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Mladinov D, Isaza E, Gosling AF, Clark AL, Kukreja J, Brzezinski M. Perioperative Fluid Management. Clin Geriatr Med 2025; 41:83-99. [PMID: 39551543 DOI: 10.1016/j.cger.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2024]
Abstract
The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the older adults are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the older adults. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Erin Isaza
- University of California, San Francisco, School of Medicine, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Andre F Gosling
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845D, Birmingham, AL 35249, USA
| | - Adrienne L Clark
- Department of Anesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Marek Brzezinski
- Department of Anesthesia and Perioperative Care, University of California, VA Medical Center-San Francisco, 4150 Clement Street, San Francisco CA 94121, USA.
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Mladinov D, Isaza E, Gosling AF, Clark AL, Kukreja J, Brzezinski M. Perioperative Fluid Management. Anesthesiol Clin 2023; 41:613-629. [PMID: 37516498 DOI: 10.1016/j.anclin.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the elderly are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the elderly. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Erin Isaza
- University of California, San Francisco, School of Medicine, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Andre F Gosling
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845D, Birmingham, AL 35249, USA
| | - Adrienne L Clark
- Department of Anesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Marek Brzezinski
- Department of Anesthesia and Perioperative Care, University of California, VA Medical Center-San Francisco, 4150 Clement Street, San Francisco CA 94121, USA.
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Ye H, Du Y, Jin Y, Liu F, He S, Guo Y. Articles on hemorrhagic shock published between 2000 and 2021: A CiteSpace-Based bibliometric analysis. Heliyon 2023; 9:e18840. [PMID: 37636355 PMCID: PMC10450864 DOI: 10.1016/j.heliyon.2023.e18840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To conduct a bibliometric analysis of literature on hemorrhagic shock published between 2000 and 2021 with the help of Citespace to explore the current status, hotspots and research trends in this regard, with the results presented in a visualized manner. Methods The data over the past 22 years were retrieved from the Web of Science (WOS) Core Collection database and downloaded as the "Full Record and Cited References". Cooperative analysis, cluster analysis, co-citation analysis, and burst analysis were performed based on the data on countries/regions, institutions, journals, authors, and keywords through Citespace. Results A total of 2027 articles were retrieved. The number of annual publications fluctuated but was generally on an upward trend. The United States stands out as the most productive country (989 articles), the University of Pittsburgh the most productive publishing institution (109 articles), SHOCK the most cited journal (1486 articles), TAO LI the most productive author (40 articles), DEITCH EA the most cited author (261 times of citation), hemorrhagic shock the most frequent keyword (725 times of occurrence), and "traumatic brain injury" the most covered article in keyword clustering (29 articles). The burst analysis revealed Harvard University as the institution with the highest strength value and the Journal of Trauma and Acute Care Surgery the most important journal. It was also concluded that HASAN B ALAM, AARON M WILLIAMS, and LIMIN ZHANG may continue to publish high-quality articles in the future. In the meanwhile, both "protect" and "transfusion" were considered the hotspots and trends in current research. Conclusions The United States has been a major contributor to the publication of the articles over the past 22 years, with the most productive publishing institution, the most cited journal, and the most cited author all coming from the US. Hemorrhagic shock, injury, resuscitation, trauma, models, activation, expression, fluid resuscitation, rats, and nitric oxide are hot topics in relevant research. According to the keyword burst analysis, the areas related to "protect" and "transfusion" may rise as the research directions in the future. However, since the hotspots in the research of hemorrhagic shock are short-lived and fast-changing, the researchers should pay more attention to the development trend in this field.
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Affiliation(s)
- Haoran Ye
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuan Du
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yueting Jin
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Fangyu Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Shasha He
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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Recent U.S. Food and Drug Administration Labeling Changes for Hydroxyethyl Starch Products Due to Concerns about Mortality, Kidney Injury, and Excess Bleeding. Anesthesiology 2022; 136:868-870. [PMID: 35258516 DOI: 10.1097/aln.0000000000004164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park SK, Park DN, Kim YW, Yoo S, Kim WH, Lim YJ, Park JS, Jun JK, Kim JT. Colloid coload versus crystalloid coload to prevent maternal hypotension in women receiving prophylactic phenylephrine infusion during caesarean delivery: a randomised controlled trial. Int J Obstet Anesth 2021; 49:103246. [PMID: 35012809 DOI: 10.1016/j.ijoa.2021.103246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 11/16/2021] [Accepted: 12/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal fluid strategy to prevent maternal hypotension during caesarean delivery remains unclear. This study aim was to compare the incidence of post-spinal anaesthesia hypotension in women receiving either colloid or crystalloid coload in the setting of prophylactic phenylephrine infusion during caesarean delivery. METHODS Healthy mothers undergoing elective caesarean delivery under spinal anaesthesia were randomised to receive a rapid intravenous coload with 6% hydroxyethyl starch 130/0.4 10 mL/kg (colloid group) or balanced crystalloid solution (Plasma Solution A) 10 mL/kg (crystalloid group) during spinal anaesthesia. All women had a prophylactic phenylephrine infusion initiated at 25 μg/min immediately after the subarachnoid block and titrated to systolic blood pressure using a standardised protocol. The primary outcome was the incidence of hypotension (systolic blood pressure <80% of baseline) until delivery. RESULTS The incidence of hypotension was 50% in the colloid group and 62% in the crystalloid group (absolute difference, -12% [95% CI -33% to 9%]; relative risk, 0.8 [95% CI 0.56 to 1.14]; P=0.314). No significant difference between groups was found in the number of hypotensive episodes (median 0.5 [IQR 0 to 1] vs 1 [0 to 2], P=0.132) or phenylephrine dose (675 [IQR 425 to 975] μg vs 750 [625 to 950] μg, P=0.109). The incidence of severe hypotension, symptomatic hypotension, bradycardia, nausea, and the neonatal outcomes were not significantly different. CONCLUSIONS This study found no benefit of colloid coload compared with crystalloid coload for preventing maternal hypotension in the presence of prophylactic phenylephrine infusion during caesarean delivery.
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Affiliation(s)
- S-K Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - D-N Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Y-W Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - S Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - W H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Y-J Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J S Park
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J K Jun
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J-T Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Santos MG, Pontes JPJ, Gonçalves Filho S, Lima RM, Thom MM, Módolo NSP, Ponce D, Navarro LH. Impact of colloids or crystalloids in renal function assessed by NGAL and KIM-1 after hysterectomy: randomized controlled trial. Braz J Anesthesiol 2021; 72:720-728. [PMID: 34848313 PMCID: PMC9660003 DOI: 10.1016/j.bjane.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/20/2021] [Accepted: 10/30/2021] [Indexed: 12/01/2022] Open
Abstract
Background Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. Methods This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg−1.h−1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. Results Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p = 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p = 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p = 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. Conclusion HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.
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Affiliation(s)
- Murillo G Santos
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil.
| | - João Paulo Jordão Pontes
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil; Santa Genoveva Complexo Hospitalar, Uberlândia, MG, Brazil
| | - Saulo Gonçalves Filho
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
| | - Rodrigo M Lima
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil; Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada
| | - Murilo M Thom
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
| | - Norma Sueli P Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
| | - Daniela Ponce
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Clínica Médica, Botucatu, SP, Brazil
| | - Lais Helena Navarro
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada; Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
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Pensier J, Deffontis L, Rollé A, Aarab Y, Capdevila M, Monet C, Carr J, Futier E, Molinari N, Jaber S, De Jong A. Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis. Anesth Analg 2021; 134:686-695. [PMID: 34854822 DOI: 10.1213/ane.0000000000005803] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement. METHODS In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant). RESULTS Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02). CONCLUSIONS In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.
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Affiliation(s)
- Joris Pensier
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Lucas Deffontis
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Amélie Rollé
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Yassir Aarab
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Mathieu Capdevila
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Clément Monet
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Julie Carr
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Emmanuel Futier
- Centre Hospitalier Universitaire Clermont-Ferrand, Département de Médecine Périopératoire, Anesthésie et Réanimation, Clermont-Ferrand, France
| | - Nicolas Molinari
- Department of Statistics, University of Montpellier Lapeyronie Hospital, UMR 729 MISTEA, Montpellier, France
| | - Samir Jaber
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France.,Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier Cedex 5 Montpellier, France
| | - Audrey De Jong
- From the Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, France.,Département d'Anesthésie-Réanimation B, Centre Hospitalier Universitaire Montpellier, Montpellier, France.,Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier Cedex 5 Montpellier, France
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Xu Y, Wang S, He L, Yu H, Yu H. Hydroxyethyl starch 130/0.4 for volume replacement therapy in surgical patients: a systematic review and meta-analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:16. [PMID: 33971968 PMCID: PMC8111748 DOI: 10.1186/s13741-021-00182-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/22/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The safety of perioperative intravenous hydroxyethyl starch (HES) products, specifically HES 130/0.4, continues to be the source of much debate. The aim of this meta-analysis was to update the existing evidence and gain further insight into the clinical effects of HES 130/0.4 on postoperative outcomes for volume replacement therapy in surgical patients. METHODS MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to March 2020 for relevant randomized controlled trials (RCTs) on perioperative use of HES 130/0.4 in adult surgical patients. The primary outcome was postoperative mortality and secondary outcomes were the incidence of acute kidney injury (AKI) and requirement for renal replacement therapy (RRT). The analysis was performed using the random-effects method and the risk ratio (RR) with a 95% confidence interval (CI). We performed the risk-of-bias assessment of eligible studies and assessed the overall quality of evidence for each outcome. RESULTS Twenty-five RCTs with 4111 participants were finally included. There were no statistical differences between HES 130/0.4 and other fluids in mortality at 30 days (RR 1.28, 95% CI 0.88 to 1.86, p = 0.20), the incidence of AKI (RR 1.23, 95% CI 0.99 to 1.53, p = 0.07), or requirement for RRT (RR 0.75, 95% CI 0.37 to 1.53, p = 0.43). Overall, there was a moderate certainty of evidence for all the outcomes. There was no subgroup difference related to the type of surgery (p = 0.17) in the incidence of AKI. As for the type of comparator fluids, however, there was a trend that was not statistically significant (p = 0.06) towards the increased incidence of AKI in the HES 130/0.4 group (RR 1.22, 95% CI 0.97 to 1.54) compared with the crystalloid group (RR 1.21, 95% CI 0.27 to 3.91). Subgroup analyses according to the type of surgery demonstrated consistent findings. CONCLUSIONS This systematic review and meta-analysis suggests that the use of HES 130/0.4 for volume replacement therapy compared with other fluids resulted in no significant difference in postoperative mortality or kidney dysfunction among surgical patients. Given the absent evidence of confirmed benefit and the potential trend of increased kidney injury, we cannot recommend the routine clinical use of HES 130/0.4 for volume replacement therapy in surgical patients from the perspective of benefit/risk profile. However, the results need to be interpreted with caution due to the limited sample size, and further well-powered RCTs are warranted. TRIAL REGISTRATION PROSPERO registry reference: CRD42020173058.
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Affiliation(s)
- Yi Xu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Siying Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Leilei He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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9
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Colomina MJ, Méndez E, Sabate A. Altered Fibrinolysis during and after Surgery. Semin Thromb Hemost 2021; 47:512-519. [PMID: 33878781 DOI: 10.1055/s-0041-1722971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Major surgery induces hemostatic changes related to surgical stress, tissue destruction, and inflammatory reactions. These changes involve a shift of volume from extravascular space to intravascular and interstitial spaces, a "physiologic" hemodilution of coagulation proteins, and an increase of plasmatic fibrinogen concentration and platelets. Increases in fibrinogen and platelets together with a simultaneous dilution of pro- and anticoagulant factors and development of a hypofibrinolytic status result in a postoperative hypercoagulable state. This profile is accentuated in more extensive surgery, but the balance can shift toward hemorrhagic tendency in specific types of surgeries, for example, in prolonged cardiopulmonary bypass or in patients with comorbidities, especially liver diseases, sepsis, and hematological disorders. Also, acquired coagulopathy can develop in patients with trauma, during obstetric complications, and during major surgery as a result of excessive blood loss and subsequent consumption of coagulation factors as well as hemodilution. In addition, an increasing number of patients receive anticoagulants and antiplatelet drugs preoperatively that might influence the response to surgical hemostasis. This review focuses on those situations that may change normal hemostasis and coagulation during surgery, producing both hyperfibrinolysis and hypofibrinolysis, such as overcorrection with coagulation factors, bleeding and hyperfibrinolysis that may occur with extracorporeal circulation and high aortic-portal-vena cava clamps, and hyperfibrinolysis related to severe maintained hemodynamic disturbances. We also evaluate the role of tranexamic acid for prophylaxis and treatment in different surgical settings, and finally the value of point-of-care testing in the operating room is commented with regard to investigation of fibrinolysis.
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Affiliation(s)
- Maria J Colomina
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
| | - Esther Méndez
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Antoni Sabate
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
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10
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Gratz J, Zotti O, Pausch A, Wiegele M, Fleischmann E, Gruenberger T, Krenn CG, Kabon B. Effect of Goal-Directed Crystalloid versus Colloid Administration on Perioperative Hemostasis in Partial Hepatectomy: A Randomized, Controlled Trial. J Clin Med 2021; 10:jcm10081651. [PMID: 33924407 PMCID: PMC8068812 DOI: 10.3390/jcm10081651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
The use of colloids may impair hemostatic capacity. However, it remains unclear whether this also holds true when colloids are administered in a goal-directed manner. The aim of the present study was to assess the effect of goal-directed fluid management with 6% hydroxyethyl starch 130/0.4 on hemostasis compared to lactated Ringer’s solution in patients undergoing partial hepatectomy. We included 50 patients in this prospective, randomized, controlled trial. According to randomization, patients received boluses of either hydroxyethyl starch or lactated Ringer’s solution within the scope of goal-directed fluid management. Minimum perioperative FIBTEM maximum clot firmness (MCF) served as the primary outcome parameter. Secondary outcome parameters included fibrinogen levels and estimated blood loss. In the hydroxyethyl starch (HES) group the minimum FIBTEM MCF value was significantly lower (effect size −6 mm, 95% CI −10 to −3, p < 0.001) in comparison to the lactated Ringer’s solution (RL) group. These results returned to normal within 24 h. We observed no difference in plasma fibrinogen levels (RL 3.08 ± 0.37 g L−1 vs HES 2.65 ± 0.64 g L−1, p = 0.18) or the amount of blood loss between the two groups (RL 470 ± 299 mL vs HES 604 ± 351 mL, p = 0.18). We showed that goal-directed use of HES impairs fibrin polymerization in a dose-dependent manner when compared with RL. Results returned to normal on the first postoperative day without administration of procoagulant drugs and no differences in blood loss were observed.
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Affiliation(s)
- Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Oliver Zotti
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - André Pausch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Marion Wiegele
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
- Correspondence:
| | - Thomas Gruenberger
- Department of Surgery, HPB-Center, Kaiser Franz Josef Hospital Vienna, Kundratstrasse 3, 1100 Vienna, Austria;
| | - Claus G. Krenn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
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11
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Löffel LM, Hahn RG, Engel D, Wuethrich PY. Intraoperative Intravascular Effect of Lactated Ringer's Solution and Hyperoncotic Albumin During Hemorrhage in Cystectomy Patients. Anesth Analg 2020; 133:413-422. [PMID: 32947291 DOI: 10.1213/ane.0000000000005173] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The intraoperative effect of 20% albumin on plasma volume during surgery involving major blood loss has not been explored extensively due to methodological difficulties. Crystalloids poorly expand the plasma volume, and using a colloid might then be a way to avoid fluid overload. As doubts have been raised about synthetic colloids, albumin solutions are currently used more extensively. This study presents a methodological development showing how plasma volume expansion can be studied in surgical settings with the coinfusion of 20% albumin and lactated Ringer's solution. METHODS In this single-arm, single-center feasibility study, an intravenous (i.v.) infusion of 3 mL·kg·BW-1 of 20% albumin was administered over 30 minutes to 23 cystectomy patients during the bleeding phase in addition to lactated Ringer's solution to correct blood loss. Blood samples were measured at regular intervals over a period of 300 minutes to estimate the blood volume expansion resulting from simultaneous infusions of lactated Ringer's and 20% albumin solutions, using a regression equation and the area under the volume-time curve method. RESULTS Mean hemorrhage was 974 mL (standard deviation [SD] ± 381). The regression method showed strong correlation (r2 = 0.58) between blood loss minus blood volume expansion and the independent effects of the infused volume of lactated Ringer's and 20% albumin solutions. The mean plasma volume expansion attributable to the infusion of lactated Ringer's solution amounted to 0.38 (95% confidence interval [CI], 0.31-0.49) of the infused volume; for the 20% albumin, it was 1.94 mL/mL (95% CI, 1.41-2.46 mL/mL) over 5 hours on average (regression method). The mean within-patient change was 0.20 mL/mL (± 0.06 mL/mL) for the lactated Ringer's solution and 2.20 mL/mL (±1.31 mL/mL) for the 20% albumin using the area under the volume-time curve method. CONCLUSIONS Blood volume expansion averaged 1.9-2.2 times the infused volume of 20% albumin during surgery associated with hemorrhage of around 1000 mL. This effect was long standing and approximately 5 times stronger than for the lactated Ringer's solution. Twenty percent albumin boosts the plasma volume expansion of lactated Ringer's solution to as high as 40% of the infused volume on the average, which is an effect that lasts at least 5 hours.
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Affiliation(s)
- Lukas M Löffel
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert G Hahn
- Research Unit, Södertälje Hospital, Södertälje, and Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Dominique Engel
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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Intravenous Fluid of Choice in Major Abdominal Surgery: A Systematic Review. Crit Care Res Pract 2020; 2020:2170828. [PMID: 32832150 PMCID: PMC7421038 DOI: 10.1155/2020/2170828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/29/2020] [Accepted: 06/30/2020] [Indexed: 12/29/2022] Open
Abstract
Background Intravenous fluid therapy plays a role in maintaining the hemodynamic status for tissue perfusion and electrolyte hemostasis during surgery. Recent trials in critically ill patients reported serious side effects of some types of fluids. Since the most suitable type of fluid is debatable, a consensus in perioperative patients has not been reached. Method We performed a systematic review of randomized control trials (RCTs) that compared two or more types of fluids in major abdominal surgery. The outcomes were related to bleeding, hemodynamic status, length of hospital stay, and complications, such as kidney injury, electrolyte abnormality, major cardiac adverse event, nausea, vomiting, and mortality. A literature search was performed using Medline and EMBASE up to December 2019. The data were pooled to investigate the effect of fluid on macrocirculation and intravascular volume effect. Results Forty-three RCTs were included. Eighteen fluids were compared: nine were crystalloids and nine were colloids. The results were categorized into macrocirculation and intravascular volume effect, microcirculation, anti-inflammatory parameters, vascular permeability, renal function (colloids), renal function and electrolytes (crystalloids), coagulation and bleeding, return of bowel function, and postoperative nausea vomiting (PONV). We found that no specific type of fluid led to mortality and every type of colloid was equivalent in volume expansion and did not cause kidney injury. However, hydroxyethyl starch and dextran may lead to increased bleeding. Normal saline can cause kidney injury which can lead to renal replacement therapy, and dextrose fluid can decrease PONV. Conclusion In our opinion, it is safe to give a balanced crystalloid as the maintenance fluid and give a colloid, such as HES130/0.4, 4% gelatin, or human albumin, as a volume expander.
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13
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Acute resuscitation with polyethylene glycol-20k: A thromboelastographic analysis. J Trauma Acute Care Surg 2020; 87:322-330. [PMID: 31033892 DOI: 10.1097/ta.0000000000002332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Previous ex vivo studies have shown that polyethylene glycol-20,000 Da (PEG-20k), a novel synthetic polymer that is highly effective for resuscitation, has a hypocoagulable effect on human blood. This study's objective was to determine the in vivo effects of PEG-20k-based resuscitation solutions on coagulation and platelet function in a porcine model of hemorrhagic shock. METHODS Anesthetized pigs underwent controlled hemorrhage until the lactate reached 7 mmol/L or 50% to 55% of their estimated blood volume was removed. A laparotomy was performed to simulate tissue injury. Low volume resuscitation (LVR) was given with fluorescein isothiocyanate-labeled 10% PEG-20k solution (100 mg/mL) or Lactated Ringers, both delivered at volumes equal to 10% of the estimated blood volume (n = 5). Thromboelastography was performed after surgery (baseline), after hemorrhage, and 15 minutes, 120 minutes, and 240 minutes postresuscitation. Hemoglobin was measured to determine changes in plasma volume. Plasma PEG-20k concentration was measured by indicator dilution. RESULTS Pigs given PEG-20k survived 2.6-fold longer than controls (p < 0.001) and had a significant increase in plasma volume demonstrated by the sustained drop in hemoglobin, relative to controls. Pigs resuscitated with LR died from hypotension an average of 90 minutes after resuscitation compared to the PEG-20k pigs, which all survived 240 minutes and were then euthanized with normal blood pressure and lactate. Administration of PEG-20k primarily decreased the thromboelastograph maximum amplitude, however this began to return toward baseline by 240 minutes. Peak plasma concentration of PEG-20k after LVR were 40% lower than predicted, based on simple dilution (5.7 mg/mL vs. 10 mg/mL) and the half-life was 59.6 minutes. CONCLUSION These data demonstrate that acute resuscitation with PEG-20k significantly improves tolerance to hypovolemia but also decreases platelet function in the coagulation cascade, which was due, in part, to its volume expanding effects.
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14
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Futier E, Garot M, Godet T, Biais M, Verzilli D, Ouattara A, Huet O, Lescot T, Lebuffe G, Dewitte A, Cadic A, Restoux A, Asehnoune K, Paugam-Burtz C, Cuvillon P, Faucher M, Vaisse C, El Amine Y, Beloeil H, Leone M, Noll E, Piriou V, Lasocki S, Bazin JE, Pereira B, Jaber S. Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial. JAMA 2020; 323:225-236. [PMID: 31961418 PMCID: PMC6990683 DOI: 10.1001/jama.2019.20833] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. OBJECTIVE To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. INTERVENTIONS Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. RESULTS Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). CONCLUSIONS AND RELEVANCE Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02502773.
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Affiliation(s)
- Emmanuel Futier
- Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Université Clermont Auvergne, CNRS, Inserm U-1103, Clermont-Ferrand, France
| | - Matthias Garot
- CHU de Lille, Pôle Anesthésie Réanimation, Hôpital Claude Huriez, Lille, France
| | - Thomas Godet
- CHU de Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Clermont-Ferrand, France
| | - Matthieu Biais
- CHU de Bordeaux, Département Anesthésie et Réanimation, Hôpital Pellegrin, Bordeaux, France
| | - Daniel Verzilli
- CHU Montpellier, Département Anesthésie et Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Montpellier, France
| | - Alexandre Ouattara
- CHU de Bordeaux, Service Anesthésie et Réanimation, Centre Medico-chirugical Magellan, Bordeaux, France
- Inserm, UMR 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Olivier Huet
- CHU de Brest, Département Anesthésie et Réanimation, Hôpital La cavale Blanche, Brest, France
| | | | - Gilles Lebuffe
- CHU de Lille, Pôle Anesthésie Réanimation, Hôpital Claude Huriez, Lille, France
| | - Antoine Dewitte
- CHU de Bordeaux, Service Anesthésie et Réanimation, Centre Medico-chirugical Magellan, Bordeaux, France
- Inserm, UMR 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Anna Cadic
- CHU de Brest, Département Anesthésie et Réanimation, Hôpital La cavale Blanche, Brest, France
| | - Aymeric Restoux
- AP-HP, Département Anesthésie et Réanimation, Hôpital Beaujon, Clichy, Paris, France
| | - Karim Asehnoune
- CHU de Nantes, Département Anesthésie et Réanimation, Hôpital Hôtel Dieu, Nantes, France
| | | | - Philippe Cuvillon
- CHU de Nîmes, Section d’Anesthésie, Département Anesthésie et Réanimation, Nîmes, France
| | - Marion Faucher
- Institut Paoli Calmettes, Département Anesthésie et Réanimation, Marseille, France
| | - Camille Vaisse
- Assistance Publique Hôpitaux de Marseille (AP-HM), Service Anesthésie et Réanimation, Hôpital Timone, Marseille, France
| | - Younes El Amine
- Centre Hospitalier de Valenciennes, Département Anesthésie et Réanimation, Valenciennes, France
| | - Hélène Beloeil
- Université de Rennes, Inserm, INRA, CHU Rennes, CIC 1414, Numecan, Pôle Anesthésie et Réanimation, Rennes, France
| | - Marc Leone
- AP-HM, Service Anesthésie et Réanimation, Hôpital Nord, Université Aix Marseille, Marseille, France
| | - Eric Noll
- Hôpitaux Universitaires de Strasbourg, Service d’Anesthésie Réanimation Chirurgicale, Hôpital Hautepierre, Strasbourg, France
| | - Vincent Piriou
- Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Service d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Lyon, France
| | | | - Jean-Etienne Bazin
- CHU de Clermont-Ferrand, Département Anesthésie et Réanimation, Hôpital Estaing, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Direction de la Recherche Clinique (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Samir Jaber
- CHU Montpellier, Département Anesthésie et Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Montpellier, France
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15
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Metry AA, Tawfik AF, Nakhla GM, Wahba RM, Ragaei MZ, Abdelmalek FA. The Effect of Adding Dopamine Infusion to Noradrenaline Infusion Combined With Restrictive Hydration on Renal Function and Tissue Perfusion during Open Abdominal Surgeries. Anesth Essays Res 2019; 13:229-235. [PMID: 31198236 PMCID: PMC6545950 DOI: 10.4103/aer.aer_34_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives This study was designed to assess the effect of adding dopamine infusion in addition to restrictive hydration combined with noradrenaline infusion on intraoperative renal function and serum lactate levels in comparison to restrictive hydration combined with noradrenaline infusion only and standard hydration during open abdominal surgeries. Patients and Methods One hundred and twenty patients were randomly assigned into three equal groups undergoing major open abdominal procedures. In Group I, dopamine infusion in addition to norepinephrine infusion were administered with restrictive hydration. In Group II, norepinephrine infusion was started before the induction of anesthesia with restrictive hydration. In Groups I and II, Ringer's solution was infused at a fixed rate of 2 mL.kg-1.h-1 until the end of surgery. In Group III, the conventional fluid replacement was introduced according maintenance, fluid deficit and third space loss. The outcome to be assessed was serial measurements of creatinine and serum lactate levels preoperatively, intraoperatively, and just postoperatively in addition to after 24 h. Results Serum lactate level was significantly low in Groups I and II than that in Group III intraoperatively and postoperatively. In addition, urine output was significantly more in Group I and Group III than in Group II. Creatinine level was higher with significance in Group II than in Group I and III 24 h postoperatively. Conclusion Dopamine infusion, when added to norepinephrine infusion combined with restricted hydration, improved urine output and creatinine level. Tissue perfusion as indicated by serum lactate level was more adequate in Groups I and II than that in Group III.
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Affiliation(s)
- Ayman Anis Metry
- Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Adham F Tawfik
- Department of Anesthesiology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - George M Nakhla
- Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rami M Wahba
- Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Milad Z Ragaei
- Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Fady A Abdelmalek
- Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Role of spleen and liver for enhanced hemostatic competence following administration of adrenaline to humans. Thromb Res 2019; 176:95-100. [PMID: 30798105 DOI: 10.1016/j.thromres.2019.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/17/2019] [Accepted: 02/15/2019] [Indexed: 11/20/2022]
Abstract
This study evaluated by thrombelastography® (TEG) and Multiplate® analyses the role of the spleen and the liver for adrenaline-induced enhanced hemostatic competence. Eight splenectomized subjects and eight matched healthy control subjects were exposed to one-hour infusion of adrenaline (6 μg/kg/h). Administration of adrenaline to the healthy subjects reduced time to TEG-detected initial fibrin formation (by 22%) and increased rate of clot development (by 10%), maximal amplitude (by 8%), platelet count (by 30%), and Multiplate evaluated Ristocetin-induced platelet aggregation (by 21%) (all p ≤ 0.05), but infusion of adrenaline did not result in significant arterial to liver vein differences for plasma markers of coagulation. In the splenectomized subjects, adrenaline reduced the TEG-determined time to initial fibrin formation (by 17%; p = 0.005) whereas rate of clot development and maximum amplitude were unaffected. Also, 6 patients undergoing liver transplantation were exposed to infusion of adrenaline (4.8 μg/kg/h) during the anhepatic phase of the operation and that increased TEG-determined rate of clot formation (by 10%; p < 0.05), maximal amplitude (by 9%; p = 0.002) and tended to reduce time to initial fibrin formation (p = 0.1). In conclusion, adrenaline enhances hemostasis as evaluated by TEG in both healthy subjects and in anhepatic patients during liver transplantation and Ristocetin-induced aggregation in control subjects. In contrast, infusion of adrenaline reduces only time to initial fibrin formation in splenectomized subjects. These findings suggest that mobilization of platelets from the spleen dominates the adrenaline-induced enhanced hemostatic competence.
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17
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Lee EH, Yun SC, Lim YJ, Jo JY, Choi DK, Choi IC. The effects of perioperative intravenous fluid administration strategy on renal outcomes in patients undergoing cardiovascular surgery: An observational study. Medicine (Baltimore) 2019; 98:e14383. [PMID: 30762739 PMCID: PMC6408081 DOI: 10.1097/md.0000000000014383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We assessed whether perioperative fluid management with balanced solutions and a limited volume of hydroxyethyl starch (renal-protective fluid management [RPF] strategy) could improve renal outcomes after cardiovascular surgery.For this retrospective observational study, we evaluated 2613 patients who underwent cardiovascular surgery from January 1, 2010 to December 31, 2013. The control group were given intravenous fluids with saline-based solutions and unlimited volumes of hydroxyethyl starch solutions and the RPF group were given intravenous fluids with RPF. The primary outcome was the incidence of acute kidney injury (AKI) and chronic dialysis within 12 months after cardiovascular surgery. Multivariable regression and propensity analyses were performed to evaluate the association between perioperative fluid management strategy and postoperative renal outcomes.Postoperative AKI and chronic dialysis occurred in 213 (21.2%) and 5 (0.5%) patients in the RPF group compared with 696 (43.2%) and 38 (2.4%) patients in the control group, respectively. After adjustment, the RPF group was linked to a decreased risk of postoperative AKI, severe AKI, persistent AKI, use of renal replacement therapy, chronic kidney disease, chronic dialysis, and a shorter postoperative extubation time and intensive care unit, and hospital stay duration.The perioperative fluid management strategy with balanced solutions and a limited volume of hydroxyethyl starch was related to improved acute and 1-year renal and clinical outcomes after cardiovascular surgery. These findings indicate the need for further definitive clinical trials on perioperative fluid management strategy.
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Affiliation(s)
- Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine
| | - Sung-Cheol Yun
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ye-Ji Lim
- Department of Anesthesiology and Pain Medicine
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18
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Fujita T, Okada N, Horikiri Y, Sato T, Fujiwara H, Mayanagi S, Kanamori J, Yamamoto H, Daiko H. Safety and efficacy of hydroxyethyl starch 6% 130/0.4/9 solution versus 5% human serum albumin in thoracic esophagectomy with 3-field lymph nodes dissection. Surg Today 2019; 49:427-434. [PMID: 30604215 DOI: 10.1007/s00595-018-1752-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/30/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE We investigated the safety and efficacy of administering hydroxyethyl starch 6% 130/0.4/9 (HES130/0.4/9) versus 5% human serum albumin (HSA), perioperatively, to patients undergoing thoracic esophagectomy with 3-field lymph-node dissection for esophageal cancer. METHODS The subjects of this study were 262 patients, scheduled to undergo thoracic esophagectomy for esophageal cancer, who were assigned to one of two groups based on the fluid replacement therapy. We compared the intraoperative and immediate postoperative hemodynamics and incidence of complications in the two groups. RESULTS Neither group suffered any adverse events. No significant differences were observed in systolic/diastolic blood pressure, heart rate, incidence of postoperative complications, postoperative urine output, or serum creatinine levels, between the groups. A mild postoperative increase (×1.5 increase) in serum creatinine levels was seen in 9.5% and 9.5% of patients in the HSA and HES130/0.4/9 groups, respectively (p = 0.99), and a moderate postoperative increase (×2.0 increase) was seen in 4.4% and 3.1%, respectively (p = 0.84). Univariate and multivariate analyses revealed that the administration of hydroxyethyl starch was not associated with a postoperative increase in serum creatinine levels. CONCLUSION Hydroxyethyl starch 6% 130/0.4/9 was well tolerated and comparable to albumin with respect to its effect on renal function during thoracic esophagectomy with 3-field lymph-node dissection.
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Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Naoya Okada
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yasumasa Horikiri
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takuji Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hisashi Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Shuhei Mayanagi
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Jun Kanamori
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiroyuki Yamamoto
- Division of Anesthesiology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients. Anesthesiology 2018; 129:1149-1158. [DOI: 10.1097/aln.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients.
Methods
The CRISTAL trial prospectively defined patients as critically ill surgical patients whenever they underwent emergency or scheduled surgery immediately before or within 24 h of intensive care unit admission and had hypovolemic shock. The primary outcome measure was death by day 28. Secondary outcome measures included death by day 90, the need for renal replacement therapy, or the need for fresh frozen plasma transfusion.
Results
There were 741 critically ill surgical patients, 356 and 385 in the crystalloid and colloid arm, respectively. Median (interquartile range) age was 66 (52 to 76) yr, and 484 (65.3%) patients were male. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) versus colloids 100 (26%; adjusted odds ratio, 0.86; 95% CI, 0.61 to 1.21; P = 0.768). Death by day 90 (111 [31.2%] vs. 122 [31.7%]; adjusted odds ratio, 0.97; 95% CI, 0.70 to 1.33; P = 0.919) did not significantly differ between groups. Renal replacement therapy was required for 42 (11.8%) patients in the crystalloids arm versus 49 (12.7%) in the colloids arm (P = 0.871).
Conclusions
The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.
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Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy. Curr Opin Crit Care 2018; 23:503-510. [PMID: 29059118 DOI: 10.1097/mcc.0000000000000466] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy. RECENT FINDINGS Mortality from major trauma continues to be a worldwide problem, and massive haemorrhage remains a major cause in 40% of potentially preventable trauma deaths. Development of trauma-induced coagulopathy challenges 25-35% of the patients further increasing trauma mortality. The pathophysiology of coagulopathy in trauma reflects at least two distinct mechanisms: Acute traumatic coagulopathy, consisting of endogenous heparinization, activation of the protein C pathway, hyperfibrinolysis and platelet dysfunction, and resuscitation associated coagulopathy. Clear fluid resuscitation with crystalloids and colloids is associated with dilutional coagulopathy and poor outcome in trauma. Haemostatic resuscitation is now the backbone of trauma resuscitation using a ratio-driven strategy aiming at 1:1:1 of red blood cells, plasma and platelets while applying goal-directed therapy early and repeatedly to control trauma-induced coagulopathy. SUMMARY Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.
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Abstract
PURPOSE OF REVIEW To discuss the recent developments in and evolvement of next generation haemostatic resuscitation in bleeding trauma. RECENT FINDINGS Mortality from major trauma is a worldwide problem, and massive haemorrhage remains a major cause of potentially preventable deaths. Development of coagulopathy further increases trauma mortality emphasizing that coagulopathy is a key target in the phase of bleeding. The pathophysiology of coagulopathy in trauma reflects at least three distinct mechanisms that may be present isolated or coexist: acute traumatic coagulopathy, coagulopathy associated with the lethal triad, and consumptive coagulopathy. The concepts of 'damage control surgery' and 'damage control resuscitation' have been developed to ensure early control of bleeding and coagulopathy to improve outcome in bleeding trauma. Haemostatic resuscitation aims at controlling coagulopathy and consists of a ratio driven strategy aiming at 1 : 1 : 1, using tranexamic acid according to CRASH-2, and applying haemostatic monitoring enabling a switch to a goal-directed approach when bleeding slows. Haemostatic resuscitation is the mainstay of trauma resuscitation and is associated with improved survival. SUMMARY The next generation of haemostatic resuscitation aims at applying a ratio 1 : 1 : 1 driven strategy while using antifibrinolytics, haemostatic monitoring and avoiding critical fibrinogen deficiency by substitution.
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Gao X, Tao Q, Zhou X, Lei W. Lactated Ringer' Solution may be Superior to Saline-Based 6% Hydroxyethyl Starch 130/0.4 for Early Resuscitation within 12 hours from Hemorrhagic Shock. J INVEST SURG 2018; 32:515-522. [PMID: 29509042 DOI: 10.1080/08941939.2018.1439550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Purpose: To compare the effects of fluid resuscitation with lactated Ringer's solution (LR) and saline-based 6% hydroxyethyl starch 130/0.4 (HES) on the inflammatory response and oxidative stress in the small intestine as well as on bacterial translocation to the liver. Methods: Sprague-Dawley rats were subjected to blood pressure-controlled hemorrhagic shock and then resuscitated with LR or HES. At 1, 3, 6, 12, and 24 hr after resuscitation, liver tissues were collected to count the bacterial colonies, and small intestines were harvested to analyze the levels of inflammatory (TNF-α and HO-1) and oxidative stress (MPO) mediators as well as the intestinal injury by immunohistochemistry, colorimetry and hematoxylin & eosin staining, respectively. Results: The expression level of TNF-α in the LR group was stable from 1 to 6 hr but decreased at 12 hr and then abruptly increased at 24 hr. The expression level of TNF-α in the LR group was significantly lower than that in the HES group, especially during the first 12 hr post-fluid infusion. MPO activity decreased to its lowest level at 3 hr but increased from 6 to 12 hr, with no difference at 24 hr between the two groups. Although a decreasing tendency was observed from 6 hr, HO-1 expression levels remained higher in the LR group than in the HES group at 12 and 24 hr, particularly at 12 hr. During the initial 12 hr, the LR group exhibited significantly lower colony-forming units in the liver tissues than the HES group. Chiu's score in the intestine decreased regardless of which resuscitative fluids were used. Conclusions: During early resuscitation (within 12 hr), LR may be superior to HES in reducing intestinal injuries by suppressing inflammatory and oxidative mediators.
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Affiliation(s)
- Xinyue Gao
- Department of Anesthesiology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Tao
- Department of Anesthesiology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - Xun Zhou
- Department of Anesthesiology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - WeiFu Lei
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong, China
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23
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Choice of fluid type: physiological concepts and perioperative indications. Br J Anaesth 2018; 120:384-396. [DOI: 10.1016/j.bja.2017.10.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
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24
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Affiliation(s)
- R. G. Hahn
- Research Unit; Södertälje Hospital; Södertälje Sweden
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25
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Fukushima T, Uchino S, Fujii T, Takinami M, Uezono S. Intraoperative hydroxyethyl starch 70/0.5 administration may increase postoperative bleeding: a retrospective cohort study. J Anesth 2017; 31:330-336. [DOI: 10.1007/s00540-017-2334-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/04/2017] [Indexed: 10/19/2022]
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Ohrt-Nissen S, Bukhari N, Dragsted C, Gehrchen M, Johansson PI, Dirks J, Stensballe J, Dahl B. Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases. Transfusion 2017; 57:1808-1817. [PMID: 28500653 DOI: 10.1111/trf.14137] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/04/2017] [Accepted: 03/04/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program. STUDY DESIGN AND METHODS Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography. RESULTS In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99). CONCLUSION A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Naeem Bukhari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Casper Dragsted
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Rigshospitalet, Capitol Region Blood Bank, Copenhagen, Denmark
| | - Jesper Dirks
- Department of Anesthesiology, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stensballe
- Department of Anesthesiology, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Section for Transfusion Medicine, Rigshospitalet, Capitol Region Blood Bank, Copenhagen, Denmark
| | - Benny Dahl
- Division of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas
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27
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Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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28
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Reduction of transfusion requirements in pediatric craniosynostosis surgery by a new local hemostatic agent. J Craniomaxillofac Surg 2016; 44:1246-51. [DOI: 10.1016/j.jcms.2016.06.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/22/2016] [Accepted: 06/27/2016] [Indexed: 11/17/2022] Open
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29
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Rasmussen KC, Secher NH, Pedersen T. Effect of perioperative crystalloid or colloid fluid therapy on hemorrhage, coagulation competence, and outcome: A systematic review and stratified meta-analysis. Medicine (Baltimore) 2016; 95:e4498. [PMID: 27495098 PMCID: PMC4979852 DOI: 10.1097/md.0000000000004498] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A meta-analysis concerning perioperative coagulation competence, hemorrhage, and outcome was conducted including the use of hydroxyethyl starches (HESs), dextran, or albumin versus administration of a crystalloid as control to assess the efficacy and safety of colloids and crystalloids for fluid administration during major elective surgery. Surgery was restricted to cardiovascular and noncardiovascular surgery, and HESs were stratified to HES 130/0.4 and HES 200/0.5. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, ISI Web of Science, EMBASE, conference proceedings, reference lists, and databases of ongoing trials. RESULTS Thirty one primary clinical randomized controlled trials included 2287 patients undergoing major surgery from January 2000 to August 2015. The perioperative changes in coagulation competence were measured by thromboelastography (TEG) maximum amplitude (MA) in 9 studies administering crystalloids versus HES and in 4 studies administering albumin versus HES. All studies but 1 disclosed increased reduction in TEG-MA following HES administration (P = 0.0001 and 0.0002). The total loss of blood was reported in 17 studies in which crystalloids were compared to HES and 12 studies reported increased blood loss after administration of HES (P < 0.003). When administering albumin versus HES, 6 studies reported reduced hemorrhage associated with albumin administration (P = 0.005). Reoperation was not significantly reduced by the use of crystalloids, but may be more frequent after HESs compared to albumin (P < 0.03). In this analysis, more patients admitted to administration of HESs were exposed to decrease coagulation competence, compared to perioperative crystalloids and albumin administration. CONCLUSION This stratified meta-analysis showed that increased blood loss was found in noncardiovascular surgery among patients receiving HES compared with crystalloids, followed by a marked reduction in TEG-MA, and infusion of 3rd-generation HES products did not influence the results significantly.
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Affiliation(s)
| | | | - Tom Pedersen
- Center of Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Denmark
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30
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Honore PM, Jacobs R, Hendrickx I, De Waele E, Spapen HD. Lactate: the Black Peter in high-risk gastrointestinal surgery patients. J Thorac Dis 2016; 8:E440-E442. [PMID: 27291163 PMCID: PMC4886011 DOI: 10.21037/jtd.2016.03.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rita Jacobs
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Inne Hendrickx
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elisabeth De Waele
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herbert D Spapen
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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31
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Ke Z, Huang Q. Haem-assisted dityrosine-cross-linking of fibrinogen under non-thermal plasma exposure: one important mechanism of facilitated blood coagulation. Sci Rep 2016; 6:26982. [PMID: 27229173 PMCID: PMC4882584 DOI: 10.1038/srep26982] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/12/2016] [Indexed: 12/14/2022] Open
Abstract
Although blood coagulation facilitated by non-thermal plasma has been reported several years ago, the insight to the involved mechanisms is still rather limited. In this work, we report our discovery of a new mechanism for the haem-promoted blood-coagulation caused by non-thermal plasma treatment. The reason for the haem role is due to that its oxidized form, namely, hematin, can promote the dityrosine cross-linking of fibrinogen, the most important coagulation protein, to form a membrane-like layer on the surface of the treated blood with plasma exposure. Both haem and non-thermal-plasma generated hydrogen peroxide are requisite for the cross-linking process. We confirmed that fibrinogen can coordinate with the haem iron to form a protein-haem complex which shows pseudo-peroxidase activity, and in the presence of hydrogen peroxide, the complex can induce the dityrosine formation between fibrinogen molecules, leading to the fibrin network necessary for the blood coagulation. Understanding of such an underlying mechanism can be useful to guide more efficient application of non-thermal plasma in the management of hemostasis, thrombosis and etc.
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Affiliation(s)
- Zhigang Ke
- Key Laboratory of Ion Beam Bioengineering, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei 230031, China
| | - Qing Huang
- Key Laboratory of Ion Beam Bioengineering, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei 230031, China.,National Synchrotron Radiation Laboratory, University of Science &Technology of China, Hefei 230026, China
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32
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Wiedermann CJ, Bellomo R, Perner A. Is the literature inconclusive about the harm from HES? No. Intensive Care Med 2016; 43:1523-1525. [PMID: 27007101 PMCID: PMC7728630 DOI: 10.1007/s00134-016-4275-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 02/15/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Christian J Wiedermann
- Department of Internal Medicine, Central Hospital of Bolzano, Lorenz-Böhler-Street 5, 39100, Bolzano, BZ, Italy.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 406] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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Rasmussen KC, Højskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Impact of Albumin on Coagulation Competence and Hemorrhage During Major Surgery: A Randomized Controlled Trial. Medicine (Baltimore) 2016; 95:e2720. [PMID: 26945358 PMCID: PMC4782842 DOI: 10.1097/md.0000000000002720] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
For patients exposed to a massive blood loss during surgery, maintained coagulation competence is important. It is less obvious whether coagulation competence influences bleeding during elective surgery where patients are exposed to infusion of a crystalloid or a colloid. This randomized controlled trial evaluates whether administration of 5% human albumin (HA) or lactated Ringer solution (LR) affects coagulation competence and in turn blood loss during cystectomy due to bladder cancer. Forty patients undergoing radical cystectomy were included to receive either 5% HA (n = 20) or LR (n = 20). Nineteen patients were analyzed in the HA group and 20 patients in the lactated Ringer group. Blinded determination of the blood loss was similar in the 2 groups of patients: 1658 (800-3300) mL with the use of HA and 1472 (700-4330) mL in the lactated Ringer group (P = 0.45). Yet, by thrombelastography (TEG) evaluated coagulation competence, albumin affected clot growth (TEG-angle 69 ± 5 vs 74° ± 3°, P < 0.01) and strength (TEG-MA: 59 ± 6 vs 67 ± 6 mm, P < 0.001) more than LR. Furthermore, by multivariate linear regression analyses reduced TEG-MA was independently associated with the blood loss (P = 0.042) while administration of albumin was related to the changes in TEG-MA (P = 0.029), aPPT (P < 0.022), and INR (P < 0.033). This randomized controlled trial demonstrates that administration of HA does not affect the blood loss as compared to infusion of LR. Also the use of HA did not affect the need for blood transfusion, the incidence of postoperative complications, or the hospital in-stay. Yet, albumin decreases coagulation competence during major surgery and the blood loss is related to TEG-MA rather than to plasma coagulation variables.
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Affiliation(s)
- Kirsten C Rasmussen
- From the Department of Anesthesiology (KCR, MH, IK, TK, HBN, BR, NHS); Department of Urology (LS); Center of Head and Orthopaedic Surgery (TP); Rigshospitalet, University of Copenhagen; Department of Transfusion Medicine, Rigshospitalet and Department of Surgery, Denmark, and University of Texas Health Medical School, Houston, TX, USA (PIJ)
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35
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Rasmussen KC, Højskov M, Ruhnau B, Salling L, Pedersen T, Goetze JP, Secher NH. Plasma pro-atrial natriuretic peptide to indicate fluid balance during cystectomy: a prospective observational study. BMJ Open 2016; 6:e010323. [PMID: 26908528 PMCID: PMC4769390 DOI: 10.1136/bmjopen-2015-010323] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES During surgery the volume of administered fluid is debated. Pro-atrial natriuretic peptide (proANP) is released by atrial distension, and we evaluated the relationship between changes in proANP associated with perioperative fluid balance. DESIGN Prospective observational study. SETTING One university/tertiary centre. PARTICIPANTS The study included patients who underwent radical cystectomy. Plasma for determination of proANP was obtained before surgery, after resection of the bladder, and at the end of surgery for 20 robotic-assisted radical cystectomy (RARC) and 20 open radical cystectomy (ORC) procedures. RESULTS The blood loss was 1871 (95% CI 1267 to 2475) vs 589 mL (378 to 801) in the ORC and RARC groups (p=0.001), respectively, and fluid balance was positive by 1518 mL (1215 to 1821) during ORC, and by 1858 mL (1461 to 2255) during RARC (p=0.163). Yet, at the end of ORC, plasma proANP was reduced by 23% (14% to 32%, p=0.001), while plasma proANP did not change significantly during RARC. Thus, plasma proANP was associated both with the perioperative blood loss (r= -0.475 (0.632 to -0.101), p=0.002), and with fluid balance (r=0.561 (0.302 to 0.740), p=0.001), indicating that a stable plasma proANP required a fluid surplus by 2.4 L (2.0 to 2.7). CONCLUSIONS There was a correlation between intraoperative haemorrhage and a decrease in plasma proANP and, taking plasma proANP to indicate filling of the heart, about 2.5 L surplus volume of lactated Ringer's solution appears to maintain cardiac preload during cystectomy. TRIAL REGISTRATION NUMBER EudraCT (2012-005040-20), Results.
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Affiliation(s)
| | - Michael Højskov
- Departments of Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
| | - Birgitte Ruhnau
- Departments of Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Tom Pedersen
- Center for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Niels H Secher
- Departments of Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
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Bedreag OH, Papurica M, Rogobete AF, Sarandan M, Cradigati CA, Vernic C, Dumbuleu CM, Nartita R, Sandesc D. New perspectives of volemic resuscitation in polytrauma patients: a review. BURNS & TRAUMA 2016; 4:5. [PMID: 27574675 PMCID: PMC4964009 DOI: 10.1186/s41038-016-0029-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 01/21/2016] [Indexed: 01/13/2023]
Abstract
Nowadays, fluid resuscitation of multiple trauma patients is still a challenging therapy. Existing therapies for volume replacement in severe haemorrhagic shock can lead to adverse reactions that may be fatal for the patient. Patients presenting with multiple trauma often develop hemorrhagic shock, which triggers a series of metabolic, physiological and cellular dysfunction. These disorders combined, lead to complications that significantly decrease survival rate in this subset of patients. Volume and electrolyte resuscitation is challenging due to many factors that overlap. Poor management can lead to post-resuscitation systemic inflammation causing multiple organ failure and ultimately death. In literature, there is no exact formula for this purpose, and opinions are divided. This paper presents a review of modern techniques and current studies regarding the management of fluid resuscitation in trauma patients with hemorrhagic shock. According to the literature and from clinical experience, all aspects regarding post-resuscitation period need to be considered. Also, for every case in particular, emergency therapy management needs to be rigorously respected considering all physiological, biochemical and biological parameters.
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Affiliation(s)
- Ovidiu Horea Bedreag
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Bd. Iosif Bulbuca nr.10, Timisoara, Timis Romania ; Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Marius Papurica
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Bd. Iosif Bulbuca nr.10, Timisoara, Timis Romania ; Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Alexandru Florin Rogobete
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Bd. Iosif Bulbuca nr.10, Timisoara, Timis Romania ; Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania ; Faculty of Chemistry, Biology, Geography, West University of Timisoara, Timisoara, Romania
| | - Mirela Sarandan
- Clinic of Anaesthesia and Intensive Care "Casa Austria", Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Carmen Alina Cradigati
- Clinic of Anaesthesia and Intensive Care "Casa Austria", Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Corina Vernic
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Corina Maria Dumbuleu
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Bd. Iosif Bulbuca nr.10, Timisoara, Timis Romania
| | - Radu Nartita
- Faculty of Chemistry, Biology, Geography, West University of Timisoara, Timisoara, Romania
| | - Dorel Sandesc
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Bd. Iosif Bulbuca nr.10, Timisoara, Timis Romania ; Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
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To use or not to use hydroxyethyl starch in intraoperative care: are we ready to answer the 'Gretchen question'? Curr Opin Anaesthesiol 2016; 28:370-7. [PMID: 25887196 DOI: 10.1097/aco.0000000000000194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The decision of the European Medicines Agency (EMA) against the use of hydroxyethyl starch (HES)-based volume replacement solutions in critically ill patients has led to a general uncertainty when dealing with HES-based solutions, even though HES-containing solutions can still be used for the treatment of hypovolaemia caused by acute (sudden) blood loss. This review discusses current evidence of the intraoperative use of HES-based solutions. RECENT FINDINGS HES solutions are often criticized for possible side-effects on the kidney, the coagulation system or tissue storage. Relevant differences exist between modern 6% HES 130/0.4 and older generation of starches. Because of pathophysiological differences between elective surgery and critical illness, the evidence on renal injury and coagulation impairment with HES administration cannot be generalized. Current data suggest that there is no clinically relevant impact of 6% HES 130/0.4 administration on perioperative renal function and coagulation. Over-resuscitation is a frequent problem associated with adverse outcomes. Due to the higher volume effect, fluid overload with HES is probably more harmful than with crystalloids, whereas goal-directed use of HES may be able to reduce intraoperative fluid accumulation and overload. SUMMARY The use of 6% HES 130/0.4 in elective surgery patients is associated with reduced fluid accumulation and no clinically relevant difference in bleeding or the rate of acute kidney injury as compared with crystalloid use alone. Current data do not allow a conclusion on mortality. As they provide no benefit, older starch preparations should not be used.
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Zhang J, Huang S, Han Y, Wang C, Shao W, Fu Z. Investigation on the Interaction of Hydroxyethyl Starch 130/0.4 (Voluven) and Serum Albumin for Pharmacokinetic and Toxicological Implications. J Biochem Mol Toxicol 2016; 30:258-64. [PMID: 26749074 DOI: 10.1002/jbt.21789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/09/2015] [Accepted: 12/15/2015] [Indexed: 11/08/2022]
Abstract
The interaction of hydroxyethyl starch 130/0.4 (Voluven) with human serum albumin (HSA) has been investigated by fluorescence (steady state and synchronous), Fourier transforms infrared (FT-IR), and circular dichroism (CD) spectroscopies. Analysis of the fluorescence quenching data of HSA by Voluven using the Stern-Volmer method revealed the formation of 1:1 ground-state complex. Evaluation of binding parameters and binding energy indicated that the binding reaction was exothermic. On the basis of fluorescence measurements, it was concluded that electrostatic forces play a crucial role in stabilizing the complex. The binding distance was calculated by using Förster resonance energy transfer (FRET) theory. The conformational changes of HSA were obtained qualitatively as well as quantitatively using synchronous fluorescence, FT-IR, and CD. The HSA underwent partial unfolding in the presence of Voluven.
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Affiliation(s)
- Jianzhong Zhang
- Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021, People's Republic of China. .,Yantaishan Hospital, Yantai, 264000, People's Republic of China.
| | - Shaoyan Huang
- Yantaishan Hospital, Yantai, 264000, People's Republic of China
| | - Yongbin Han
- People's Hospital of Rizhao, Rizhao, 276826, People's Republic of China
| | - Chenghai Wang
- Yantaishan Hospital, Yantai, 264000, People's Republic of China
| | - Wei Shao
- Yantaishan Hospital, Yantai, 264000, People's Republic of China
| | - Zhijian Fu
- Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021, People's Republic of China
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Abstract
PURPOSE OF REVIEW Infusion therapy is essential in intravascular hypovolaemia and extravascular fluid deficits. Crystalloidal fluids and colloidal volume replacement affect blood coagulation when infused intravenously. The question remains if this side-effect of infusion therapy is clinically relevant in patients with and without bleeding manifestations, and if fluid-induced coagulopathy is a risk factor for anaemia, blood transfusion, and mortality, and a driver for resource use and costs. RECENT FINDINGS Pathomechanisms of dilutional coagulopathy and evidence for its clinical relevance in perioperative and critically ill patients are reviewed. Furthermore, the article discusses medicolegal aspects. SUMMARY The dose-dependent risk of dilutional coagulopathy differs between colloids (dextran > hetastarch > pentastarch > tetrastarch, gelatins > albumin). Risk awareness includes monitoring for early signs of side-effects. With rotational thromboelastometry/thrombelastography, the deterioration not only in clot strength but also in clot formation and in platelet interaction can be assessed. Fibrinogen concentrate administration may be considered in severe bleeding as well as relevant dilutional coagulopathy. Targeted doses of gelatins and tetrastarches seem to have no proven adverse effect on anaemia and allogeneic blood transfusions. Further studies are needed.
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Basora M, Colomina MJ, Moral V, Asuero de Lis MS, Boix E, Jover JL, Llau JV, Rodrigo MP, Ripollés J, Calvo Vecino JM. Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:29-47. [PMID: 26343809 DOI: 10.1016/j.redar.2015.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/24/2015] [Accepted: 06/26/2015] [Indexed: 06/05/2023]
Abstract
The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.
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Affiliation(s)
- M Basora
- Anestesiología y Reanimación, Hospital Clínic, Barcelona, España.
| | - M J Colomina
- Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - V Moral
- Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, España
| | - M S Asuero de Lis
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Boix
- Anestesiología y Reanimación, Hospital Universitario del Vinalopó, Elche, Alicante, España
| | - J L Jover
- Anestesiología y Reanimación, Hospital Verge dels Lliris, Alcoi, Alicante, España
| | - J V Llau
- Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España
| | - M P Rodrigo
- Anestesiología y Reanimación, Hospital de Basurto, Bilbao, España
| | - J Ripollés
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, España
| | - J M Calvo Vecino
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Universidad Complutense, Madrid, España
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Comparison of hydroxyethyl starch colloids with crystalloids for surgical patients. Eur J Anaesthesiol 2016; 33:42-8. [DOI: 10.1097/eja.0000000000000328] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Rasmussen KC, Hoejskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Coagulation competence for predicting perioperative hemorrhage in patients treated with lactated Ringer's vs. Dextran--a randomized controlled trial. BMC Anesthesiol 2015; 15:178. [PMID: 26646213 PMCID: PMC4672483 DOI: 10.1186/s12871-015-0162-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 12/02/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Perioperative hemorrhage may depend on coagulation competence and this study evaluated the influence of coagulation competence on blood loss during cystectomy due to bladder cancer. METHODS Forty patients undergoing radical cystectomy were included in a randomized controlled trial to receive either lactated Ringer's solution or Dextran 70 (Macrodex ®) that affects coagulation competence. RESULTS By thrombelastography evaluated coagulation competence, Dextran 70 reduced "maximal amplitude" (MA) by 25 % versus a 1 % reduction with the administration of lactated Ringer's solution (P <0.001). Blinded evaluation of the blood loss was similar in the two groups of patients - 2339 ml with the use of Dextran 70 and 1822 ml in the lactated Ringer's group (P = 0.27). Yet, the blood loss was related to the reduction in MA (r = -0.427, P = 0.008) and by multiple regression analysis independently associated with MA (P = 0.01). Thus, 11 patients in the dextran group (58 %) developed a clinical significant blood loss (>1500 ml) compared to only four patients (22 %) in the lactated Ringer's group (P = 0.04). CONCLUSIONS With the use of Dextran 70 vs. lactated Ringer's solution during cystectomy, a relation between hemorrhage and coagulation competence is demonstrated. Significant bleeding develops based on an about 25 % reduction in thrombelastography determined maximal amplitude. A multivariable model including maximal amplitude discriminates patients with severe perioperative bleeding during cystectomy. TRIAL REGISTRATION The study was accepted on January 7(th), 2013 at www.clinicaltrialsregister.eu EudraCT 2012-005040-20.
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Affiliation(s)
- Kirsten C Rasmussen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Department of Anesthesiology, Rigshospitalet 2043, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
| | - Michael Hoejskov
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Per I Johansson
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Irina Kridina
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Kistorp
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Lisbeth Salling
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Henning B Nielsen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Birgitte Ruhnau
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Tom Pedersen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Niels H Secher
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Abstract
Anesthesiologists play a pivotal role in facilitating recovery of patients undergoing colorectal surgery, as many Enhanced Recovery After Surgery (ERAS) elements are under their direct control. Successful implementation of ERAS programs requires that anesthesiologists become more involved in perioperative care and more aware of the impact of anesthetic techniques on surgical outcomes and recovery. Key to achieving success is strict adherence to the principle of aggregation of marginal gains. This article reviews anesthetic and analgesic care of patients undergoing elective colorectal surgery in the context of an ERAS program, and also discusses anesthesia considerations for emergency colorectal surgery.
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Affiliation(s)
- Gabriele Baldini
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada.
| | - William J Fawcett
- Royal Surrey County Hospital, Postgraduate School, University of Surrey, Guildford GU2 7XX, UK
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Choi SS, Kim SH, Kim YK. Fluid management in living donor hepatectomy: Recent issues and perspectives. World J Gastroenterol 2015; 21:12757-12766. [PMID: 26668500 PMCID: PMC4671031 DOI: 10.3748/wjg.v21.i45.12757] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/28/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.
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45
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Feix JA, Peery CA, Gan TJ, Warner DS, James ML, Zomorodi A, McDonagh DL. Intra-operative hydroxyethyl starch is not associated with post-craniotomy hemorrhage. SPRINGERPLUS 2015; 4:350. [PMID: 26191477 PMCID: PMC4502051 DOI: 10.1186/s40064-015-1126-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/29/2015] [Indexed: 11/10/2022]
Abstract
Background Intraoperative intravascular volume expansion with hydroxyethyl starch-based colloids is thought to be associated with an increased risk of post-craniotomy hemorrhage. Evidence for this association is limited. Associations between resuscitation with hydroxyethyl starch and risk of repeat craniotomy for hematoma evacuation were examined. Methods Using a retrospective cohort of neurosurgical patients at Duke University Medical Center between March 2005 and March 2012, patient characteristics were compared between those who developed post-craniotomy hemorrhage and those who did not. Results A total of 4,109 craniotomy procedures were analyzed with 61 patients having repeat craniotomy for post-operative hemorrhage (1.5%). The rate of reoperation in the group receiving 6% High Molecular Weight Hydroxyethyl Starch (Hextend®) was 2.6 vs. 1.3% for patients that did not receive hetastarch (P = 0.13). The reoperation rate for those receiving 6% hydroxyethyl Starch 130/0.4 (Voluven®) was 1.4 vs. 1.6% in patients not receiving Voluven (P = 0.85). Conclusions In this retrospective cohort, intra-operative hydroxyethyl starch was not associated with an increased risk of post-craniotomy hemorrhage.
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46
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Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients. Br J Surg 2015; 103:14-26. [DOI: 10.1002/bjs.9943] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/24/2015] [Accepted: 08/19/2015] [Indexed: 11/10/2022]
Abstract
Abstract
Background
There is uncertainty regarding the safety of different volume replacement solutions. The aim of this study was systematically to review evidence of crystalloid versus colloid solutions, and to determine whether these results are influenced by trial design or clinical setting.
Methods
PubMed, Embase and the Cochrane Central Register of Controlled Trials were used to identify randomized clinical trials (RCTs) that compared crystalloids with colloids as volume replacement solutions in patients with traumatic injuries, those undergoing surgery and in critically ill patients. Adjusted odds ratios (ORs) for mortality and major morbidity including renal injury were pooled using fixed-effect and random-effects models.
Results
Some 59 RCTs involving 16 889 patients were included in the analysis. Forty-one studies (69 per cent) were found to have selection, detection or performance bias. Colloid administration did not lead to increased mortality (32 trials, 16 647 patients; OR 0·99, 95 per cent c.i. 0·92 to 1·06), but did increase the risk of developing acute kidney injury requiring renal replacement therapy (9 trials, 11 648 patients; OR 1·35, 1·17 to 1·57). Sensitivity analyses that excluded small and low-quality studies did not substantially alter these results. Subgroup analyses by type of colloid showed that increased mortality and renal replacement therapy were associated with use of pentastarch, and increased risk of renal injury and renal replacement therapy with use of tetrastarch. Subgroup analysis indicated that the risks of mortality and renal injury attributable to colloids were observed only in critically ill patients with sepsis.
Conclusion
Current general restrictions on the use of colloid solutions are not supported by evidence.
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Affiliation(s)
- S H Qureshi
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - S I Rizvi
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - N N Patel
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - G J Murphy
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
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Patel MS, Niemann CU, Sally MB, De La Cruz S, Zatarain J, Ewing T, Crutchfield M, Enestvedt CK, Malinoski DJ. The Impact of Hydroxyethyl Starch Use in Deceased Organ Donors on the Development of Delayed Graft Function in Kidney Transplant Recipients: A Propensity-Adjusted Analysis. Am J Transplant 2015; 15:2152-8. [PMID: 25904248 DOI: 10.1111/ajt.13263] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/20/2015] [Accepted: 01/31/2015] [Indexed: 01/25/2023]
Abstract
Our objective was to evaluate the impact of hydroxyethyl starch (HES) use in organ donors after neurologic determination of death (DNDD) on recipient renal graft outcomes. The following data elements were prospectively collected for every DNDD managed by a single organ procurement organization from June 2011 to July 2013: demographics; critical care endpoints; treatments, including the use of HES; graft cold ischemia time (CIT); and the occurrence of recipient delayed graft function (DGF, dialysis in the first week after transplantation). Logistic regression was performed to identify independent predictors of DGF with a p-value <0.05. The results were then adjusted for each donor's calculated propensity to receive HES. Nine hundred eighty-six kidneys were transplanted from 529 donors. Forty-two percent received HES (1217 ± 528 mL) and 35% developed DGF. Kidneys from DNDDs who received HES had a higher crude rate of DGF (41% vs. 31%, p < 0.001). After accounting for the propensity to receive HES, independent predictors of DGF were age (OR 1.02 [1.01-1.04] per year), CIT (OR 1.04[1.02-1.06] per hour), creatinine (OR 1.5 [1.32-1.72] per mg/dL) and HES use (OR 1.41 [1.02-1.95]). HES use during donor management was independently associated with a 41% increase in the risk of DGF in kidney transplant recipients.
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Affiliation(s)
- M S Patel
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - C U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.,Department of Surgery, University of California San Francisco, San Francisco, CA
| | - M B Sally
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, OR.,Department of Surgery, Oregon Health and Science University, Portland, OR
| | - S De La Cruz
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, OR.,Department of Surgery, Oregon Health and Science University, Portland, OR
| | - J Zatarain
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - T Ewing
- School of Medicine, University of California, Davis, Sacramento, CA
| | - M Crutchfield
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, OR
| | - C K Enestvedt
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - D J Malinoski
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, OR.,Department of Surgery, Oregon Health and Science University, Portland, OR
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The brain relaxation and cerebral metabolism in stroke volume variation-directed fluid therapy during supratentorial tumors resection: crystalloid solution versus colloid solution. J Neurosurg Anesthesiol 2015; 26:320-7. [PMID: 24487733 DOI: 10.1097/ana.0000000000000046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Compared with goal-directed crystalloid therapy, goal-directed colloid therapy during high-risk surgery may improve postoperative outcome. Whether intraoperative fluid therapy based on goal-directed protocol with different types of fluid has distinctive effects on brain relaxation and cerebral metabolism during craniotomy remains unclear. METHODS Forty patients with supratentorial brain tumors undergoing craniotomy were randomly assigned to either a Ringer's Lactate-based goal-directed group (LR group, n=20) or a 6% hydroxyethyl starch-based goal-directed group (HES group, n=20). The goal was achieved by maintaining a target stroke volume variation (SVV<13%) by volume loading with LR or HES throughout the procedure. The primary outcome is brain relaxation scales, an indirect evaluation of ICP; secondary endpoints include cerebral metabolism variables (jugular venous oxygen saturation [SjvO(2)], arterial-jugular venous differences in oxygen [CajvO(2)], glucose [A-JvGD], lactate [A-JvLD], and cerebral extraction ratio for oxygen [CERO(2)]) and fluid volumes. RESULTS There is no significant difference between the LR and HES groups on brain relaxation scales (P=0.845), or measures of cerebral oxygenation and metabolism. Intragroup comparisons showed that CERO(2) increased by 14.3% (P=0.009, LR group) and 13.2% (P=0.032, HES group), respectively, and SjvO(2) was decreased by 8.8% (P=0.016, LR group) and 8.1% (P=0.026, HES group), respectively, after tumor removal, compared with baseline. During surgery, the LR group (3070±1138 mL) received more fluid than the HES group (2041±758 mL, P=0.002). CONCLUSIONS In patients undergoing supratentorial tumor resection, goal-directed HES therapy was not superior to goal-directed LR therapy for brain relaxation or cerebral metabolism, although less fluid was needed to maintain the target SVV in the HES-based group than in the LR-based group.
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Abstract
PURPOSE OF REVIEW This review article explores the recent literature regarding the optimal type and amount of intravenous fluids for the trauma patient from the time of injury through their ICU stay. It discusses damage control principles as well as targeted resuscitation utilizing new technology. RECENT FINDINGS In the prehospital arena, intravenous fluids have been associated with worse patient outcomes due to increased coagulopathy and time to definitive care. Once in the trauma bay, damage control resuscitation principles apply to the severely injured patient. Large volume crystalloid infusion increases mortality. The best patient outcomes have been found with transfusion of blood products in a ratio that closely mimics whole blood. Thrombelastography is a useful adjunct in resuscitation and can help guide the judicious use of blood products. New technology can help providers ascertain when a patient is appropriately resuscitated by determining adequate global and regional perfusion. SUMMARY During the resuscitation of the acutely injured patient, crystalloids should be limited in favor of blood components. Damage control principles apply until definitive hemostasis is obtained, at which point the focus should change to targeted resuscitation using traditional global endpoints of resuscitation in conjunction with determinants of regional perfusion.
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Kancir ASP, Johansen JK, Ekeloef NP, Pedersen EB. The effect of 6% hydroxyethyl starch 130/0.4 on renal function, arterial blood pressure, and vasoactive hormones during radical prostatectomy: a randomized controlled trial. Anesth Analg 2015; 120:608-618. [PMID: 25627076 DOI: 10.1213/ane.0000000000000596] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Although hydroxyethyl starch (HES) is commonly used as an intravascular volume expander in surgical patients, recent studies suggest that it may increase the risk of renal failure in critically ill patients. We hypothesized that patients undergoing radical prostatectomy and receiving HES would be more likely to develop markers of renal failure, such as increasing urinary neutrophil gelatinase-associated lipocalin (u-NGAL), creatinine clearance (C(crea)), and decreasing urine output (UO). METHODS In a randomized, double-blinded, placebo-controlled study, 40 patients referred for radical prostatectomy received either 6% HES 130/0.4 or saline 0.9%; 7.5 mL/kg during the first hour of surgery and 5 mL/kg in the following hours; u-NGAL, urine albumin, C(crea), UO, arterial blood pressure, and plasma concentrations of creatinine, renin, angiotensin II, aldosterone, and vasopressin were measured before, during, and after surgery. RESULTS Thirty-six patients completed the study. u-NGAL, C(crea), UO, plasma neutrophil gelatinase-associated lipocalin, p-creatinine, urine albumin, and arterial blood pressure were the same in both groups. Blood loss was higher in the HES group (HES 1250 vs saline 750 mL), while p-albumin was reduced to a significantly lower level. P-renin and p-angiotensin-II increased in both groups, whereas p-aldosterone and p-vasopressin increased significantly in the saline group. CONCLUSIONS We found no evidence of nephrotoxicity after infusion of 6% HES 130/0.4 in patients undergoing prostatectomy with normal preoperative renal function. Hemodynamic stability and infused fluid volume were the same in both groups. We observed an increased blood loss in the group given 6% HES 130/0.4.
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Affiliation(s)
- Anne Sophie Pinholt Kancir
- From the University Clinic for Nephrology and Hypertension, Department of Medical Research and Medicine, and Department of Anesthesiology, Holstebro Hospital and University of Aarhus, Holstebro, Denmark; Department of Urology, Holstebro Hospital, Holstebro, Denmark; Department of Anesthesiology, Holstebro Hospital, Holstebro, Denmark; and University Clinic for Nephrology and Hypertension, Department of Medical Research and Department of Medicine, Holstebro Hospital and University of Aarhus, Holstebro, Denmark
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