|
1
|
Imran N, Ayesh A, Workeneh B, Shahait A. Sodium Bicarbonate: Use and Misuse in Clinical Medicine. Am J Ther 2024; 31:e508-e510. [PMID: 38657126 DOI: 10.1097/mjt.0000000000001709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Nashat Imran
- Nephrology Division, Internal Medicine Department, Wayne State University School of Medicine, Detroit, MI
| | - Ali Ayesh
- Nephrology Division, Internal Medicine Department, Wayne State University School of Medicine, Detroit, MI
| | - Biruh Workeneh
- Division of Nephrology, Baylor College of Medicine, Houston, TX
| | - Awni Shahait
- School of Medicine, Department of Surgery, Southern Illinois University, Carbondale, IL
| |
Collapse
|
|
2
|
Hypertonic saline for fluid resuscitation in ICU patients post-cardiac surgery (HERACLES): a double-blind randomized controlled clinical trial. Intensive Care Med 2020; 46:1683-1695. [PMID: 32519005 DOI: 10.1007/s00134-020-06132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Recent evidence questions a liberal approach to fluid resuscitation in intensive care unit (ICU) patients. Here, we assess whether use of hypertonic saline applied as single infusion at ICU admission after cardiac surgery can reduce cumulative perioperative fluid volume. METHODS Prospective randomized double-blind single-center clinical trial investigates effects of a single infusion of hypertonic saline (HS) versus normal saline (comparator). Primary endpoint was the cumulative amount of fluid administered in patients in the hypertonic saline versus the 0.9% saline groups (during ICU stay). Upon ICU admission, patients received a single infusion of 5 ml/kg body weight of 7.3% NaCl (or 0.9% NaCl) over 60 min. Patients undergoing cardiac surgery for elective valvular and/or coronary heart disease were included. Patients with advanced organ dysfunction, infection, and/or patients on chronic steroid medication were excluded. RESULTS A total of 101 patients were randomized to receive the study intervention (HS n = 53, NS n = 48). Cumulative fluid intake on the ICU (primary endpoint) did not differ between the HS and the NS groups [median 3193 ml (IQR 2052-4333 ml) vs. 3345 ml (IQR 2332-5043 ml)]. Postoperative urinary output until ICU discharge was increased in HS-treated patients [median 2250 ml (IQR 1640-2690 ml) vs. 1545 ml (IQR 1087-1976 ml)], and ICU fluid balance was lower in the HS group when compared to the NS group [296 ml (IQR - 441 to 1412 ml) vs. 1137 ml (IQR 322-2660 ml)]. CONCLUSION In a monocentric prospective double-blind randomized clinical trial, we observed that hypertonic saline did not reduce the total fluid volume administered on the ICU in critically ill cardiac surgery patients. Hypertonic saline infusion was associated with timely increase in urinary output. Variations in electrolyte and acid-base homeostasis were transient, but substantial in all patients.
Collapse
|
|
3
|
Pfortmueller CA, Messmer AS, Hess B, Reineke D, Jakob L, Wenger S, Waskowski J, Zuercher P, Stoehr F, Erdoes G, Luedi MM, Jakob SM, Englberger L, Schefold JC. Hypertonic saline for fluid resuscitation after cardiac surgery (HERACLES): study protocol for a preliminary randomised controlled clinical trial. Trials 2019; 20:357. [PMID: 31200756 PMCID: PMC6570959 DOI: 10.1186/s13063-019-3420-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/09/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Intraoperative and postoperative management of cardiac surgery patients is complex, involving the application of differential vasopressors and volume therapy. It has been shown that a positive fluid balance has a major impact on postoperative outcome. Today, the advantages and disadvantages of buffered crystalloid solutes are a topic of controversy, with no consensus being reached so far. The use of hypertonic saline (HS) has shown promising results with respect to lower total fluid balance and postoperative weight gain in critically ill patients in preliminary studies. However, collection of more data on HS in critically ill patients seems warranted. This preliminary study aims to investigate whether fluid resuscitation using HS in patients following cardiac surgery results in less total fluid volume being administered. METHODS In a prospective double-blind randomised controlled clinical trial, we aim to recruit 96 patients undergoing elective cardiac surgery for ischaemic and/or valvular heart disease. After postoperative admission to the intensive care unit (ICU), patients will be randomly assigned to receive 5 ml/kg ideal body weight HS (7.3% NaCl) or normal saline (NS, 0.9% NaCl) infused within 60 min. Blood and urine samples will be collected preoperatively and postoperatively up to day 6 to assess changes in renal, cardiac, inflammatory, acid-base, and electrolyte parameters. Additionally, we will perform renal ultrasonography studies to assess renal blood flow before, during, and after infusion, and we will measure total body water using preoperative and postoperative body composition analysis (bioimpedance). Patients will be followed up for 90 days. DISCUSSION The key objective of this study is to assess the cumulative amount of fluid administered in the intervention (HS) group versus control (NS) group during the ICU stay. In this preliminary, prospective, randomised controlled clinical trial we will test the hypothesis that use of HS results in less total fluids infused and less postoperative weight gain when compared to the standard of intensive care in cardiac surgery patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT03280745 . Registered on 12 September 2017.
Collapse
Affiliation(s)
- Carmen A. Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Anna S. Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Benjamin Hess
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laura Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Stefanie Wenger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Frederik Stoehr
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Lars Englberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C. Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| |
Collapse
|
|
4
|
Pfortmueller CA, Kabon B, Schefold JC, Fleischmann E. Crystalloid fluid choice in the critically ill : Current knowledge and critical appraisal. Wien Klin Wochenschr 2018; 130:273-282. [PMID: 29500723 DOI: 10.1007/s00508-018-1327-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
Abstract
Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.
Collapse
Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Barbara Kabon
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
|
5
|
Pfortmueller CA, Schefold JC. Hypertonic saline in critical illness - A systematic review. J Crit Care 2017; 42:168-177. [PMID: 28746899 DOI: 10.1016/j.jcrc.2017.06.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/29/2017] [Accepted: 06/17/2017] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The optimal approach to fluid management in critically ill patients is highly debated. Fluid resuscitation using hypertonic saline was used in the past for more than thirty years, but has recently disappeared from clinical practice. Here we provide an overview on the currently available literature on effects of hypertonic saline infusion for fluid resuscitation in the critically ill. METHODS Systematic analysis of reports of clinical trials comparing effects of hypertonic saline as resuscitation fluid to other available crystalloid solutions. A literature search of MEDLINE and the Cochrane Controlled Clinical trials register (CENTRAL) was conducted to identify suitable studies. RESULTS The applied search strategy produced 2284 potential publications. After eliminating doubles, 855 titles and abstracts were screened and 40 references retrieved for full text analysis. At total of 25 scientific studies meet the prespecified inclusion criteria for this study. CONCLUSION Fluid resuscitation using hypertonic saline results in volume expansion and less total infusion volume. This may be of interest in oedematous patients with intravascular volume depletion. When such strategies are employed, renal effects may differ markedly according to prior intravascular volume status. Hypertonic saline induced changes in serum osmolality and electrolytes return to baseline within a limited period in time. Sparse evidence indicates that resuscitation with hypertonic saline results in less perioperative complications, ICU days and mortality in selected patients. In conclusion, the use of hypertonic saline may have beneficial features in selected critically ill patients when carefully chosen. Further clinical studies assessing relevant clinical outcomes are warranted.
Collapse
Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
| |
Collapse
|
|
6
|
Sirvinskas E, Sneider E, Svagzdiene M, Vaskelyte J, Raliene L, Marchertiene I, Adukauskiene D. Hypertonic hydroxyethyl starch solution for hypovolaemia correction following heart surgery. Perfusion 2016; 22:121-7. [PMID: 17708161 DOI: 10.1177/0267659107078484] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The aim of the study was to evaluate the effect of hypertonic NaCl hydroxyethyl starch solution on haemodynamics and cardiovascular parameters in the early postoperative period in patients for correction of hypovolaemia after heart surgery. Methods. Eighty patients undergoing myocardial revascularisation at the Clinic of Cardiac Surgery of the Heart Centre (Kaunas University of Medicine) were randomly divided into two groups. The HyperHaes® group (n = 40) received 250 ml 7.2% NaCl/6% HES solution and the control Ringer's acetate group (n = 40) received placebo (500ml Ringer's acetate solution) for volume correction after the surgery. Results. After infusion of HyperHaes® solution, cardiac index increased from 2.69 (0.7) to 3.52 (0.8)l/min/m2, systemic vascular resistance index, pulmonary vascular resistance index and the gradient between central and peripheral temperature decreased, and oxygen transport parameters improved. Ringer's group patients needed more intensive infusion therapy (4050.0 (1102.2) ml in the Ringer's group, 3513.7(762.5) ml in the HyperHaes® group). During the first 24 hours postoperatively, diuresis was significantly higher in the HyperHaes® group (3640.0 (1122.9) ml and 2736.0 (900.7) ml), total fluid balance was lower in HyperHaes® group (1405.6 (1519.0) ml and 2718.3 (1508.0) ml, respectively). After the infusion of HyperHaes ® solution, no adverse events were noted. Conclusions. HyperHaes ® solution had a positive effect on haemodynamic parameters and microcirculation. Oxygen transport was more effective after HyperHaes® solution infusion. Higher diuresis, lower need for the infusion therapy for the first 24 hours and lower total fluid balance were determined in the HyperHaes® group. No adverse effects were observed after HyperHaes® solution infusion. Perfusion (2007) 22, 121—127.
Collapse
Affiliation(s)
- Edmundas Sirvinskas
- Institute for Biomedical Research of Kaunas University of Medicine, Kaunas, Lithuania.
| | | | | | | | | | | | | |
Collapse
|
|
7
|
Shrum B, Church B, McArthur E, Burns KEA, Znajda T, McAlister V, Cochrane Anaesthesia Group. Hypertonic salt solution for peri-operative fluid management. Cochrane Database Syst Rev 2016; 2016:CD005576. [PMID: 27271480 PMCID: PMC8627702 DOI: 10.1002/14651858.cd005576.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Fluid excess may place people undergoing surgery at risk for various complications. Hypertonic salt solution (HS) maintains intravascular volume with less intravenous fluid than isotonic salt (IS) solutions, but may increase serum sodium. This review was published in 2010 and updated in 2016. OBJECTIVES To determine the benefits and harms of HS versus IS solutions administered for fluid resuscitation to people undergoing surgery. SEARCH METHODS In this updated review we have searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 4, 2016); MEDLINE (January 1966 to April 2016); EMBASE (January 1980 to April 2016); LILACS (January 1982 to April 2016) and CINAHL (January 1982 to April 2016) without language restrictions. We conducted the original search on April 30th, 2007, and reran it on April 8th, 2016. SELECTION CRITERIA We have included randomized clinical trials (RCTs) comparing HS to IS in people undergoing surgery, irrespective of blinding, language, and publication status. DATA COLLECTION AND ANALYSIS Two independent review authors read studies that met our selection criteria. We collected study information and data using a data collection sheet with predefined parameters. We have assessed the impact of HS administration on mortality, organ failure, fluid balance, serum sodium, serum osmolarity, diuresis and physiologic measures of cardiovascular function. We have pooled the data using the mean difference (MD) for continuous outcomes. We evaluated heterogeneity between studies by I² percentage. We consider studies with an I² of 0% to 30% to have no or little heterogeneity, 30% to 60% as having moderate heterogeneity, and more than 60% as having high heterogeneity. In studies with low heterogeneity we have used a fixed-effect model, and a random-effects model for studies with moderate to high heterogeneity. MAIN RESULTS We have included 18 studies with 1087 participants of whom 545 received HS compared to 542 who received IS. All participants were over 18 years of age and all trials excluded high-risk patients (ASA IV). All trials assessed haematological parameters peri-operatively and up to three days post-operatively.There were three (< 1%) deaths reported in the IS group and four (< 1%) in the HS group, as assessed at 90 days in one study. There were no reports of serious adverse events. Most participants were in a positive fluid balance postoperatively (4.4 L IS and 2.5 L HS), with the excess significantly less in HS participants (MD -1.92 L, 95% confidence interval (CI) -2.61 to -1.22 L; P < 0.00001). IS participants received a mean volume of 2.4 L and HS participants received 1.49 L, significantly less fluid than IS-treated participants (MD -0.91 L, 95% CI -1.24 to -0.59 L; P < 0.00001). The maximum average serum sodium ranged between 138.5 and 159 in HS groups compared to between 136 and 143 meq/L in the IS groups. The maximum serum sodium was significantly higher in HS participants (MD 7.73, 95% CI 5.84 to 9.62; P < 0.00001), although the level remained within normal limits (136 to 146 meq/L).A high degree of heterogeneity appeared to be related to considerable differences in the dose of HS between studies. The quality of the evidence for the outcomes reported ranged from high to very low. The risk of bias for many of the studies could not be determined for performance and detection bias, criteria that we assess as likely to impact the study outcomes. AUTHORS' CONCLUSIONS HS reduces the volume of intravenous fluid required to maintain people undergoing surgery but transiently increases serum sodium. It is not known if HS affects survival and morbidity, but this should be examined in randomized controlled trials that are designed and powered to test these outcomes.
Collapse
Affiliation(s)
- Brad Shrum
- University Hospital London Health Sciences CentreGeneral Surgery Experimental LaboratoryDepartment of Surgery339 Windermere RoadLondonONCanadaN6A 5A5
| | - Brian Church
- Department of Anesthesia, University of Western Ontario1 Canadian Field Hospital, Canadian Forces Medical ServiceD2‐315 Victoria HospitalLondonONCanadaN6A 5A5
| | - Eric McArthur
- Victoria HospitalELL‐218800 Commissioners Rd ELondonONCanada
| | - Karen EA Burns
- Keenan Research Centre/Li Ka Shing Knowledge Institute, University of TorontoInterdepartmental Division of Critical Care30 Bond Street, Rm 4‐045 Queen WingTorontoONCanadaM5B 1WB
| | - Tammy Znajda
- Lakeshore General HospitalDepartments of General Surgery and Intensive Care Medicine160 Stillview AvePointe‐ClaireQCCanadaH9R 2Y2
| | - Vivian McAlister
- University of Western OntarioDepartment of SurgeryC4‐212, University HospitalLondonONCanadaN6A 5A5
| | | |
Collapse
|
|
8
|
Abstract
BACKGROUND Fluid excess may place patients undergoing surgery at risk for various complications. Hypertonic saline (HS) maintains intravascular volume with less intravenous fluid than isotonic salt (IS) solutions, but may increase serum sodium. OBJECTIVES To determine the benefits and harms of HS versus IS solutions administered to patients undergoing surgery. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library) Issue 1, 2009; MEDLINE (1966 to 2009); EMBASE (1980 to 2009); LILACS (to August 2009) and CINAHL (1982 to 2009) without language restrictions. SELECTION CRITERIA We included randomized clinical trials where HS was compared to IS in patients undergoing surgery, irrespective of blinding, language, and publication status. DATA COLLECTION AND ANALYSIS We assessed the impact of HS administration on mortality, organ failure, fluid balance, serum sodium, serum osmolarity, diuresis and physiologic measures of cardiovascular function. We pooled data using odds ratio or mean difference (MD) for binary and continuous outcomes, respectively, using random-effects models. MAIN RESULTS We included 15 studies with 614 participants. One death in each group and no other serious adverse events were reported. While all patients were in a positive fluid balance postoperatively, the excess was significantly less in HS patients (standardized mean difference (SMD) -1.43L, 95% confidence interval (CI) 0.8 to 2.1 L less; P < 0.00001). Patients treated with HS received significantly less fluid than IS-treated patients (MD -2.4L 95% (CI) 1.5 to 3.2 L less; P < 0.00001) without differences in diuresis between the groups. Maximum intraoperative cardiac index was significantly increased with HS (SMD 0.6 L/min/M2 higher, 95% CI 0.1 to 1.0, P = 0.02) but Intraoperative pulmonary artery wedge pressure remained unchanged. While the maximum serum sodium and the serum sodium at the end of the study were significantly higher in HS patients, the level remained within normal limits (136 to 146 meq/L). AUTHORS' CONCLUSIONS HS reduces the volume of intravenous fluid required to maintain patients undergoing surgery but transiently increases serum sodium. It is not known if HS effects patient survival and morbidity but it should be tested in randomized clinical trials that are designed and powered to test these outcomes.
Collapse
Affiliation(s)
- Vivian McAlister
- Canadian Forces Medical Service, University of Western Ontario, C4-212, University Hospital, London, Ontario, Canada, N6A 5A5
| | | | | | | |
Collapse
|
|
9
|
Azoubel G, Nascimento B, Ferri M, Rizoli S. Operating room use of hypertonic solutions: a clinical review. Clinics (Sao Paulo) 2008; 63:833-40. [PMID: 19061009 PMCID: PMC2664287 DOI: 10.1590/s1807-59322008000600021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 08/04/2008] [Indexed: 11/22/2022] Open
Abstract
Hyperosmotic-hyperoncotic solutions have been widely used during prehospital care of trauma patients and have shown positive hemodynamic effects. Recently, there has been a growing interest in intra-operative use of hypertonic solutions. We reviewed 30 clinical studies on the use of hypertonic saline solutions during surgeries, with the majority being cardiac surgeries. Reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions in this population. Well-designed clinical trials are highly needed, particularly in aortic aneurysm repair surgeries, where hypertonic solutions have shown many beneficial effects. Examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies.
Collapse
Affiliation(s)
- Gustavo Azoubel
- Department of Surgery, University of Toronto - Toronto, Canada
| | - Bartolomeu Nascimento
- Department of Trauma and Critical Care, Sunnybrook Health Sciences Centre - Toronto, Ontario, Canada.
/
, Tel.: 416 5194041
| | - Mauricio Ferri
- Department of Trauma and Critical Care, Sunnybrook Health Sciences Centre - Toronto, Ontario, Canada.
/
, Tel.: 416 5194041
| | - Sandro Rizoli
- Department of Surgery, University of Toronto - Toronto, Canada
- Department of Trauma and Critical Care, Sunnybrook Health Sciences Centre - Toronto, Ontario, Canada.
/
, Tel.: 416 5194041
| |
Collapse
|
|
10
|
Half-molar sodium-lactate solution has a beneficial effect in patients after coronary artery bypass grafting. Intensive Care Med 2008; 34:1796-803. [DOI: 10.1007/s00134-008-1165-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2007] [Accepted: 04/24/2008] [Indexed: 12/16/2022]
|
|
11
|
Shao YS, Zhang YT, Peng KQ, Quan ZY. Effects of 7.5% hypertonic saline on fluid balance after radical surgery for gastrointestinal carcinoma. World J Gastroenterol 2005; 11:1577-81. [PMID: 15786530 PMCID: PMC4305934 DOI: 10.3748/wjg.v11.i11.1577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effects of 7.5% hypertonic saline on positive fluid balance and negative fluid balance, after radical surgery for gastrointestinal carcinoma.
METHODS: Fifty-two patients with gastrointestinal carcinoma undergoing radical surgery were studied. The patients were assigned to receive either Ringer lactate solution following 4 mL/kg of 7.5% hypertonic saline (the experimental group, n = 26) or Ringer lactate solution (the control group, n = 26) during the early postoperative period in SICU. Fluid infusion volumes, urine outputs, fluid balance, body weight change, PaO2/FiO2 ratio, anal exhaust time as well as the incidence of complication and mortality were compared between the two groups.
RESULTS: Urine outputs on the operative day and the first postoperative day in experimental group were significantly more than in control group (P<0.000001, P = 0.000114). Fluid infusion volumes on the operative day and the first postoperative day were significantly less in experimental group than in control group (P = 0.000042, P = 0.000415). The volumes of the positive fluid balance on the operative day and during the first 48 h after surgery, in experimental group, were significantly less than in control group (P<0.000001). Body weight gain post-surgery was significantly lower in experimental group than in control group (P<0.000001). The body weight fall in experimental group occurred earlier than in control group (P<0.000001). PaO2/FiO2 ratio after surgery was higher in experimental group than in control group (P = 0.000111). The postoperative anal exhaust time in experimental group was earlier than in control group (P = 0.000006). The overall incidence of complications and the incidence of pulmonary infection were lower in experimental group than in control group (P = 0.0175, P = 0.0374).
CONCLUSION: 7.5% hypertonic saline has an intense diuretic effect and causes mobilization of the retained fluid, which could reduce fluid infusion volumes and positive fluid balance after radical surgery for gastrointestinal carcinoma, as well as, accelerate the early appearance of negative fluid balance after the surgery, improve the oxygen diffusing capacity of the patients’ alveoli, and lower the overall incidence of complications and pulmonary infection after the surgery.
Collapse
Affiliation(s)
- Yong-Sheng Shao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Jianghan University, Wuhan 430015, Hubei Province, China.
| | | | | | | |
Collapse
|
|
12
|
Abstract
The optimal fluid for the resuscitation of critically ill and injured patients remains the subject of considerable controversy. Hypertonic crystalloid solutions such as hypertonic saline provide rapid volume expansion, have an acceptable safety profile, and are easy to store and transport. Recent meta-analyses suggest a trend toward increased survival in patients given hypertonic saline, and it has been suggested that they may have particular benefit in certain groups of patients such as hypovolaemic head injury patients. This short review examines the physiological and experimental evidence supporting the use of hypertonic saline in fluid resuscitation.
Collapse
|
|
13
|
Shukla A, Hashiguchi N, Chen Y, Coimbra R, Hoyt DB, Junger WG. Osmotic regulation of cell function and possible clinical applications. Shock 2004; 21:391-400. [PMID: 15087814 DOI: 10.1097/00024382-200405000-00001] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Inflammation and immunosuppression can cause acute respiratory distress syndrome, multiple organ failure, and sepsis, all of which are lethal posttraumatic complications in trauma patients. Prevention of the inflammation and immunosuppression has been a main focus of trauma researcher for many years. Recently, hypertonic resuscitation has attracted attention as a possible therapeutic approach to counteract such deleterious immune responses in trauma patients. We have begun to understand how hypertonic fluids affect immune cell signaling, and a number of experimental and clinical studies have started to reveal valuable information on the clinical efficacy and the limitations of hypertonic resuscitation fluids. Knowledge of how osmotic cues regulate immune cell function will enable us to fully exploit the clinical potential of hypertonic resuscitation to reduce inflammatory and anergic complications in trauma patients.
Collapse
Affiliation(s)
- Alok Shukla
- Department of Surgery/Trauma, University of California San Diego, San Diego, California 92103, USA
| | | | | | | | | | | |
Collapse
|
|
14
|
Alpar EK, Killampalli VV. Effects of hypertonic dextran in hypovolaemic shock: a prospective clinical trial. Injury 2004; 35:500-6. [PMID: 15081328 DOI: 10.1016/s0020-1383(03)00196-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2003] [Indexed: 02/02/2023]
Abstract
The aim of this paper is to report the results of prospective clinical trials of hypertonic saline dextran (HSD) in the resuscitation of hypovolaemic shock in critically injured patients. There are many types of fluids, which can be administered intravenously. Recent interest in the usage of HSD solution has confirmed that they have a place in resuscitation of a patient in shock. Heart rate and arterial pressure recovered well with HSD solution. The plasma osmolarity, sodium and potassium levels were significantly elevated in patients resuscitated with HSD. Urine output recovered rapidly and was well maintained throughout.
Collapse
Affiliation(s)
- Emin Kaya Alpar
- Department of Trauma and Orthopaedic Surgery, University Hospital Selly Oak NHS Trust, Raddlebarn Road, Birmingham B29 6JD, UK.
| | | |
Collapse
|
|
15
|
Bueno R, Resende AC, Melo R, Neto VA, Stolf NAG. Effects of hypertonic saline-dextran solution in cardiac valve surgery with cardiopulmonary bypass. Ann Thorac Surg 2004; 77:604-11; discussion 611. [PMID: 14759446 DOI: 10.1016/s0003-4975(03)01486-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hypertonic saline-dextran (HSD) solution may be beneficial in patients undergoing coronary artery surgery with cardiopulmonary bypass. Valvular dysfunction is associated with high pulmonary wedge pressure, pulmonary hypertension, and ventricular dysfunction. Fluid overload or transient left ventricular failure may occur with HSD infusion in such patients. This study evaluates the cardiorespiratory effects and tolerance of HSD solution infusion in patients undergoing cardiac valve surgery. METHODS This prospective, randomized, double-blind study compared clinical, laboratory, hemodynamic, and respiratory measurements, and fluid balance in 50 patients over a 48-hour period after cardiopulmonary bypass for cardiac valve surgery. Twenty-five patients received 4 mL/kg of HSD during 20 minutes before cardiopulmonary bypass (HSD group). The control group received the same volume of Ringer's solution (Ringer group). RESULTS Hospital mortality was zero. The HSD patients had a near zero fluid balance (6.5 +/- 13.5 mL/Kg/48 hours), and the control patients had a positive balance (91.0 +/- 33.7 mL/Kg/48 hours). Hemoglobin was similar in both groups, but more blood transfusions were necessary in the Ringer group (1.21 +/- 1.28 vs 0.48 +/- 0.59 units per patients). The HSD solution induced a higher cardiac index and left ventricular systolic work index postoperatively, and a lower systemic vascular resistance index until 6, 24, and 48 hours. Right ventricular systolic work index increased and pulmonary vascular resistance index decreased after HSD infusion. A better Pao(2)/Fio(2) relation was observed at 1 and 6 hours postoperatively in the HSD group and was associated with a shorter extubation time (432.0 +/- 123.6 vs 520.8 +/- 130.2 minutes). Increased oxygen delivery index occurred in the HSD group. The HSD infusion was well tolerated as none of the patients experienced fluid overload or had left ventricular failure develop. No other complication attributable to the use of HSD solution was observed. CONCLUSIONS The HSD solution infusion in patients during cardiac valve surgery with cardiopulmonary bypass was well tolerated. Hemodynamic and respiratory functions improved and fluid balance was near zero during the first 48 hours as compared with a large positive balance in the control group. We conclude that HSD infusion is advantageous for patients undergoing cardiac valve surgery.
Collapse
Affiliation(s)
- Ronaldo Bueno
- Department of Cardiovascular Surgery, Beneficência Portuguesa Hospital, São Paulo, Brazil.
| | | | | | | | | |
Collapse
|
|
16
|
Bunn F, Roberts IG, Tasker R, Trivedi D, Cochrane Injuries Group. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2004; 2004:CD002045. [PMID: 15266460 PMCID: PMC7017932 DOI: 10.1002/14651858.cd002045.pub2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hypertonic solutions are considered to have a greater ability to expand blood volume and thus elevate blood pressure and can be administered as a small volume infusion over a short time period. On the other hand, the use of hypertonic solutions for volume replacement may also have important disadvantages. OBJECTIVES To determine whether hypertonic crystalloid decreases mortality in patients with hypovolaemia. SEARCH STRATEGY We searched MEDLINE, EMBASE, The Cochrane Controlled Trials Register and the specialised register of the Cochrane Injuries Group. We checked reference lists of all articles identified and searched the National Research Register. SELECTION CRITERIA Randomised trials comparing hypertonic to isotonic and near isotonic crystalloid in patients with trauma, burns or undergoing surgery. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed the quality of the trials. MAIN RESULTS Fourteen trials with a total of 956 participants are included in the meta-analysis. The pooled relative risk (RR) for death in trauma patients was 0.84 (95% confidence interval [CI] 0.69-1.04); in patients with burns 1.49 (95% CI 0.56-3.95); and in patients undergoing surgery 0.51 (95% CI 0.09, 2.73). In the one trial that gave data on disability using the Glasgow outcome scale, the relative risk for a poor outcome was 1.00 (95% CI 0.82, 1.22). REVIEWERS' CONCLUSIONS This review does not give us enough data to be able to say whether hypertonic crystalloid is better than isotonic and near isotonic crystalloid for the resuscitation of patients with trauma, burns, or those undergoing surgery. However, the confidence intervals are wide and do not exclude clinically significant differences. Further trials which clearly state the type and amount of fluid used and that are large enough to detect a clinically important difference are needed.
Collapse
Affiliation(s)
- Frances Bunn
- University of HertfordshireCentre for Research in Primary and Community CareCollege LaneHatfieldHertfordshireUKAL10 9PN
| | - Ian G Roberts
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupNorth CourtyardKeppel StreetLondonUKWC1E 7HT
| | - Robert Tasker
- Department of PaediatricsUniversity of Cambridge School of Clinical MedicineBox 116, Addenbrooks HospitalHills RoadCambridgeUKCB2 2QQ
| | - Daksha Trivedi
- University of HertfordshireCentre for Research in Primary and Community CareCollege LaneHatfieldHertfordshireUKAL10 9PN
| | | |
Collapse
|
|
17
|
Järvelä K, Koskinen M, Kööbi T. Effects of hypertonic saline (7.5%) on extracellular fluid volumes in healthy volunteers. Anaesthesia 2003; 58:878-81. [PMID: 12911361 DOI: 10.1046/j.1365-2044.2003.03332.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study evaluated the effects of 7.5% saline on plasma and other extracellular fluid volumes. After baseline measurements, eight healthy postmenopausal female volunteers received 4 ml.kg-1 of hypertonic saline over 30 min. After the fluid infusion, the volunteers were studied for 60 min. Plasma volume was measured using a dilution of 125-iodine-labelled human albumin. Extracellular water and cardiac output were measured by whole body impedence cardiography. The infused volume was 4 ml.kg-1 (average 260 ml). Plasma volume increased rapidly during the infusion (mean +/- standard deviation, 442 +/- 167 ml). At the end of the 1-h follow-up period, plasma volume had increased by on average 465 ml (SD 83). The increase of extracellular water at the end of infusion and at the end of study was 650 ml (SD 93) and 637 ml (SD 192), respectively. The highest serum sodium recorded in the volunteers was 158 mmol.l-1. The effect of 7.5% saline on plasma volume was rapid and lasted for at least 1 h. Plasma volume remained elevated by more than the infused volume at the end of the study. The increase in plasma and extracellular fluid volumes was partly achieved by mobilizing intracellular water to extracellular compartment.
Collapse
Affiliation(s)
- K Järvelä
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, PO Box 2000, 33521 Tampere, Finland.
| | | | | |
Collapse
|
|
18
|
Gosling P. Salt of the earth or a drop in the ocean? A pathophysiological approach to fluid resuscitation. Emerg Med J 2003; 20:306-15. [PMID: 12835337 PMCID: PMC1726159 DOI: 10.1136/emj.20.4.306] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The evolved endocrine response after injury leads to sodium, chloride, and water retention at a time when large volumes of sodium containing fluids are given to maintain the circulation and preserve tissue oxygenation. Sodium, chloride, and water are also retained because of increased systemic vascular permeability to plasma proteins, especially albumin, which sequesters fluid in the interstitial space and causes oedema. Excessive fluid and electrolyte retention and interstitial oedema are associated with the systemic inflammatory response syndrome and multiple organ dysfunction, and failure. This review attempts an overview of these processes and addresses the question, "Can manipulation of fluid resuscitation influence the inflammatory response to injury and organ function". Results of randomised controlled prospective clinical studies suggest that limiting the sodium and chloride input and optimal use of synthetic colloids, which are well retained in the vascular space, can reduce the inflammatory response to injury and improve organ function.
Collapse
Affiliation(s)
- P Gosling
- Department, Selly Oak Hospital University Hospital Birmingham NHS Trust, Raddlebarn Road, Birmingham B29 6LD, UK.
| |
Collapse
|
|
19
|
Kramer GC. Hypertonic resuscitation: physiologic mechanisms and recommendations for trauma care. THE JOURNAL OF TRAUMA 2003; 54:S89-99. [PMID: 12768109 DOI: 10.1097/01.ta.0000065609.82142.f1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hypertonic saline solutions, with or without added colloid, have received extensive evaluation as volume expanders in both animal studies and clinical trials. Most studies have used 7.5% NaCl/6% dextran 70 (HSD). HSD's primary mechanism of action is rapid osmotic mobilization of cellular water into the blood volume. The measured volume expansion efficiency of HSD is equal to 10 times that of lactated Ringer's solution. Part of HSD's effectiveness is because of the hyperosmotic vasodilation of both systemic and pulmonary vessels. Increased cardiac effectiveness occurs because of the combination of increased preload (venous return) and reduced afterload (vasodilation). Increased cardiac contractility also has been reported in several studies and may play a role, but other studies refute a direct effect on contractility. HSD has been shown to be effective and safe with preexisting dehydration. Animal studies of immune function suggest that increased osmolarity prevents T-cell depression and decreases neutrophil activation. Several perioperative and eight randomized, blinded trauma trials have shown safety and reduced volume needs and suggest increased survival, particularly in head- and penetrating-injury patients. Infusion rates for HSD of 10 to 20 minutes may be recommended for the initial resuscitation of hypotensive trauma.
Collapse
Affiliation(s)
- George C Kramer
- Department of Anesthesiology, Resuscitation Research Laboratories, University of Texas Medical Branch, Galveston 77555-0801, USA.
| |
Collapse
|
|
20
|
Rana MW, Shapiro MJ, Ali MA, Chang YJ, Taylor WH. Deferoxamine and hespan complex as a resuscitative adjuvant in hemorrhagic shock rat model. Shock 2002; 17:339-42. [PMID: 11954838 DOI: 10.1097/00024382-200204000-00018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The optimal type and amount of fluid for resuscitation of injured patients in hemorrhagic hypovolemic shock remains controversial. Use of deferoxamine, an iron chelator and oxygen-free radical scavenger, and hespan (hydroxyethyl starch), a colloid plasma expander, was evaluated in a rat hemorrhagic shock model. Eighty Sprague-Dawley male rats were utilized in four experiments. In these rats, bi-femoral cutdowns were performed for blood withdrawal, resuscitation, blood sampling, and continuous blood pressure monitoring. All rats, except control (with bilateral cutdown only), were bled and maintained at 40 mmHg for 90 min. The shed blood was returned and animals were resuscitated. One hour later, 2 mg/kg lidocaine was injected and blood samples were taken at 10, 15, 30, and 60 min for evaluation of lidocaine derivative monoethylglycinexylidide (MEGX) by fluorescent polarization immunoassay. In experiment 1 (n = 31), resuscitation with different volumes of Ringer's lactate (7.5 mL, 15.0 mL, and 30.0 mL/kg) was compared and 7.5 mL/kg LR was most beneficial. In experiment 2 (n = 22), resuscitation with three doses of Hespan (3.75 mL, 7.5 mL, and 15 mL/kg) was compared. A dose of 15 mL/kg significantly improved the liver function. In experiment 3 (n = 15), resuscitations with two doses of deferoxamine (30 mg and 100 mg/kg) were compared. A dose of 100 mg/kg significantly improved the liver function. In experiment 4 (n = 12), a combination of deferoxamine (100 mg/kg) and Hespan (3.75 and 7.5 mL) was used. Deferoxamine (100 mg/kg) complexed with 7.5 mL of Hespan was found the most beneficial resuscitation. This conjugate could be a choice as a resuscitative adjuvant in hypovolemic shock without any side effects.
Collapse
Affiliation(s)
- M Waheed Rana
- Department of Anatomy, Saint Louis University Health Sciences Center, Missouri 63104, USA
| | | | | | | | | |
Collapse
|
|
21
|
Bunn F, Roberts I, Tasker R, Akpa E. Hypertonic versus isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2002:CD002045. [PMID: 11869619 DOI: 10.1002/14651858.cd002045] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypertonic solutions are considered to have a greater ability to expand blood volume and thus elevate blood pressure and can be administered as a small volume infusion over a short time period. On the other hand, the use of hypertonic solutions for volume replacement may also have important disadvantages. OBJECTIVES To determine whether hypertonic crystalloid decreases mortality in patients with hypovolaemia with and without head injuries. SEARCH STRATEGY We searched MEDLINE, EMBASE, The Cochrane Controlled Trials Register and the Specialised register of the Injuries Group. We checked reference lists of all articles identified and searched the National Research Register. SELECTION CRITERIA Randomised trials comparing hypertonic to isotonic crystalloid in patients with trauma, burns or undergoing surgery. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed the quality of the trials. MAIN RESULTS Seventeen trials were identified with a total of 869 participants. Data on death were obtained in twelve of the studies. Only one trial reported data on disability. The pooled RR for death in trauma patients was 0.84 (95% CI 0.61-1.16), in patients with burns 1.49 (95% CI 0.56-3.95), and in patients undergoing surgery 0.62 (95% cI 0.08-4.57). In the one trial that gave data on disability using the Glasgow Outcome Scale the relative risk was 0.99 (95% CI 0.06-15.93). REVIEWER'S CONCLUSIONS This review does not give us enough data to be able to say whether hypertonic crystalloid is better than isotonic crystalloid for the resuscitation of patients with trauma, burns, or those undergoing surgery. However, the confidence intervals are wide and do not exclude clinically significant differences. Further trials are needed comparing hypertonic to isotonic crystalloid. Trials need to be large enough to detect a clinically important difference.
Collapse
Affiliation(s)
- F Bunn
- Public Health Intervention Research Unit, London School of Hygiene & Tropical Medicine, 49-51 Bedford Square, London, UK, WC1B 3DP.
| | | | | | | |
Collapse
|
|
22
|
Järvelä K, Kööbi T, Kauppinen P, Kaukinen S. Effects of hypertonic 75 mg/ml (7.5%) saline on extracellular water volume when used for preloading before spinal anaesthesia. Acta Anaesthesiol Scand 2001; 45:776-81. [PMID: 11421840 DOI: 10.1034/j.1399-6576.2001.045006776.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prevention of hypotension during spinal anaesthesia is commonly achieved using fluid preloading. This may result in a substantial amount of excess free water retained in the body after spinal anaesthesia. We aimed to evaluate the effects of 7.5% hypertonic saline on extracellular water volume and haemodynamics when used for fluid preloading before spinal anaesthesia. METHODS This randomised double-blind study evaluated the effects of 75 mg/ml (7.5%) hypertonic saline (HS) on extracellular water volume and haematocrit in patients undergoing arthroscopy or other lower limb surgery under spinal anaesthesia. Amounts of 1.6 ml/kg of HS (20 patients) or 13 ml/kg of 9 mg/ml normal saline (20 patients) were administered for preloading before spinal anaesthesia with a 10 mg dose of 0.5% hyperbaric bupivacaine. Etilefrine was administered in order to maintain mean arterial pressure (MAP) at >or=80% of its baseline value. Whole-body impedance cardiography-derived cardiac index (CI) and extracellular water (ECW) were measured. RESULTS There were no significant differences in demographic data or in the number of blocked segments. ECW remained similar in both groups despite the much smaller amount of infused free water in the HS group. There were no significant differences between the groups in CI values during the study. The amount of etilefrine administered was similar in the treatment groups. Dilution of haematocrit was also similar in both groups. CONCLUSION Hypertonic 75 mg/ml (7.5%) saline is an alternative for preloading before spinal anaesthesia in situations where excess free water administration is not desired. It is effective in small doses of 1.6 ml/kg, which increase the extracellular water, plasma volume and cardiac output, and thus maintain haemodynamic stability during spinal anaesthesia.
Collapse
Affiliation(s)
- K Järvelä
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland.
| | | | | | | |
Collapse
|
|
23
|
Järvelä K, Koskinen M, Kaukinen S, Kööbi T. Effects of hypertonic saline (7.5%) on extracellular fluid volumes compared with normal saline (0.9%) and 6% hydroxyethyl starch after aortocoronary bypass graft surgery. J Cardiothorac Vasc Anesth 2001; 15:210-5. [PMID: 11312481 DOI: 10.1053/jcan.2001.21964] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the effects of hypertonic (7.5%) saline (HS), normal (0.9%) saline (NS), and 6% hydroxyethyl starch (HES) on extracellular fluid volumes in the early postoperative period after cardiopulmonary bypass. DESIGN A prospective, randomized, double-blind study. SETTING University teaching hospital. PARTICIPANTS Forty-eight patients scheduled for elective coronary artery bypass graft surgery. INTERVENTIONS Patients were randomly allocated to receive 4 mL/kg of HS, NS, or HES during 30 minutes when volume loading was needed during the postoperative rewarming period in the intensive care unit. Plasma volume was measured using a dilution of iodine-125-labeled human serum albumin. Extracellular water and cardiac output were measured by whole-body impedance cardiography. MEASUREMENTS AND MAIN RESULTS Plasma volume had increased by 19 +/- 7% in the HS group and by 10 +/- 3% in the NS group (p = 0.001) at the end of the study fluid infusion. After 1-hour follow-up time, the plasma volume increase was greatest (23 +/- 8%) in the group receiving HES (p < 0.001). The increase of extracellular water was greater than the infused volume in the HS and HES groups at the end of the infusion. One-hour diuresis after the study infusion was greater in the HS group (536 +/- 280 mL) than in the NS (267 +/- 154 mL, p = 0.006) and HES groups (311 +/- 238 mL, p = 0.025). CONCLUSION The effect of HS on plasma volume was short-lasting, but it stimulated excretion of excess body fluid accumulated during cardiopulmonary bypass and cardiac surgery. HS may be used in situations in which excess free water administration is to be avoided but the intravascular volume needs correction.
Collapse
Affiliation(s)
- K Järvelä
- Department of Anaesthesia, Tampere University Hospital, Tampere, Finland
| | | | | | | |
Collapse
|
|
24
|
|
|
25
|
Abstract
BACKGROUND AND OBJECTIVE Patients undergoing coronary artery bypass grafting often require volume loading after operation. In this situation hypertonic saline may be beneficial in restoring the haemodynamic balance and removing excess extravascular fluid. METHODS Forty coronary artery bypass grafting patients were randomly assigned to receive either hypertonic saline 7.5% (20 patients) or 0.9% saline (20 patients) as a single dose of 4 mL kg-1 over 30 min in the postoperative rewarming phase in the intensive care unit. RESULTS Mean arterial pressure increased in the hypertonic saline group from 82 +/- 10 (SD) to 104 +/- 17 mmHg (P = 0.002) vs. the normal saline group), and the cardiac index rose from 2.3 +/- 0.5 to 3.4 +/- 0.8 L min-1 m2 (P = 0.002 vs. the normal group). The haemodynamic effect of hypertonic saline lasted only about 1 h. Diuresis was greater in the hypertonic saline group both at 1 h (hypertonic saline: 490 +/- 274 vs. normal saline: 204 +/- 130 mL; P = 0.001) and 10 h (hypertonic saline: 1952 +/- 554 vs. normal saline: 1421 +/- 514 mL; P = 0.003). CONCLUSIONS No adverse effects were seen. The hypertonic saline had a strong diuretic effect and may be beneficial in coronary artery bypass graft patients after operations. This is because of its value as a short-term plasma expander and the diuresis eliminates excessive fluid from the body. A larger study is needed to determine whether the benefits outweigh the possible side-effects in these patients.
Collapse
Affiliation(s)
- K Järvelä
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, PO Box 2000, FIN-33521 Tampere, Finland
| | | |
Collapse
|
|
26
|
Järvelä K, Honkonen SE, Järvelä T, Kööbi T, Kaukinen S. The comparison of hypertonic saline (7.5%) and normal saline (0.9%) for initial fluid administration before spinal anesthesia. Anesth Analg 2000; 91:1461-5. [PMID: 11094001 DOI: 10.1097/00000539-200012000-00031] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertonic saline can be used for initial fluid administration before spinal anesthesia. It is effective in small-volume fluid resuscitation. This randomized double-blinded study compared the effects of 7.5% hypertonic saline (HS) and 0.9% normal saline (NS) in doses containing 2 mmol/kg of sodium in 40 ASA physical status I-II patients undergoing arthroscopy or other lower limb surgery under spinal anesthesia. We infused 1.6 mL/kg of HS or 13 mL/kg of NS for initial fluid administration before spinal anesthesia induced with a 10-mg dose of 0.5% hyperbaric bupivacaine. Etilefrine was administered to maintain mean arterial pressure at > or =80% of its control value. Systolic and diastolic blood pressure, heart rate, and cardiac index did not differ between the groups, and the amount of etilefrine administered was similar in the treatment groups. In all our patients, the plasma sodium concentrations were within the normal range after surgery and serum osmolality was within the normal range after spinal anesthesia. The time and the volume of the first micturition were similar in both groups, despite the much smaller amount of infused free water in the HS group. We conclude that 7.5% HS was as good as NS for the initial fluid administration before spinal anesthesia when the amount of sodium was kept unchanged.
Collapse
Affiliation(s)
- K Järvelä
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland
| | | | | | | | | |
Collapse
|
|
27
|
Sirieix D, Hongnat JM, Delayance S, D'Attellis N, Vicaut E, Bérrébi A, Paris M, Fabiani JN, Carpentier A, Baron JF. Comparison of the acute hemodynamic effects of hypertonic or colloid infusions immediately after mitral valve repair. Crit Care Med 1999; 27:2159-65. [PMID: 10548199 DOI: 10.1097/00003246-199910000-00014] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the acute hemodynamic effect of hypertonic saline and/or colloid solutions as volume resuscitation in postoperative mitral valve repair patients. DESIGN Prospective, randomized trial. SETTING Postoperative cardiac intensive care unit of Broussais Hospital. PATIENTS Twenty-six patients who underwent mitral valve repair were prospectively studied. Two patients were excluded during the study. INTERVENTIONS During the immediate postoperative period, when wedge pressure decreases to <8 mm Hg, patients were randomly assigned to receive 250 mL of either hypertonic saline 7.2%-hydroxyethyl starch 6% (molecular weight, 200,000; hydroxyethylation ratio, 0.5) solution (HS-HES group), hypertonic saline 7.2% solution (HS group), or hydroxyethyl starch 6% solution (HES group). The infusion was completed within 15 mins. No additional volume was infused throughout the study. MEASUREMENTS AND MAIN RESULTS Standard hemodynamic measurements and echocardiographic data demonstrated that HS-HES and HS induced a higher increase in left ventricular end-diastolic area than HES. In the HS-HES and HS groups, systemic vascular resistances decreased significantly and end-systolic area tended to decrease. In the HES group, systemic vascular resistances did not change and end-systolic area tended to increase. Accordingly, ejection fraction increased significantly by 21% and 18% with HS-HES (from 50.5 +/- 5.5 to 61.2 +/- 4.8) and HS (from 49.7 +/- 3.6 to 58.8 +/- 3.3), respectively, and did not change with HES. A major increase in cardiac index was observed after hypertonic solutions infusion, from 2.9 +/- 0.3 to 4.1 +/- 0.4 L/min/m2 in the HS-HES group and from 2.7 +/- 0.3 to 3.8 +/- 0.4 L/min/m2 in the HS group. Then, cardiac index progressively returned to baseline values within the 3 hrs after the infusion. No significant difference was observed between HS-HES and HS. In these groups, plasma sodium increased significantly after the infusion and remained higher than baseline values throughout the study. Adverse events were observed only with hypertonic solution administration: hypotensive episodes, sudden increases in pulmonary capillary wedge pressure, and ventricular arrhythmias. These side effects are likely attributable to a too-high dose and/or rate of infusion. All patients included in the study were discharged from the hospital before the 10th postoperative day. CONCLUSION We conclude that in patients who have undergone mitral valve repair, postoperative infusion of hypertonic saline solutions increases left ventricular preload and left ventricular ejection fraction. The use of these hypertonic solutions may be of interest in patients with valvular cardiomyopathy. A titrated dose and a low rate of infusion may substantially improve the safety.
Collapse
Affiliation(s)
- D Sirieix
- Department of Anesthesiology, Broussais Hospital, Paris, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
28
|
Ogino R, Suzuki K, Kohno M, Nishina M, Kohama A. Effects of hypertonic saline and dextran 70 on cardiac contractility after hemorrhagic shock. THE JOURNAL OF TRAUMA 1998; 44:59-69. [PMID: 9464750 DOI: 10.1097/00005373-199801000-00005] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The effects of a bolus of 7.5% NaCl-6% dextran 70 (HSD) on cardiac contractility were evaluated in anesthetized sheep with hemorrhagic shock. BACKGROUND HSD has been shown to be effective at resuscitation in cases of hypovolemia caused by hemorrhage. Common hemodynamic findings after the injection of HSD in hemorrhagic shock are the restoration of cardiac output, increased blood pressure, and improvement of peripheral circulation. Some mechanisms by which HSD maintains circulation in hemorrhagic shock have been proposed: rapid shift of fluid from intracellular to extracellular space, improved peripheral perfusion, and increased cardiac contractility. Conflicting data exist, however, regarding the positive effect of HSD on cardiac contractility after hemorrhagic shock. METHODS Hemorrhagic shock was induced by shedding mean blood volume of 31.4 mL/kg, and mean blood pressure was maintained at 50 mm Hg for 30 minutes. The HSD group (n = 6) received HSD (4 mL/kg), and the saline group (n = 6) received normal saline (40 mL/kg) after shock. Cardiac functions were measured in both groups using the left ventricular end-systolic pressure-volume relationship and preload recruitable stroke work during the experimental period: before shock, immediately after the resuscitation, and 2 hours after resuscitation. RESULTS Hemodynamic parameters in both groups demonstrated similar changes throughout the experimental period without significant difference between the two groups. Not only the slopes of end-systolic pressure-volume relationship and preload recruitable stroke work but also their placements did not result in any significant differences between the groups. CONCLUSION HSD seems to be an effective resuscitation fluid after hemorrhagic shock because the volume required to maintain circulation is smaller than that of normal saline. Our data, however, show that HSD does not enhance cardiac contractility after hemorrhagic shock.
Collapse
Affiliation(s)
- R Ogino
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan.
| | | | | | | | | |
Collapse
|
|
29
|
|
|
30
|
Kramer GC, Elgjo GI, Poli de Figueiredo LF, Wade CE. 7 Hyperosmotic-hyperoncotic solutions. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s0950-3501(97)80009-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
|
31
|
Moon PF, Kramer GC. Hypertonic saline-dextran resuscitation from hemorrhagic shock induces transient mixed acidosis. Crit Care Med 1995; 23:323-31. [PMID: 7532561 DOI: 10.1097/00003246-199502000-00019] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate the magnitude and mechanism of potential metabolic acidosis after resuscitation with 7.5% sodium chloride/6% dextran-70. DESIGN Blinded, randomized, control trial. SETTING Laboratory setting. SUBJECTS Sixteen healthy Yorkshire swine. INTERVENTIONS Anesthetized, mechanically ventilated swine underwent 90 mins of hemorrhagic hypotension (mean arterial pressure of 50 to 55 mm Hg), and a lactic acid infusion (1.5 to 2.4 mmol/kg) was given during the last 60 mins of hemorrhage to produce pretreatment acidosis. The pigs were then given either 4 mL/kg of intravenous normal saline (n = 8) or 7.5% sodium chloride/6% dextran-70 (n = 8). Groups then received isotonic lactated Ringer's solution to restore and maintain cardiac output for 120 mins. MEASUREMENTS AND MAIN RESULTS There was no difference between groups during baseline or shock for any parameter. At the end of shock, arterial pH and base balance were below baseline values. During resuscitation, cardiac output was reached and maintained in both groups. One minute after infusion of hypertonic saline/dextran, there was a significant but transient decrease in arterial pH (from 7.407 +/- 0.015 to 7.339 +/- 0.025) and base balance (from -6.5 +/- 0.7 to -9.9 +/- 1.0 mmol/L). These changes returned to shock levels by 10 mins and then normalized to baseline levels. Hypertonic saline dextran resulted in an immediate hypernatremia, hyperchloremia, and hypokalemia, a decrease in inorganic strong ion difference (calculated as sodium plus potassium minus chloride concentrations), and no immediate change in anion gap. The normal saline group did not show an initial transient decrease in pH and base balance during resuscitation. Plasma lactate, total protein, and hemoglobin concentrations decreased equally in both groups, although they decreased more quickly with hypertonic saline/dextran. CO2 temporarily and insignificantly increased in arterial blood slightly more after the administration of hypertonic saline/dextran. By 120 mins, acid-base, electrolyte and protein changes were normalizing with hypertonic saline/dextran, while pH, base balance, and protein were decreasing below shock values in animals initially treated with normal saline. CONCLUSIONS Hypertonic saline/dextran caused an immediate, transient acidemia, which was primarily due to a hyperchloremic, hypokalemic, metabolic acidosis with normal anion gap and decreased inorganic strong ion difference, but which was partially due to a mild transient respiratory acidosis. The acidemia was transient because of the offsetting alkalotic effects of decreasing serum protein, normalization of electrolytes, and transient nature of the increase in CO2. Lactic acidosis was not the cause of the acidemia. Over time, the acid-base status appeared to be improved more effectively with hypertonic saline/dextran than with isotonic saline resuscitation.
Collapse
Affiliation(s)
- P F Moon
- Department of Clinical Sciences, Cornell University, Ithaca, NY
| | | |
Collapse
|
|
32
|
Horton JW, White DJ, Hunt JL. Delayed hypertonic saline dextran administration after burn injury. THE JOURNAL OF TRAUMA 1995; 38:281-6. [PMID: 7532723 DOI: 10.1097/00005373-199502000-00027] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE AND DESIGN Experimental studies in our laboratory showed that hypertonic saline dextran (HSD; 7.5 NaCl in 6% dextran 70) given as a small bolus (4 mL/kg) immediately after burn injury in guinea pigs improved cardiac contractile performance and reduced the total fluids requirements. Although these data confirm the cardioprotective effects of HSD given immediately postburn, prehospital and early inhospital management of severely burned patients consists of aggressive crystalloid fluid resuscitation to correct intravascular volume deficits. The question arose as to whether delaying HSD for several hours after initiating crystalloid resuscitation would provide cardioprotection. MATERIALS AND METHODS Third-degree scald burns comprising 45 +/- 1% of the total body surface area (burn groups, n = 40) or 0% for controls (group 1, n = 12) were produced; in groups 2 to 5, lactated Ringer's (LR) resuscitation was initiated immediately postburn according to the Parkland formula, 4 mL/kg/% burn. In group 2, (n = 12), LR was continued for 24 hours. HSD was administered as an i.v. bolus at either 1 hour (group 3, n = 10), 4 hours (group 4, n = 9), or 8 hours postburn (group 5, n = 9); immediately after HSD administration, LR was continued (1 mL/kg/% burn) until 24 hours postburn. RESULTS Compared to sham burn controls, hearts from burned animals treated with LR alone had significant cardiac dysfunction, as indicated by a lower left ventricular pressure and +/- dP/dt. Compared with hearts from LR-treated animals, hearts from burned animals treated with HSD 1 hour (HSD-1) and 4 hours (HSD-4) after burn injury had significantly higher LVP and +/- dP/dt. Ventricular function curves calculated for HSD-1 and HSD-4 groups were comparable to those calculated for hearts from sham burns. Delaying HSD administration until 8 hours after burn provided little cardioprotection. CONCLUSIONS Our data indicate that HSD effectively maintains cardiac function and reduces overall total fluid requirements if administered within 4 hours after burn injury.
Collapse
Affiliation(s)
- J W Horton
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | | | | |
Collapse
|
|
33
|
Abstract
The surgeon should be cognizant of both the intraoperative and postoperative consequences of intraoperative fluid administration. Optimal fluid management should take into consideration the patient's overall condition and should not be based solely on the cardiovascular response to volume loading. The selection of a particular fluid for resuscitation solution should be tailored to the patient's individual situation. No single fluid preparation will be appropriate for all clinical situations. Crystalloids, colloids, and hypertonic saline solutions have all been shown to be effective in restoring intravascular volume. Each has its own relative advantages and disadvantages and will be appropriate in differing situations. Colloid preparations should not be avoided for fear of inducing pulmonary edema, and the use of hypertonic solutions should not be precluded by fear of potential metabolic complications. The judicious use of both hypertonic solutions and colloids is safe. For the vast majority of routine surgical cases, where the patient is hemodynamically stable and postoperative fluid overloading is not a significant problem, isotonic crystalloids such as lactated Ringer's are both sufficient and cost effective.
Collapse
Affiliation(s)
- L E Ratner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | |
Collapse
|
|
34
|
Vassar MJ, Holcroft JW. Use of Hypertonic-Hyperoncotic Fluids for Resuscitation of Trauma Patients. J Intensive Care Med 1992. [DOI: 10.1177/088506669200700406] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypertonic sodium chloride solutions in concentrations ranging from 1.5% to 24% have been studied for use in the resuscitation of burn and hemorrhagic shock victims for many years. In animal studies, in the setting of small volume resuscitation, hypertonic sodium chloride is superior to standard isotonic crystalloid resuscitation for restoration of hemodynamic stability. The combination of hypertonic sodium chloride with a hyperoncotic colloid solution sustains hemodynamic improvements for an additional hour. Hypertonic-hyperoncotic solutions restore vascular volume primarily by drawing water out of the cell and then selectively partitioning some of the newly recruited fluid within the plasma space. The hyperosmolar state also augments microcirculatory flow, reduces cerebral edema formation, and perhaps increases myocardial contractility. The ability to increase cardiac output with small volume hypertonic-hyperoncotic resuscitation may solve some of the problems related to fluid resuscitation in the prehospital setting when transport times are prolonged or mass casualties need to be treated. Decreasing the volume of fluid required during resuscitation may also prove beneficial in the setting of craniocerebral trauma where the administration of large volumes of crystalloid can increase intracranial pressure. The largest clinical experiences have been reported with the administration of 4 mL/kg of 7.5% sodium chloride combined with 6% dextran 70. These studies have shown that this solution is safe to administer and effective for reversal of hypotension. Whether or not the ability to reverse hypotension will translate into improved survival remains undetermined at present and will require larger multi-institutional trials.
Collapse
Affiliation(s)
- Mary J. Vassar
- Department of Surgery, School of Medicine, University of California, Davis, Sacramento, CA
| | - James W. Holcroft
- Department of Surgery, School of Medicine, University of California, Davis, Sacramento, CA
| |
Collapse
|
|
35
|
Shackford SR. Hypertonic-Hyperoncotic Solutions: The Ideal Prehospital Fluid for Trauma Victims? J Intensive Care Med 1992. [DOI: 10.1177/088506669200700402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Steven R. Shackford
- Chairman, Department of Surgery The University of Vermont College of Medicine Burlington, VT 05401
| |
Collapse
|
|
36
|
|
|
37
|
Abstract
This study evaluated resuscitation of endotoxin shock with 7.5% hypertonic saline dextran (HSD 2400 mOsm) by measuring hemodynamic and regional blood flow responses. Endotoxin challenge (1 mg/kg) in adult dogs caused a significant decrease in mean arterial blood pressure (MABP), cardiac output (CO), left ventricular +/- dP/dt max, and regional blood flow (radioactive microspheres). Cardiocirculatory dysfunction and acid-base derangements persisted throughout the experimental period in untreated endotoxin shock (group 1, n = 10). In contrast both regimens of fluid resuscitation (group 2, n = 11: bolus of 4 mL/kg HSD followed by a constant infusion of lactated Ringer's [LR] to maintain MABP and CO at baseline values; group 3, n = 10; LR alone given as described for group 2) improved regional perfusion and corrected acid-base disturbances similarly in all dogs. Hypertonic saline dextran enhanced all indices of cardiac contraction and relaxation more than LR alone. The total volume of LR required to maintain MABP and CO at baseline values was less in the HSD group (59.2 +/- 6.8 mL/kg) than in the LR alone group (158 +/- 16 mL/kg, p = 0.01). The net fluid gain (infused volume minus urine output and normalized for kilogram body weight) was five times greater in the LR (24.8 +/- 6.2 mL/kg) than in the HSD group (4.6 +/- 1.2 mL/kg, p = 0.01). Lung water was similar in all dogs, regardless of the regimen of fluid resuscitation. Hypertonic saline dextran effectively resuscitates endotoxin shock in this canine model.
Collapse
Affiliation(s)
- J W Horton
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235-9031
| | | |
Collapse
|
|
38
|
|
|
39
|
Sondeen JL, Gonzaludo GA, Loveday JA, Rodkey WG, Wade CE. Hypertonic saline/dextran improves renal function after hemorrhage in conscious swine. Resuscitation 1990; 20:231-41. [PMID: 1708908 DOI: 10.1016/0300-9572(90)90006-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This study was performed to determine whether resuscitation with a single bolus of 7.5% NaCl/6% Dextran 70 (hypertonic saline/Dextran, HSD) could restore renal function following hemorrhage. Chronically instrumented, conscious pigs were hemorrhaged 28 ml/kg. This level of hemorrhage reduced mean arterial pressure (MAP) and cardiac output (CO) to nearly half, renal blood flow (RBF) to approximately 25%, and glomerular filtration rate (GFR) and urine flow (V) to less than 10% of their initial values. A single, 4 ml/kg bolus injection of HSD increased MAP and RBF to approximately 80% of baseline values and restored CO and GFR to levels which were significantly different from control values. These improvements were sustained for 2 h with no further treatment. Urine flow transiently increased although not to pre-hemorrhage values, and then subsided. Plasma osmolality increased from 275 to 282 mOsm/kg H2O, and plasma sodium increased from 141 to 149 mEq/l. Recovery following administration of an equal volume of normal saline was significantly less for all variables. Euvolemic animals showed no response in MAP, CO, RBF, or GFR when treated with HSD although V, osmotic and sodium excretion increased. These results demonstrate that resuscitation with HSD following hemorrhage not only restores MAP and CO, but maintains renal function as well.
Collapse
Affiliation(s)
- J L Sondeen
- Division of Military Trauma Research, Letterman Army Institute of Research, Presidio of San Francisco, CA 94129-6800
| | | | | | | | | |
Collapse
|
|
40
|
Riou B, Carli P. [Hypertonic sodium chloride and hemorrhagic shock]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1990; 9:536-46. [PMID: 2278420 DOI: 10.1016/s0750-7658(05)80225-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Numerous experimental studies on the effects of hypertonic saline in haemorrhagic shock have been published and controlled clinical studies are now beginning to be reported. Animals suffering from an otherwise lethal haemorrhagic shock survived when given hypertonic sodium chloride solution (7.5%, 2,400 mosmol.1-1). In most studies, this solution was more efficient than isotonic fluids in treating controlled haemorrhage. Although the mechanisms involved are not yet fully understood, they certainly include the following: 1) plasma volume expansion due to osmotic fluid shifts into the vascular compartment from intra- and extra-cellular fluid reservoirs, as hypertonic saline induces hypernatraemia and hyperosmolarity, both effects linked to the sodium load; 2) non specific precapillary vasodilation of renal, coronary and splanchnic vessels; 3) arterial and venous vasoconstriction in muscle and skin, due to a vagal reflex set off by the lung osmoreceptors, the efferent pathway of which is likely to be the sympathetic nervous system; 4) increased myocardial contractility. Hypertonic saline also decreases intracranial pressure, and improves lung function during resuscitation of haemorrhagic shock. However, hypertonic saline should not yet be used routinely in man, except in controlled clinical studies. Indeed, there are as yet not enough data concerning humans. Moreover, during uncontrolled haemorrhage, hypertonic saline increased blood pressure, and therefore bleeding, thus reducing survival rates. Further clinical studies are required before hypertonic saline could be safely recommended for treatment of haemorrhagic shock.
Collapse
Affiliation(s)
- B Riou
- Département d'Anesthésie-Réanimation, CHU Pitié-Salpetrière, Paris
| | | |
Collapse
|