection types and infection-induced cancer treatments. Finally, we highlighted the challenges and critical perspectives of bacteriophage therapy for future clinical development.

Assessment of Hydroxyethyl Starch (6% HES 130/0.4) Kidney Storage in Critically Ill Dogs: A Post-mortem Prospective Study

Objective: Intravenous hydroxyethyl starch (HES) solutions are potentially nephrotoxic due to rapid renal tissue uptake, subsequent osmotic nephrosis, and long-lasting intracellular storage. This study aimed to investigate the severity of intracellular storage of HES in renal tissue samples from critically ill dogs receiving 6% HES 130/0.4.

Materials and Methods: Fresh, post-mortem (<2 h after death) renal tissue samples were analyzed through histology, immunohistochemistry (HES 130/0.4-specific antibodies), and electron microscopy for the severity of renal tubular vacuolization (VAC), intravacuolar HES accumulation (ACC), and ultra-structure impairment. Moreover, we investigated the relationship between VAC or ACC grade and HES dose (mL/kg), duration of HES administration (h), and pre-HES plasma creatinine concentrations.

Results: Histology revealed that 2/20 dogs (10%) had no, 11/20 dogs (55%) had mild, 5/20 dogs (25%) had moderate, and 2/20 dogs (10%) had severe VAC. Immunohistochemistry revealed that 5/20 dogs (25%) had no, 6/20 dogs (30%) had mild, 7/20 dogs (35%) had moderate, and 2/20 dogs (10%) had severe ACC. Both changes were predominantly found in the distal tubular epithelium of mild and moderate cases, and all tubular segments were affected in severe cases. Seven of 20 dogs (35%) had osmotic nephrosis (ON). On electron microscopy, large granules with an electron-dense content were repeatedly detected in individual cells, mainly in the distal tubules. No correlation was found between cumulative HES dose or duration of HES administration and VAC grade, ACC grade, or presence/absence of ON.

Conclusion: A high percentage of dogs had renal tubular HES storage and one-third of dogs showed HES-induced ON. Short-term HES administration caused VAC and ACC, regardless of the dose or duration of administration. In contrast to previous studies, HES 130/0.4 deposits were mainly located in the renal distal tubule.