Resuscitation fluid practices in Brazilian intensive care units: a secondary analysis of Fluid-TRIPS

Objective

To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS.

Methods

This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice.

Results

On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only.

Conclusion

Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.

Effect of surgical technique in subtotal and bilateral thyroidectomy on risk of postoperative parathyroid insufficiency development--our experience

One of the postoperative complications after strumectomy is hypoparathyroidism. Therefore, the purpose of our study was to evaluate the effect of the surgical technique on the development of parathyroid gland insufficiency in our group of patients. Subtotal, bilateral strumectomies were performed according to Rothmund's suggestions. Randomized controlled trial was performed in two groups. In the first group of 19 patients, main trunk of the inferior thyroid artery was ligated and in the second one consisting of 18 patients, only the branches of this artery were ligated. Total calcium and PTH levels were evaluated pre- and postoperatively. Based on the biochemical and clinical data, no statistically significant differences in the development of postoperative hypoparathyroidism in relation to performed surgical techniques were observed.

The cytotoxicity of mafosfamide on G-CSF mobilized hematopoietic progenitors is reduced by SH groups of albumin--implications for further purging strategies

The efficacy of mafosfamide purging depends on factors like incubation time, drug and erythrocyte concentration. To determine the influence of protein-bound SH groups in the incubation medium, the cytotoxicity of mafosfamide on G-CSF mobilized CD34+/- cells was evaluated by short-term culture assays and drug concentration measurements. 100 micromol/ml mafosfamide was incubated for 30 min in five buffers (PBS, PBS with 1%, 5% and 10% BSA and plasma). The mean calculated areas under the concentration-time curves (AUC) were 2489 +/- 198, 1561 +/- 286, 976 +/- 201, 585 +/- 62 and 605 +/- 196 micromol/l/min. The mean reductions of CFU-GM growth were 79.4%, 73.0%, 62.5%, 30.3%, 6.2% respectively. Similar results were obtained for BFU-E. Regression analysis showed a good correlation between cytotoxicity and AUCs (CFU-GM: r = 0.8195; BFU-E: r = 0.8207). This effect is well explained by the different concentrations of SH moieties in the incubation medium resulting in a higher drug binding capacity. The profound difference between AUCs and CFU-GMs in plasma and 10% BSA cannot be explained by the quantity of SH-groups. It is probably due to an additional enzymatic drug degeneration by the 3'-5'exonuclease subsite of plasma DNA polymerase. In conclusion, the concentration of albumin-associated SH groups strongly influences the cytotoxicity of mafosfamide. It has to be considered as a new and important aspect in ex vivo bone marrow purging.

[The natural history study of 208 patients with atherosclerosis of the lower extremities and diabetes mellitus]

Analysis of 208 patients with atherosclerosis of the lower extremities and co-existing diabetes mellitus was performed to document actual symptoms, to propose a classification of extremity ischemic to localisate atherosclerotic changes and to evaluate therapeutic methods and their results. Authors suggest that to improve therapeutic results in this group of patients necessary is as follows: (a) early diagnosis of atherosclerotic ischemia of extremities, (b) proper preparing to revascularization, (c) early reconstruction of ischemic vessels, (d) good specialist controls in after surgery period.

On the abdominal aortic aneurysms: pulsatile state considerations

Pulsatile blood flow using incompressible newtonian fluid is investigated numerically in abdominal aortic aneurysm models with the aid of transient Navier-Stokes equations for axisymmetric geometry. The arterial wall is assumed to be rigid. The actual arterial pressure-velocity pulse at the abdominal aorta is used as the inlet boundary condition to the aneurysm. The corresponding velocity at every time-step is assumed to be fully developed parabolic profile at the inlet. Time-dependent formation of vortices and occurrence of stagnation zones are analyzed in this numerical study. It has been found that the distal end of the aneurysm is subjected to maximum shear stress and pressure during the entire cycle. This analysis also confirms that the mechanical forces on the arterial wall, developed by the blood flow which is pulsatile in nature, may play an important role in both development and growth of aneurysms. It has also been found that a quasi-steady state may be used to explain sufficiently the basic flow characteristic within the aneurysm. The wall shear stress in the quasi-steady state at the distal end of the aneurysm during the most adverse condition was approximately the same as in the pulsatile state for a similar situation.

[A study of natural history in 208 patients with atherosclerosis of lower limb arteries and diabetes mellitus]

In the recent years a constant increase of the number of surgical patients with associated diabetes mellitus is observed. Surgical risk is still higher and therapeutic results are worse than in patients without diabetes mellitus. Many years of experience of our department in the surgical treatment of lower limb atherosclerosis (A0) in patients with diabetes, and also the previously published results of studies make possible drawing of conclusions and formulating of a general view. The studies were carried out in 208 patients with A0 and diabetes mellitus. On admission, 65.9% of the patients had IV degrees of limb ischaemia according to Fontaine. Vascular operations in these patients accounted only for 25% of all operations and were performed in 37% of patients. Amputations accounted even for 53.7% of all operations, and among them major amputations accounted for 56.3%. The early and remote results of the operations carried out were subjected to statistical analysis and presented using cumulated indices.

On the subclavian steal syndrome in vitro studies

An elastic model of the arterial system has been used in which a specially designed pumping unit simulated the heart action. Physiological pressures and normal geometry, size, and flow distribution together with the normal cardiac output and use of prosthetic heart valves are the features of the system. Atherosclerosis was simulated by introducing blockages of known cross-section at specific sites of predilection. It has been shown that, for some specific occlusion magnitude in the left or right subclavian, or in the brachycephalic arteries, the stagnant no blood flow condition will appear in the left vertebral, or the right vertebral, or right common carotid, or the right internal carotid arteries. For larger occlusions the blood flow in these arteries reverses its direction, i.e., the "steal syndrome" appears. It is shown that besides the known single steal syndrome there exists also a double steal syndrome, i.e., blood reverses its flow direction simultaneously in two arteries, both on the right side of the arterial system. This blood is taken from the circle of Willis, which at the same time is significantly supplemented by the increased blood flow through the other arteries leading into the circle of Willis.

[A rarely observed cause of renal artery stenosis and subsequent arterial hypertension]

An atypical and very rare case of renovascular hypertension is described. Hypertension was caused by compression of the renal artery by a crus of the diaphragm.

[Infected cecostomy treated with Riebler's dental paste]

Riebler's dental paste is well known to dentists and is widely used in conservative treatment of infected dental pulp. The possibility is described of its successful use in the treatment of suppurative cutaneocaecostomy, one of the most serious surgical complications.

[Bilateral amputations after multiple vascular operations in patients with advanced ischemia of the lower extremities]

In 62 patients 72 repeated multiple operations on the arteries of lower extremities were carried out. In 7 cases both lower extremities had to be amputated at mid-femoral level. The time from the first vascular operations to the amputation of the other extremity ranged from 6 months and 16 days to 8 years and 30 days (mean 5 years).

Recurrences after surgical treatment of patients with post-thrombotic syndrome of the lower extremities

A Linton flap operation was performed in 148 patients with post-thrombotic syndrome of the lower extremities. One-hundred and five patients were followed up from 6 months to 10 years and 14.5% of cases had recurrent ulcers. The most common causes of recurrence was further deep venous thrombosis or remaining incompetent perforating veins. All patients with a recurrence of their ulcer had a further operation and incompetent perforating veins were ligated and divided with good clinical results.

Effect of Aortic Arch Atherosclerotic Formations on Blood Mass Flow Distribution

The effect of the aortic arch atherosclerotic formations on blood mass flow distribution is determined experimentally on the aortic arch model, derived from x-ray traces, for the average values of the governing parameters: Reynolds number, unsteadiness parameter, and velocity fluctuation parameter. A computer program incorporating the experimrntal data is developed, which predicts approximately the flow distribution for various arterial blockages.

Effect of ischemic anoxia on electrical and mechanical activity of the totally isolated porcine stomach

Electrical and mechanical activity were recorded from totally isolated whole porcine stomachs perfused with homologous blood. Stagnant, complete ischemia was then produced by closing the gastric artery and vein for various periods of time up to 3 h. After a given period of ischemia, blood was recirculated for 10 min and then pentagastrin was injected into the gastric artery. The vagus nerve was also electrically stimulated at various stages of anoxia and recirculation. After up to 90 min of ischemia, stomachs were able to demonstrate electrical control activity of low frequency after 10 min of blood recirculation. After injection of pentagastrin, electrical control activity rapidly became normal. When ischemia lasted 120 min or longer, recirculation of blood did not induce reappearance of electrical control activity, but pentagastrin injection produced a normal response. After ischemia of 240 min duration or longer, recirculation and pentagastrin had no effect. In previously ischemic stomachs the response to vagal stimulation occurred only in the stomachs responding to pentagastrin.

Effect of ischemic anoxia on myoelectrical and mechanical activity of the totally isolated canine stomach

Electrical and mechanical activities were recorded from the totally isolated canine stomach perfused with homologous blood of a living oxygenator-supported dog. Stagnant ischemic anoxia was induced by closing inflow and outflow blood from the isolated organ for various periods of time up to four hours. Recording of electrical and mechanical activity was performed prior to, during, and after the anoxic periods. After a given period of ischemia, blood was recirculated for ten minutes, and the pentagastrin was injected into the gastric artery. After up to three hours of anoxia, stomachs were able to show recordable electrical activity when perfused for ten minutes with homologous blood. Up to this period of three hours, stomachs also responded to the injection of pentagastrin. Pentagastrin accelerated the normalization of electrical and mechanical activity of previously anoxic stomachs. After 3.5 to 4.0 hours of anoxia, recirculation of blood through the stomach and injection of pentagastrin had no effect on electrical and mechanical activity of the gastric musculature.

Electrical and mechanical activity of the isolated canine stomach perfused with homologous, in vitro, oxygenated blood

Electrical and mechanical activity was recorded from six totally isolated canine stomachs perfused with homologous blood oxygenated in vitro. Reactions to electrical vagal stimulation to cholinergic drugs and to pentagastrin were recorded. Electrical control activity, electrical response activity and mechanical response of isolated stomachs, observed in this in vitro system, were identical to those found in canine-isolated stomachs perfused with cross-circulated blood of living animals. It appears that when a living animal is included in the perfusion system of the isolated stomach, drugs used for gastric stimulation are rapidly metabolized and, due to this physiological clearance, repeated injections of stimulants can be given for several hours. Using the in vitro perfusion system, as in this experiment, injected drugs accumulate in the perfusion blood, as no clearance mechanism is available. Partial or total exchange of perfusion blood is therefore recommended. With these reservations, the in vitro system appears to be an easy method for the study of nonstimulated and stimulated electrical and mechanical activity of the totally isolated canine stomach.

The effect of drugs on the electrical and mechanical activity of the isolated porcine stomach

Electrical and mechanical activity was recorded from totally isoltted porcine stomachs perfused with homologous blood, The electrical control activity, response activity, and mechanical reaction to various hormones and drugs stimulationg these activities were recorded. The drugs were injected directly into the gastric artery of the isolated organ. Normal response to cholinergic stimulants and to pentagastrin was observed. The effect of blockers such as atropine, hexamethonium and tetrodotosin on the action of stimulants was also assessed. The results of this study suggest that the release of acetylcholine is involved in the mechanism of action of pentagastrin. They also demonstrate the usefulness of the isolated porcine stomach approach to the study of gastric myoelectrical and mechanical activity.

Effect of release of endogenous gastrin on myoelectrical and mechanical activity of isolated canine stomach

The myoelectrical and mechanical activities of the totally isolated, canine stomachs were recorded using five sets of bipolar silver-wire electrodes and one strain gauge. Stomachs were perfused extracorporeally with the blood of living supporting dogs which served as oxygenators and dialysers. Each supporting dog had a permanent antral pouch, accessible for the purpose of irrigation. To suppress the release of endogenous gastrin, this antral pouch and the antrum of the ex vivo stomach were irrigated with acid (pH 3). To induce the release of gastrin, one or both antra were irrigated with 0.2-percent acetylcholine or with 1 M glycine. To compare the action of endogenous gastrin with exogenous gastrin-like peptide, pentagastrin was infused into the gastric artery in doses of 4 mug/h and 8 mug/h. Control recordings were done during the acid irrigation. Endogenous gastrin released from antra by acetylcholine or glycine caused identical changes in the recordings as exogenous pentagastrin. There was a marked increase in the frequency of electrical control activity and of gastric contractions recorded as increased mechanical response. The results indicate that the ex vivo stomach can be used for study of the effect of endogenous gastrin musculature activity under the experimental conditions described.