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Simovic MO, Bynum J, Liu B, Dalle Lucca JJ, Li Y. Impact of Immunopathy and Coagulopathy on Multi-Organ Failure and Mortality in a Lethal Porcine Model of Controlled and Uncontrolled Hemorrhage. Int J Mol Sci 2024; 25:2500. [PMID: 38473750 DOI: 10.3390/ijms25052500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Uncontrolled hemorrhage is a major preventable cause of death in patients with trauma. However, the majority of large animal models of hemorrhage have utilized controlled hemorrhage rather than uncontrolled hemorrhage to investigate the impact of immunopathy and coagulopathy on multi-organ failure (MOF) and mortality. This study evaluates these alterations in a severe porcine controlled and uncontrolled hemorrhagic shock (HS) model. Anesthetized female swine underwent controlled hemorrhage and uncontrolled hemorrhage by partial splenic resection followed with or without lactated Ringer solution (LR) or Voluven® resuscitation. Swine were surveyed 6 h after completion of splenic hemorrhage or until death. Blood chemistry, physiologic variables, systemic and tissue levels of complement proteins and cytokines, coagulation parameters, organ function, and damage were recorded and assessed. HS resulted in systemic and local complement activation, cytokine release, hypocoagulopathy, metabolic acidosis, MOF, and no animal survival. Resuscitation with LR and Voluven® after HS improved hemodynamic parameters (MAP and SI), metabolic acidosis, hyperkalemia, and survival but resulted in increased complement activation and worse coagulopathy. Compared with the LR group, the animals with hemorrhagic shock treated with Voluven® had worse dilutional anemia, coagulopathy, renal and hepatic dysfunction, increased myocardial complement activation and renal damage, and decreased survival rate. Hemorrhagic shock triggers early immunopathy and coagulopathy and appears associated with MOF and death. This study indicates that immunopathy and coagulopathy are therapeutic targets that may be addressed with a high-impact adjunctive treatment to conventional resuscitation.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - James Bynum
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Bin Liu
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | | | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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2
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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3
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Grau-Mercier L, Coisy F, Markarian T, Muller L, Roger C, Lefrant JY, Claret PG, Bobbia X. Can blood loss be assessed by echocardiography? An experimental study on a controlled hemorrhagic shock model in piglets. J Trauma Acute Care Surg 2022; 92:924-930. [PMID: 34991127 DOI: 10.1097/ta.0000000000003518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment of the volemic loss is a major challenge during the management of hemorrhagic shock. Echocardiography is an increasingly used noninvasive tool for hemodynamic assessment. In mechanically ventilated patients, some studies suggest that respiratory variations of mean subaortic time-velocity integral (∆VTI) would be predictive of fluid filling response. An experimental model of controlled hemorrhagic shock provides a precise approach to study correlation between blood volume and cardiac ultrasonographic parameters. OBJECTIVES The main objective was to analyze the ∆VTI changes during hemorrhage in an anesthetized-piglet model of controlled hemorrhagic shock. The secondary objective was to evaluate ∆VTI during the resuscitation process after hemorrhage and other echocardiographic parameters changes during the whole protocol. METHODS Twenty-four anesthetized and ventilated piglets were bled until mean arterial pressure reached 40 mm Hg. Controlled hemorrhage was maintained for 30 minutes before randomizing the piglets to two resuscitation groups: fluid filling group resuscitated with saline solution and noradrenaline group resuscitated with saline solution and noradrenaline. Echocardiography and hemodynamic measures, including pulsed pressure variations (PPV), were performed at different stages of the protocol. RESULTS The correlation coefficient between ΔVTI and PPV with the volume of bleeding during the hemorrhagic phase were respectively 0.24 (95% confidence interval, 0.08-0.39; p < 0.01) and 0.57 (95% CI, 0.44-0.67; p < 0.01). Two parameters had a moderate correlation coefficient with hemorrhage volume (over 0.5): mean subaortic time-velocity index (VTI) and mitral annulus diastolic tissular velocity (E'). CONCLUSION In this hemorrhagic shock model, ΔVTI had a low correlation with the volume of bleeding, but VTI and E' had a correlation with blood volume comparable to that of PPV.
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Affiliation(s)
- Laura Grau-Mercier
- From the Division of Anesthesiology, Critical Care, Pain and Emergency Medicine (L.G.-M., F.C., L.M., C.R., J.-Y.L., P.-G.C.), Nîmes University Hospital, Prévention et prise en charge de la défaillance circulatoire des patients en état de choc (IMAGINE), University of Montpellier, Nîmes; Department of Emergency Medicine (T.M.), Timone University Hospital, Marseille; and Department of Emergency Medicine (X.B.), Montpellier University Hospital Université de Montpellier, Prévention et prise en charge de la défaillance circulatoire des patients en état de choc (IMAGINE), University of Montpellier, Montpellier, France
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5
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Zarbock A, Buhre W. Hydroxyethyl Starch in the Perioperative Period: Friend, Foe, or Still an Unsolved Issue? Anesth Analg 2022; 134:683-685. [PMID: 35299209 DOI: 10.1213/ane.0000000000005903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alexander Zarbock
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Wolfgang Buhre
- Division of Anesthesiology, Perioperative Medicine, Emergency and Critical Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
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6
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Zieleskiewicz L, Claret PG, Muller L, de La Coussaye JE, Lefrant JY, Schuster I, Roger C, Bobbia X. Global longitudinal strain changes during hemorrhagic shock: An experimental study. Turk J Emerg Med 2020; 20:97-104. [PMID: 32832728 PMCID: PMC7416855 DOI: 10.4103/2452-2473.290066] [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: 02/29/2020] [Revised: 05/04/2020] [Accepted: 05/19/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Global longitudinal strain (GLS) appears sensitive and reproducible to identify left ventricular systolic dysfunction. The main objective was to analyze the GLS changes in an anesthetized-piglet model of controlled hemorrhagic shock (HS). The secondary objective was to evaluate if GLS changes was different depending on the expansion fluid treatment with or without norepinephrine. METHODS Eighteen anesthetized and ventilated piglets were bled until the mean arterial pressure reached 40 mmHg. Controlled hemorrhage was maintained for 30 min before randomizing the piglets to three resuscitation groups: control group, LR group (resuscitated with lactated ringer), and NA group (resuscitated with lactated ringer and norepinephrine). RESULTS There was no difference in the baseline hemodynamic, biological, and ultrasound data among the three groups. During the hemorrhagic phase, the GLS increased significantly from 25 mL/kg of depletion. During the resuscitation phase, the GLS decreased significantly from 20 mL/kg of fluid administration. There was no difference in GLS variation among the groups during the hemorrhagic, maintenance, and resuscitation phases. CONCLUSION In our HS model, GLS increased with hemorrhage and decreased during resuscitation, showing its preload dependence.
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Affiliation(s)
- Laurent Zieleskiewicz
- Department of Anesthesiology and Intensive Care, North Hospital, APHM, Aix Marseille Univ., INSERM, INRA, C2VN, Marseille, France
| | - Pierre-Géraud Claret
- Department of Anesthesiology, Critical Care, Montpellier University, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.,Faculty of Medicine, Montpellier-Nimes University,EA 2992, Nîmes, France
| | - Laurent Muller
- Department of Anesthesiology, Critical Care, Montpellier University, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.,Faculty of Medicine, Montpellier-Nimes University,EA 2992, Nîmes, France
| | - Jean Emmanuel de La Coussaye
- Department of Anesthesiology, Critical Care, Montpellier University, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.,Faculty of Medicine, Montpellier-Nimes University,EA 2992, Nîmes, France
| | - Jean Yves Lefrant
- Department of Anesthesiology, Critical Care, Montpellier University, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.,Faculty of Medicine, Montpellier-Nimes University,EA 2992, Nîmes, France
| | - Iris Schuster
- Department of Sports Medicine and Cardiology (CEMAPS 30), Nîmes University Hospital and PhyMedExp, INSERM U1046, CNRS UMR9214, Montpellier University, Montpellier, France
| | - Claire Roger
- Department of Anesthesiology, Critical Care, Montpellier University, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.,Faculty of Medicine, Montpellier-Nimes University,EA 2992, Nîmes, France
| | - Xavier Bobbia
- Department of Anesthesiology, Critical Care, Montpellier University, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.,Faculty of Medicine, Montpellier-Nimes University,EA 2992, Nîmes, France
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7
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Abstract
A moderately liberal IV fluid regimen, using a balanced crystalloid, and consideration of the use of an advanced hemodynamic monitor in a setting of an enhanced recovery pathway are recommended for major surgery.
Supplemental Digital Content is available in the text.
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8
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Fluid resuscitation with hydroxyethyl starch in perioperative acute hemorrhagic shock. J Anesth 2020; 34:317-319. [DOI: 10.1007/s00540-020-02748-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/10/2020] [Indexed: 01/31/2023]
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10
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Kontouli Z, Staikou C, Iacovidou N, Mamais I, Kouskouni E, Papalois A, Papapanagiotou P, Gulati A, Chalkias A, Xanthos T. Resuscitation with centhaquin and 6% hydroxyethyl starch 130/0.4 improves survival in a swine model of hemorrhagic shock: a randomized experimental study. Eur J Trauma Emerg Surg 2018; 45:1077-1085. [PMID: 30006694 DOI: 10.1007/s00068-018-0980-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/10/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE To investigate the effects of the combination of centhaquin and 6% hydroxyethyl starch 130/0.4 (HES 130/0.4) in a swine model of hemorrhagic shock. METHODS Twenty Landrace-Large White pigs were instrumented and subjected to hemorrhagic shock. The animals were randomly allocated in two experimental groups, the control (group CO, n = 10) and the centhaquin groups (0.015 mg/kg, n = 10, group CH). Acute hemorrhage was induced by stepwise blood withdrawal (18 mL/min) from the internal jugular vein until MAP decreased to 40-45 mmHg, whereas anesthesia remained constant. All animals received HES 130/0.4 solution in the resuscitation phase until their mean arterial pressure (MAP) reached 90% of the baseline. The animals were observed for 60 min, during which no further resuscitation was attempted. RESULTS The total amount of blood and the bleeding time did not differ significantly between group CO and group CH (120 ± 13 vs. 120 ± 14 mL, p = 0.6; 20 ± 2 vs. 20 ± 1 min, p = 0.62, respectively). During the hemorrhagic phase, only a difference in heart rate (97.6 ± 4.4 vs. 128.4 ± 3.6 beats/min, p = 0.038) was observed between the two groups. The time required to reach the target MAP was significantly shorter in the centhaquin group compared to controls (13.7 ± 0.4 vs. 19.6 ± 0.84 min, p = 0.012). During the resuscitation phase, a statistical significant difference was observed in MAP (75.2 ± 1.6 vs. 89.8 ± 2.1 mmHg, p = 0.02) between group CO and group CH. During the observation phase, a statistical significant difference was observed in SVR (1109 ± 32.65 vs. 774.6 ± 21.82 dyn s/cm5, p = 0.039) and cardiac output (5.82 ± 0.31 vs. 6.9 ± 0.78 L/min, p = 0.027) between the two groups. Two animals of group CO and seven animals of group CH survived for 24 h (p = 0.008). We observed a marked increase in microvascular capillary permeability in group CO compared to group CH, with the wet/dry weight ratio being significantly higher in group CO compared to group CH (4.8 ± 1.6 vs. 3.08 ± 0.6, p < 0.001). CONCLUSIONS The combination of centhaquin 0.015 mg/kg and HES 130/0.4 resulted in shorter time to target MAP, lower wet-to-dry ratio, and better survival rates after resuscitation from hemorrhagic shock.
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Affiliation(s)
- Zinais Kontouli
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Chryssoula Staikou
- Department of Anesthesiology, Medical School, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neonatology, Medical School, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Ioannis Mamais
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Health Sciences, European University Cyprus, Nicosia, Cyprus
- Department of Life Sciences, European University Cyprus, Nicosia, Cyprus
| | - Evaggelia Kouskouni
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Biopathology, Medical School, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Anil Gulati
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Athanasios Chalkias
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larisa, Greece.
- , Larisa, Greece.
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Abstract
PURPOSE OF REVIEW To review epidemiology and pathophysiology of acute kidney injury (AKI) in trauma patients and propose strategies that aim at preventing AKI after trauma. RECENT FINDINGS AKI in trauma patients has been reported to be as frequent as 50% with an association to a prolonged length of stay and a raise in mortality. Among the specific risk factors encountered in trauma patients, hemorrhagic shock, rhabdomyolysis severity, age, and comorbidities are independently associated with AKI occurrence. Resuscitation with balanced solutes seems to have beneficial effects on renal outcome compared with NaCl 0.9%, particularly in the context of rhabdomyolysis. However, randomized clinical studies are needed to confirm this signal. Abdominal compartment syndrome (ACS) is rare but has to be diagnosed to initiate a dedicated therapy. SUMMARY The high incidence of AKI in trauma patients should lead to early identification of those at risk of AKI to establish a resuscitation strategy that aims at preventing AKI.
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Ramchandran S, Day LM, Line B, Buckland AJ, Passias P, Protopsaltis T, Bendo J, Huncke T, Errico TJ, Bess S. The Impact of Different Intraoperative Fluid Administration Strategies on Postoperative Extubation Following Multilevel Thoracic and Lumbar Spine Surgery: A Propensity Score Matched Analysis. Neurosurgery 2018; 85:31-40. [DOI: 10.1093/neuros/nyy226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 05/01/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Subaraman Ramchandran
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Louis M Day
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Breton Line
- Department of Orthopedic surgery, Rocky Mountain Scoliosis and spine center, Denver, Colorado
| | - Aaron J Buckland
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Peter Passias
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - John Bendo
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Tessa Huncke
- Department of Anesthesiology, NYU Hospital for Joint Diseases, New York, New York
| | - Thomas J Errico
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shay Bess
- Department of Orthopedic surgery, Rocky Mountain Scoliosis and spine center, Denver, Colorado
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13
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Mendler MR, Schwarz S, Hechenrieder L, Kurth S, Weber B, Höfler S, Kalbitz M, Mayer B, Hummler HD. Successful Resuscitation in a Model of Asphyxia and Hemorrhage to Test Different Volume Resuscitation Strategies. A Study in Newborn Piglets After Transition. Front Pediatr 2018; 6:192. [PMID: 30042934 PMCID: PMC6048263 DOI: 10.3389/fped.2018.00192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/11/2018] [Indexed: 12/31/2022] Open
Abstract
Background: Evidence for recommendations on the use of volume expansion during cardiopulmonary resuscitation in newborn infants is limited. Objectives: To develop a newborn piglet model with asphyxia, hemorrhage, and cardiac arrest to test different volume resuscitation on return of spontaneous circulation (ROSC). We hypothesized that immediate red cell transfusion reduces time to ROSC as compared to the use of an isotonic crystalloid fluid. Methods: Forty-four anaesthetized and intubated newborn piglets [age 32 h (12-44 h), weight 1,220 g (1,060-1,495g), Median (IQR)] were exposed to hypoxia and blood loss until asystole occurred. At this point they were randomized into two groups: (1) Crystalloid group: receiving isotonic sodium chloride (n = 22). (2) Early transfusion group: receiving blood transfusion (n = 22). In all other ways the piglets were resuscitated according to ILCOR 2015 guidelines [including respiratory support, chest compressions (CC) and epinephrine use]. One hour after ROSC piglets from the crystalloid group were randomized in two sub-groups: late blood transfusion and infusion of isotonic sodium chloride to investigate the effects of a late transfusion on hemodynamic parameters. Results: All animals achieved ROSC. Comparing the crystalloid to early blood transfusion group blood loss was 30.7 ml/kg (22.3-39.6 ml/kg) vs. 34.6 ml/kg (25.2-44.7 ml/kg), Median (IQR). Eleven subjects did not receive volume expansion as ROSC occurred rapidly. Thirty-three animals received volume expansion (16 vs. 17 in the crystalloid vs. early transfusion group). 14.1% vs. 10.5% of previously extracted blood volume in the crystalloid vs. early transfusion group was infused before ROSC. There was no significant difference in time to ROSC between groups [crystalloid group: 164 s (129-198 s), early transfusion group: 163 s (162-199 s), Median (IQR)] with no difference in epinephrine use. Conclusions: Early blood transfusion compared to crystalloid did not reduce time to ROSC, although our model included only a moderate degree of hemorrhage and ROSC occurred early in 11 subjects before any volume resuscitation occurred.
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Affiliation(s)
- Marc R Mendler
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - Stephan Schwarz
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - Lisbeth Hechenrieder
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - Steven Kurth
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Severin Höfler
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Helmut D Hummler
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany.,Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
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14
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Aronson S, Nisbet P, Bunke M. Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers. Perioper Med (Lond) 2017; 6:15. [PMID: 29075482 PMCID: PMC5649061 DOI: 10.1186/s13741-017-0071-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Fluid resuscitation during cardiac surgery is common with significant variability in clinical practice. Our goal was to investigate current practice patterns of fluid volume expansion in patients undergoing cardiac surgeries in the USA. Methods We conducted a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists. Survey questions were designed to assess clinical decision-making patterns of intravenous (IV) fluid utilization in cardiovascular surgery for five types of patients who need volume expansion: (1) patients undergoing cardiopulmonary bypass (CPB) without bleeding, (2) patients undergoing CPB with bleeding, (3) patients undergoing acute normovolemic hemodilution (ANH), (4) patients requiring extracorporeal membrane oxygenation (ECMO) or use of a ventricular assist device (VAD), and (5) patients undergoing either off-pump coronary artery bypass graft (OPCABG) surgery or transcatheter aortic valve replacement (TAVR). First-choice fluid used in fluid boluses for these five patient types was requested. Descriptive statistics were performed using Kruskal-Wallis test and follow-up tests, including t tests, to evaluate differences among respondent groups. Results The most commonly preferred indicators of volume status were blood pressure, urine output, cardiac output, central venous pressure, and heart rate. The first choice of fluid for patients needing volume expansion during CPB without bleeding was crystalloids, whereas 5% albumin was the most preferred first choice of fluid for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most frequently used adjunct fluid to crystalloids. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one third preferred a mixture of 25% albumin and crystalloids. Less interstitial edema and more sustained volume expansion were considered the most important colloid traits in volume expansion. Conclusions Fluid utilization practice patterns in the USA varied depending on patient characteristics and clinical specialties of health care professionals. Electronic supplementary material The online version of this article (10.1186/s13741-017-0071-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Solomon Aronson
- Department of Anesthesiology, Duke University, 201 Trent Drive, 101 Baker House, Durham, NC 27710 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungryneck Blvd. Suite C-303, Mt. Pleasant, SC 29464 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 T.W. Alexander Drive, 4101 Research Commons, Research Triangle Park, Raleigh, NC 27709 USA
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Blood biochemical changes in pigs after infusion with acetate-buffered or lactate-buffered crystalloid solutions. Lab Anim (NY) 2016; 44:268-73. [PMID: 26091132 DOI: 10.1038/laban.739] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/18/2014] [Indexed: 01/15/2023]
Abstract
Perioperative fluid therapy is an important component of many medical procedures with animals. Buffered crystalloid solutions avoid inducing metabolic acidosis, but lactated solutions can elevate blood lactate concentrations and acetated solutions have not been thoroughly investigated using large animals. Here, the authors compare blood biochemical parameters in 20 juvenile pigs after perioperative fluid administration of an acetate-buffered solution (Elo-Mel isoton, EMI) or a lactate-buffered solution (lactated Ringer's solution, LRS). The authors measured blood lactate, glucose and electrolyte concentrations before and after administering the test fluid during surgery. Blood lactate concentration after administration was significantly higher in pigs that received LRS than in pigs that received EMI, but glucose and electrolyte concentrations did not differ significantly between treatment groups before or after administration. These findings suggest that EMI might be a preferable option for perioperative fluid therapy in pigs.
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Miller TE, Bunke M, Nisbet P, Brudney CS. Fluid resuscitation practice patterns in intensive care units of the USA: a cross-sectional survey of critical care physicians. Perioper Med (Lond) 2016; 5:15. [PMID: 27313844 PMCID: PMC4910257 DOI: 10.1186/s13741-016-0035-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/09/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA. METHODS We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume. RESULTS Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices. CONCLUSIONS Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg. 4101, Research Triangle Park, NC 27709 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungry Neck Blvd., Suite C-303, Charleston, SC 29464 USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
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Roger C, Louart B, Louart G, Bobbia X, Claret PG, Perez-Martin A, Muller L, Lefrant JY. Does the infusion rate of fluid affect rapidity of mean arterial pressure restoration during controlled hemorrhage. Am J Emerg Med 2016; 34:1743-9. [PMID: 27397668 DOI: 10.1016/j.ajem.2016.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/10/2016] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE This study aimed to compare 2 fluid infusion rates of lactated Ringer (LR) and hydroxyethyl starch (HES) 130/0.4 on hemodynamic restoration at the early phase of controlled hemorrhagic shock. METHODS Fifty-six anesthetized and ventilated piglets were bled until mean arterial pressure (MAP) reached 40 mm Hg. Controlled hemorrhage was maintained for 30 minutes. After this period, 4 resuscitation groups were studied (n=14 for each group): HES infused at 1 or 4mL/kg per minute or LR1 infused at 1 or 4mL/kg per minute until baseline MAP was restored. Hemodynamic assessment using PiCCO monitoring and biological data were collected. RESULTS Time to restore baseline MAP ±10% was significantly lower in LR4 group (11±11 minutes) compared to LR1 group (41±25 minutes) (P=.0004). Time to restore baseline MAP ±10% was significantly lower in HES4 group (4±3 minutes) compared to HES1 (11±4 minutes) (P=.0003). Time to restore baseline MAP ±10% was significantly lower with HES vs LR whatever the infusion rate. No statistically significant difference was observed in cardiac output, central venous saturation, extravascular lung water, and arterial lactate between 4 and 1 mL/kg per minute groups. CONCLUSIONS In this controlled hemorrhagic shock model, a faster infusion rate (4 vs 1mL/kg per minute) significantly decreased the time for restoring baseline MAP, regardless of the type of infused fluid. The time for MAP restoration was significantly shorter for HES as compared to LR whatever the fluid infusion rate.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Benjamin Louart
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Guillaume Louart
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Xavier Bobbia
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Pierre-Geraud Claret
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France
| | - Antonia Perez-Martin
- Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
| | - Laurent Muller
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France.
| | - Jean-Yves Lefrant
- Department of Anesthesiology, Emergency and Critical Care Medicine, Nimes University Hospital, 30029 Nîmes, France; Physiology Department, EA 2992, Faculté de Médecine de Nîmes, Université Montpellier 1, 30029 Nîmes, France
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19
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Chana AS, Mahajan RP. BJA 2014; An overview. Br J Anaesth 2015; 114:ix-xvi. [PMID: 25500411 DOI: 10.1093/bja/aeu455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A S Chana
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
| | - R P Mahajan
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
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20
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Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2014; 62:158-68. [DOI: 10.1007/s12630-014-0266-y] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022] Open
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Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. Best Pract Res Clin Anaesthesiol 2014; 28:261-73. [PMID: 25208961 DOI: 10.1016/j.bpa.2014.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 06/27/2014] [Accepted: 07/02/2014] [Indexed: 12/20/2022]
Abstract
The underlying principles guiding fluid management in any setting are very simple: maintain central euvolemia, and avoid salt and water excess. However, these principles are frequently easier to state than to achieve. Evidence from recent literature suggests that avoidance of fluid excess is important, with excessive crystalloid use leading to perioperative weight gain and an increase in complications. A zero-balance approach aimed at avoiding fluid excess is recommended for all patients. For major surgery, there is a sizeable body of evidence that an individualized goal-directed fluid therapy (GDFT) improves outcomes. However, within an Enhanced Recovery program only a few studies have been published, yet so far GDFT has not achieved the same benefit. Balanced crystalloids are recommended for most patients. The use of colloids remains controversial; however, current evidence suggests they can be beneficial in intraoperative patients with objective evidence of hypovolemia.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; Durham VAMC, Durham, NC 27710, USA.
| | - Tong J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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