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Kong S, Kwon H. Potassium level changes in chronic kidney disease patients following balanced crystalloid administration in the emergency department. Medicine (Baltimore) 2023; 102:e35026. [PMID: 37773798 PMCID: PMC10545324 DOI: 10.1097/md.0000000000035026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/09/2023] [Indexed: 10/01/2023] Open
Abstract
One common reason why clinicians are often hesitate to administer balanced crystalloids in the emergency department is the potential occurrence of unexpected hyperkalemia in patients with chronic kidney disease (CKD). In order to investigate the changes in potassium levels resulting from the administration of balanced crystalloids, specially Plasma Solution A (a generic version of Plasma-Lyte), to emergency department patients with CKD, we conducted an evaluation. A retrospective cohort study was conducted at a single academic hospital. Our study included patients with CKD who received intravenous Plasma Solution A and underwent electrolyte follow-up testing within 24 hours of administration. In total, there were 745 patients included in this study, of whom 87 had CKD. Through a 1:1 propensity score matching procedure for factors other than the estimated glomerular filtration rate, we matched 87 patients with normal kidney function to 87 CKD patients. For patients with CKD, the mean standard deviation SD administered volume of Plasma Solution A was 28.7 (21.0) mL/kg, and the mean SD administration duration was 13.2 (4.5) hours. The mean SD potassium level decreased from 4.3 (0.6) mmol/L to 4.1 (0.6) mmol/L (P = .029). Our study findings suggest that there may be no significant harmful increase in potassium levels or worsening of renal function within 24 hours after the intravenous administration of approximately 2 L of Plasma Solution A to patients with CKD.
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Affiliation(s)
- Sungsig Kong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gumi-dong, Bundang-gu, Sungnam-si, Gyeonggi-do, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gumi-dong, Bundang-gu, Sungnam-si, Gyeonggi-do, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Vignarajah M, Berg A, Abdallah Z, Arora N, Javidan A, Pitre T, Fernando SM, Spence J, Centofanti J, Rochwerg B. Intraoperative use of balanced crystalloids versus 0.9% saline: a systematic review and meta-analysis of randomised controlled studies. Br J Anaesth 2023; 131:463-471. [PMID: 37455198 DOI: 10.1016/j.bja.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The evidence regarding optimal crystalloid use in the perioperative period remains unclear. As the primary aim of this study, we sought to summarise the data from RCTs examining whether use of balanced crystalloids compared with 0.9% saline (saline) leads to differences in patient-important outcomes. METHODS We searched Ovid MEDLINE, Embase, the Cochrane library, and Clinicaltrials.gov, from inception until December 15, 2022, and included RCTs that intraoperatively randomised adult participants to receive either balanced fluids or saline. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences (MDs), along with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool, and certainty of evidence using GRADE. RESULTS Of 5959 citations, we included 38 RCTs (n=3776 patients). Pooled analysis showed that intraoperative use of balanced fluids compared with saline had an uncertain effect on postoperative mortality analysed at the longest point of follow-up (RR 1.51, 95% CI: 0.42-5.36) and postoperative need for renal replacement therapy (RR 0.95, 95% CI: 0.56-1.59), both very low certainty. Furthermore, use of balanced crystalloids probably leads to a higher postoperative serum pH (MD 0.05, 95% CI: 0.04-0.06), moderate certainty. CONCLUSIONS Use of balanced crystalloids, compared with saline, in the perioperative setting has an uncertain effect on mortality and need for renal replacement therapy but probably improves postoperative acid-base status. Further research is needed to determine whether balanced crystalloid use affects patient-important outcomes. CLINICAL TRIAL REGISTRATION CRD42022367593.
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Affiliation(s)
| | - Annie Berg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zahra Abdallah
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Naman Arora
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Shrivastava P, Murmu R, Suman S, Verma S, Lakra L, Kumar S. The Effect on Serum Electrolytes in Patients Undergoing Elective Craniotomy for Supratentorial Brain Tumors Using PlasmaLyte A and Normal Saline as Intravenous Replacement Fluid. Cureus 2023; 15:e42656. [PMID: 37644938 PMCID: PMC10461887 DOI: 10.7759/cureus.42656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/31/2023] Open
Abstract
Background and aim The type of fluid which is administered to patients is very crucial and important. In this study normal saline is compared with PlasmaLyte A in patients undergoing craniotomy for supratentorial brain tumors. Generally normal saline is used in neurosurgical patients; it is seen to be associated with hyperchloremic acidosis. A balanced crystalloid, e.g. PlasmaLyte A, maintains a better metabolic status than normal saline. This study was planned to study the metabolic effects of using PlasmaLyte A as compared with normal saline as intravenous fluids in patients undergoing supratentorial brain tumour surgeries. Methods This is a prospective, randomized, double-blinded study in patients undergoing craniotomy for supratentorial brain tumors. Written informed consent was taken from patients and they were divided into two groups, Group A and B of 40 patients each by computer-generated random numbers. Group A received PlasmaLyte A and Group B received normal saline intra-operatively as maintenance fluid. Heart rate, mean arterial pressure, total fluid administered, serum sodium, serum potassium, chloride, lactate, pH, serum urea, serum creatinine, osmolarity, and urine output were assessed at different time intervals in both groups. Blood urea and creatinine were assessed to see acute kidney injury. Results There was no difference in mean values of serum sodium, potassium, lactate, serum urea, creatinine and serum osmolarity in both groups throughout the study period. However there was a rise in serum chloride and a low pH was noted in Group B. The urine output was also similar in both groups. The metabolic status of patients receiving PlasmaLyte was better than those receiving normal saline. Conclusion Normal saline may cause hyperchloremic metabolic acidosis which may be avoided by using balanced crystalloids. The use of balanced crystalloids should be preferred to normal saline in neurosurgical patients to ensure a better metabolic status and good clinical outcome.
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Affiliation(s)
| | - Ravi Murmu
- Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Saurabh Suman
- Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Saket Verma
- Biochemistry (Trauma Centre), Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Ladhu Lakra
- Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Sanjay Kumar
- Anaesthesiology and Critical Care, All India Institute of Medical Sciences Deoghar, Deoghar, IND
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Zhou FQ. Pyruvate as a Potential Beneficial Anion in Resuscitation Fluids. Front Med (Lausanne) 2022; 9:905978. [PMID: 35991638 PMCID: PMC9382911 DOI: 10.3389/fmed.2022.905978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
There have been ongoing debates about resuscitation fluids because each of the current fluids has its own disadvantages. The debates essentially reflect an embarrassing clinical status quo that all fluids are not quite ideal in most clinical settings. Therefore, a novel fluid that overcomes the limitations of most fluids is necessary for most patients, particularly diabetic and older patients. Pyruvate is a natural potent antioxidant/nitrosative and anti-inflammatory agent. Exogenous pyruvate as an alkalizer can increase cellular hypoxia and anoxia tolerance with the preservation of classic glycolytic pathways and the reactivation of pyruvate dehydrogenase activity to promote oxidative metabolism and reverse the Warburg effect, robustly preventing and treating hypoxic lactic acidosis, which is one of the fatal complications in critically ill patients. In animal studies and clinical reports, pyruvate has been shown to play a protective role in multi-organ functions, especially the heart, brain, kidney, and intestine, demonstrating a great potential to improve patient survival. Pyruvate-enriched fluids including crystalloids and colloids and oral rehydration solution (ORS) may be ideal due to the unique beneficial properties of pyruvate relative to anions in contemporary existing fluids, such as acetate, bicarbonate, chloride, citrate, lactate, and even malate. Preclinical studies have demonstrated that pyruvate-enriched saline is superior to 0.9% sodium chloride. Moreover, pyruvate-enriched Ringer’s solution is advantageous over lactated Ringer’s solution. Furthermore, pyruvate as a carrier in colloids, such as hydroxyethyl starch 130/0.4, is more beneficial than its commercial counterparts. Similarly, pyruvate-enriched ORS is more favorable than WHO-ORS in organ protection and shock resuscitation. It is critical that pay attention first to improving abnormal saline with pyruvate for ICU patients. Many clinical trials with a high dose of intravenous or oral pyruvate were conducted over the past half century, and results indicated its effectiveness and safety in humans. The long-term instability of pyruvate aqueous solutions and para-pyruvate cytotoxicity is not a barrier to the pharmaceutical manufacturing of pyruvate-enriched fluids for ICU patients. Clinical trials with sodium pyruvate-enriched solutions are urgently warranted.
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Rauserova-Lexmaulova L, Prokesova B, Blozonova A, Vanova-Uhrikova I, Rehakova K, Fusek M. Effects of the Administration of Different Buffered Balanced Crystalloid Solutions on Acid-Base and Electrolyte Status in Dogs with Gastric Dilation-Volvulus Syndrome: a randomized clinical trial. Top Companion Anim Med 2021; 46:100613. [PMID: 34737069 DOI: 10.1016/j.tcam.2021.100613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/22/2021] [Accepted: 10/29/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the effect of three different buffered balanced crystalloid solutions on acid-base status and electrolyte concentrations in dogs with gastric dilation-volvulus (GDV) syndrome. METHODS The study design was a prospective, randomized clinical trial of 40 dogs. The dogs were randomly assigned to one of three groups according to the fluid used: Hartmann's solution (H), Plasmalyte (PL), and Ringerfundin (RF). Hemoglobin, albumin, lactate, electrolyte, and acid-base parameters were determined before fluid administration (T0) and at the end of surgery (T1). Results were assessed by one-way ANOVA, Fisher's exact test, the Wilcoxon signed-rank test, the Kruskal-Wallis test, and a linear mixed-effect regression model. A significance level of 0.05 was used in all analyses. RESULTS Bicarbonate and base excess (BE) levels increased and chloride concentration decreased in the PL group; in contrast, strong ion difference apparent (SIDapp) decreased and chloride concentration increased in the RF group. The mixed-effect model confirmed a significant interaction between the type of solution and time on the changes in bicarbonate, BE, anion gap (AG), SIDapp, and chloride levels. CLINICAL SIGNIFICANCE Significantly different effects in acid-base parameters were observed in dogs after intravenous administration of H, PL, and RF. However, clinical significance of these changes is lacking, requiring further investigation in a larger randomized controlled clinical trial.
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Affiliation(s)
- Leona Rauserova-Lexmaulova
- Department of Surgery and Orthopedics, Small Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Czech Republic.
| | - Barbara Prokesova
- Department of Surgery and Orthopedics, Small Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Czech Republic
| | - Aneta Blozonova
- Department of Surgery and Orthopedics, Small Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Czech Republic
| | - Ivana Vanova-Uhrikova
- Small Animal Clinical Laboratory, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Czech Republic
| | - Kristina Rehakova
- Small Animal Clinical Laboratory, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Czech Republic
| | - Michal Fusek
- Department of Mathematics, Faculty of Electrical Engineering and Communication, Brno University of Technology, Czech Republic
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Hasim N, Bakar MAA, Islam MA. Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Children (Basel) 2021; 8:children8090785. [PMID: 34572217 PMCID: PMC8471545 DOI: 10.3390/children8090785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023]
Abstract
Hyponatraemia is a known complication in hospitalised children receiving maintenance intravenous fluid. Several studies have been published to investigate the efficacy and safety of intravenous fluids in children. However, there is still an ongoing debate regarding the ideal solution to be used in the paediatric population. Therefore, the aim of this meta-analysis was to investigate the safety and efficacy of administering isotonic versus hypotonic intravenous maintenance fluid in hospitalised children. An extensive search was undertaken on PubMed, Web of Science, Scopus, ScienceDirect, Google Scholar and Cochrane Library on 28 December 2020. Only randomised controlled trials (RCTs) were included. We used the random-effects model for all analyses. Risk ratio (RR) and mean difference with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. This study is registered with PROSPERO (CRD42021229067). Twenty-two RCTs with a total of 3795 participants were included. The studies encompassed surgical and medical patients admitted to intensive care unit as well as to general wards. We found that hypotonic fluid significantly increases the risk of hyponatremia at both ≤24 h (RR 0.34; 95% CI: 0.26–0.43, p < 0.00001) and >24 h (RR 0.48; 95% CI: 0.36–0.64, p < 0.00001). Isotonic fluid increases the risk of hypernatraemia at ≤24 h (RR 2.15; 95% CI: 1.24–3.73, p = 0.006). The prevalence of hyponatraemia was also higher in the hypotonic group at both ≤24 h (5.7% vs. 23.3%) and >24 h (6.0% vs. 26.3%). There was no statistically significant difference in the risk of developing adverse outcomes between the two groups. Mean serum and urine sodium as well as serum osmolality/osmolarity was lower in the hypotonic group. Isotonic solution is protective against the development of hyponatraemia while hypotonic solution increases the risk of hyponatraemia.
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Affiliation(s)
- Norfarahin Hasim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Mimi Azliha Abu Bakar
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
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Heming N, Moine P, Coscas R, Annane D. Perioperative fluid management for major elective surgery. Br J Surg 2020; 107:e56-e62. [PMID: 31903587 DOI: 10.1002/bjs.11457] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adequate fluid balance before, during and after surgery may reduce morbidity. This review examines current concepts surrounding fluid management in major elective surgery. METHOD A narrative review was undertaken following a PubMed search for English language reports published before July 2019 using the terms 'surgery', 'fluids', 'fluid therapy', 'colloids', 'crystalloids', 'albumin', 'starch', 'saline', 'gelatin' and 'goal directed therapy'. Additional reports were identified by examining the reference lists of selected articles. RESULTS Fluid therapy is a cornerstone of the haemodynamic management of patients undergoing major elective surgery. Both fluid overload and hypovolaemia are deleterious during the perioperative phase. Zero-balance fluid therapy should be aimed for. In high-risk patients, individualized haemodynamic management should be titrated through the use of goal-directed therapy. The optimal type of fluid to be administered during major surgery remains to be determined. CONCLUSION Perioperative fluid management is a key challenge during major surgery. Individualized volume optimization by means of goal-directed therapy is warranted during high-risk surgery. In most patients, balanced crystalloids are the first choice of fluids to be used in the operating theatre. Additional research on the optimal type of fluid for use during major surgery is needed.
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Affiliation(s)
- N Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
| | - P Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
| | - R Coscas
- Department of Vascular Surgery, Ambroise Paré Hospital, GHU APHP University Paris-Saclay, Boulogne-Billancourt, France.,U1018, Centre de Recherche en Épidémiologie et Santé des Populations, UVSQ and University Paris-Saclay, Villejuif, France
| | - D Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
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Abstract
Fluid therapy to restore and/or maintain tissue perfusion may affect patient outcomes in perioperative, emergency, and intensive care. Kinetic analyses and outcome-oriented studies have provided more insight into fluid management. Crystalloids are slowly distributed to the interstitial space, and the efficiency (proportion of infused fluid retained in the bloodstream) is 50%−75% as long as infusion continues and may increase up to 100% when the arterial pressure has decreased. Elimination of the infused fluid during general anesthesia and surgery is very slow, amounting to only 10%–20% compared with that in conscious patients. When the endothelial glycocalyx layer is degraded in sepsis or trauma-induced systemic inflammation, turnover of colloids and crystalloids is accelerated and the efficiency is reduced, which may lead to tissue edema, inflammation, poor wound healing, and organ dysfunction. Balanced crystalloids are pragmatic initial resuscitation fluids and improve patient outcomes compared to saline (0.9% sodium chloride). Albumin may be beneficial, but other synthetic colloids appear to increase the risk of acute kidney injury and death among patients in the intensive care unit. Fluid kinetics is likely to change based on patient physiological conditions (e.g., general anesthesia, surgery, stress, dehydration, blood pressure, or inflammation) and fluid types. To maximize efficacy and minimize iatrogenic side effects, fluids should be prescribed based on individual patient factors, disease states, and other treatment remedies.
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Affiliation(s)
- Dongho Kang
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kyung Yeon Yoo
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Levin M, Cunnington AJ, Wilson C, Nadel S, Lang HJ, Ninis N, McCulloch M, Argent A, Buys H, Moxon CA, Best A, Nijman RG, Hoggart CJ. Effects of saline or albumin fluid bolus in resuscitation: evidence from re-analysis of the FEAST trial. Lancet Respir Med 2019; 7:581-593. [PMID: 31196803 PMCID: PMC6593355 DOI: 10.1016/s2213-2600(19)30114-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/11/2019] [Accepted: 03/21/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Fluid resuscitation is the recommended management of shock, but increased mortality in febrile African children in the FEAST trial. We hypothesised that fluid bolus-induced deaths in FEAST would be associated with detectable changes in cardiovascular, neurological, or respiratory function, oxygen carrying capacity, and blood biochemistry. METHODS We developed composite scores for respiratory, cardiovascular, and neurological function using vital sign data from the FEAST trial, and used them to compare participants from FEAST with those from four other cohorts and to identify differences between the bolus (n=2097) and no bolus (n=1044) groups of FEAST. We calculated the odds of adverse outcome for each ten-unit increase in baseline score using logistic regression for each cohort. Within FEAST participants, we also compared haemoglobin and plasma biochemistry between bolus and non-bolus patients, assessed the effects of these factors along with the vital sign scores on the contribution of bolus to mortality using Cox proportional hazard models, and used Bayesian clustering to identify subgroups that differed in response to bolus. The FEAST trial is registered with ISRCTN, number ISRCTN69856593. FINDINGS Increasing respiratory (odds ratio 1·09, 95% CI 1·07-1·11), neurological (1·26, 1·21-1·31), and cardiovascular scores (1·09, 1·05-1·14) were associated with death in FEAST (all p<0·0001), and with adverse outcomes for specific scores in the four other cohorts. In FEAST, fluid bolus increased respiratory and neurological scores and decreased cardiovascular score at 1 h after commencement of the infusion. Fluid bolus recipients had mean 0·33 g/dL (95% CI 0·20-0·46) reduction in haemoglobin concentration after 8 h (p<0·0001), and at 24 h had a decrease of 1·41 mEq/L (95% CI 0·76-2·06; p=0·0002) in mean base excess and increase of 1·65 mmol/L (0·47-2·8; p=0·0070) in mean chloride, and a decrease of 0·96 mmol/L (0·45 to 1·47; p=0·0003) in bicarbonate. There were similar effects of fluid bolus in three patient subgroups, identified on the basis of their baseline characteristics. Hyperchloraemic acidosis and respiratory and neurological dysfunction induced by saline or albumin bolus explained the excess mortality due to bolus in Cox survival models. INTERPRETATION In the resuscitation of febrile children, albumin and saline boluses can cause respiratory and neurological dysfunction, hyperchloraemic acidosis, and reduction in haemoglobin concentration. The findings support the notion that fluid resuscitation with unbuffered electrolyte solutions may cause harm and their use should be cautioned. The effects of lower volumes of buffered solutions should be evaluated further. FUNDING Medical Research Council, Department for International Development, National Institute for Health Research, Imperial College Biomedical Research Centre.
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Affiliation(s)
- Michael Levin
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK.
| | - Aubrey J Cunnington
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Clare Wilson
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Simon Nadel
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK; Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Hans Joerg Lang
- Paediatric Referent, Médecins sans Frontières, Brussels, Belgium
| | - Nelly Ninis
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Andrew Argent
- Red Cross Children's Hospital, Cape Town, South Africa
| | - Heloise Buys
- Red Cross Children's Hospital, Cape Town, South Africa
| | - Christopher A Moxon
- Wellcome Centre for Integrative Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Abigail Best
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ruud G Nijman
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK; Department of Paediatric Emergency Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clive J Hoggart
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
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Bhaskaran K, Arumugam G, Vinay Kumar PV. A prospective, randomized, comparison study on effect of perioperative use of chloride liberal intravenous fluids versus chloride restricted intravenous fluids on postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass grafting surgeries. Ann Card Anaesth 2019; 21:413-418. [PMID: 30333337 PMCID: PMC6206797 DOI: 10.4103/aca.aca_230_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Context and Aims: Off-pump coronary artery bypass graft (OPCABG) is a form of CABG surgery. It is performed without the use of cardiopulmonary bypass machine as a surgical treatment for coronary heart disease. Acute kidney injury (AKI) is one of the common postoperative complications of OPCABG. Previous studies suggest important differences related to intravenous fluid (IVF) chloride content and renal function. We hypothesize that perioperative use of chloride restricted IVFs may decrease incidence and severity of postoperative AKI in patients undergoing OPCABG. Methods: Six hundred patients were randomly divided into two groups of 300 each. In Group A (n = 300), chloride liberal IVFs, namely, hydroxyethyl starch (130/0.4) in 0.9% normal saline (Voluven), 0.9% normal saline, and Ringer's lactate were used for perioperative fluid management. In Group B (n = 300), chloride-restricted IVFs, namely, hydroxyethyl starch (130/0.4) in balanced colloid solution (Volulyte) and balanced salt crystalloid solution (PlasmaLyte A), were used for perioperative fluid management. Serum creatinine values were taken preoperatively, postoperatively at 24 h and at 48 h. Postoperative AKI was determined by AKI network (AKIN) criteria. Results: In Group A, 9.2% patients and in Group B 4.6% patients developed Stage-I AKI determined by AKIN criteria which was statistically significant (P < 0.05). Conclusion: Perioperative use of chloride restricted IVF was found to decrease incidence of postoperative AKI. The use of chloride liberal IVF was associated with hyperchloremic metabolic acidosis.
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Affiliation(s)
- K Bhaskaran
- Department of Anaesthesia, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - P V Vinay Kumar
- Department of Anaesthesia, Sri Siddhartha Medical College, Tumakur, Karnataka, India
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Dawson R, Wignell A, Cooling P, Barrett D, Vyas H, Davies P. Physico-chemical stability of Plasma-Lyte 148® and Plasma-Lyte 148® + 5% Glucose with eight common intravenous medications. Paediatr Anaesth 2019; 29:186-192. [PMID: 30472805 DOI: 10.1111/pan.13554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/18/2018] [Accepted: 11/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Plasma-Lyte 148® is a balanced, crystalloid intravenous (IV) fluid which is both calcium-free and isotonic. It prevents the hyperchloremic metabolic acidosis and iatrogenic hyponatremia seen with use of 0.9% sodium chloride and hypotonic solutions, respectively. However, data on compatibility with commonly used drugs are lacking. AIMS To investigate the stability of Plasma-Lyte 148® and Plasma-Lyte 148® + 5% Glucose with eight commonly used therapeutic agents when compared with 5% glucose and 0.9% sodium chloride as diluents. We aimed to provide vital data which may facilitate the introduction of what appears to be a safer and more economic fluid. METHODS Plasma-Lyte 148® and Plasma-Lyte 148® + 5% Glucose were mixed with morphine, midazolam, fentanyl, ketamine, clonidine, aminophylline, salbutamol, and furosemide at set concentrations. Comparisons were made to 0.9% sodium chloride and 5% glucose fluid controls. Six repeats of each IV fluid and drug admixture were analyzed through high-performance liquid chromatography at three time points: 0, 2, and 24 hours. A concentration change of <5% was defined as chemically stable. Physical stability was assessed by observation of precipitate formation or color change. pH changes were measured using a Fisherbrand Hydrus 300 pH meter. RESULTS Relative to starting concentration, all drugs except midazolam were stable to ±3%. All examined therapeutic agents were chemically stable at 2 and 24 hours relative to control solutions. No precipitate formed in any of the samples. All Plasma-Lyte 148® and Plasma-Lyte 148® + 5% Glucose drug admixtures remained in a safe, peripheral administration pH range of 5-9 and were closer to the pH of blood than standard fluid-drug admixtures. CONCLUSION Morphine, fentanyl, ketamine, salbutamol, aminophylline, and clonidine are stable for 24 hours when mixed with Plasma-Lyte 148® and Plasma-Lyte 148®+5% Glucose for administration at concentrations equivalent to those found at a typical Y-site with maintenance fluid. Furosemide is stable at lower concentrations than those seen at a Y-site, but midazolam displayed instability.
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Affiliation(s)
- Rachael Dawson
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew Wignell
- School of Pharmacy, University of Nottingham, Nottingham, UK.,Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, UK
| | - Paul Cooling
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - David Barrett
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Harish Vyas
- School of Medicine, University of Nottingham, Nottingham, UK.,Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, UK
| | - Patrick Davies
- School of Medicine, University of Nottingham, Nottingham, UK.,Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, UK
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12
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Torres SF, Iolster T, Schnitzler EJ, Siaba Serrate AJ, Sticco NA, Rocca Rivarola M. Hypotonic and isotonic intravenous maintenance fluids in hospitalised paediatric patients: a randomised controlled trial. BMJ Paediatr Open 2019; 3:e000385. [PMID: 31206070 PMCID: PMC6542423 DOI: 10.1136/bmjpo-2018-000385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/27/2019] [Accepted: 03/30/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To compare the changes in serum sodium and acid/base status in patients receiving hypotonic and isotonic solutions. DESIGN A randomised, controlled and double-blind clinical trial. SETTING Department of Paediatrics in a tertiary general hospital (Hospital Universitario Austral) in Buenos Aires, Argentina. PATIENTS Children between 29 days and 15 years of age who were hospitalised in the paediatric intensive care unit and general hospital between 12 January 2010 and 30 November 2016, and who required exclusively parenteral maintenance solutions for at least 24 hours. INTERVENTIONS A hypotonic solution with 77 mEq/L sodium chloride (0.45% in 5% dextrose) and isotonic solution with 150 mEq/L (0.9% in 5% dextrose) were infused for 48 hours and were labelled. MAIN OUTCOME MEASURE The main outcome was to evaluate the incidence of hyponatraemia between patients treated with parenteral hydration with hypotonic or isotonic fluids. The secondary outcome was to estimate the incidence of metabolic acidosis induced by each of the solutions. RESULTS The 299 patients in the present study were randomised to groups that received the hypotonic solution (n=154) or isotonic solution (n=145). The mean serum sodium concentration measurements at 12 hours were 136.3±3.9 mEq/L and 140.1±2.3 mEq/L in the hypotonic and isotonic groups, respectively, with a hyponatraemia incidence of 8.27% (n=12) and 18.8% (n=29) (p<0.001). At 24 hours, 12.4% (n=18) of the isotonic group had developed hyponatraemia compared with 46.1% (n=71) of the hypotonic group (p<0.001). The mean serum sodium concentration measurements were 134.4±5.6 and 139.3±3.1, respectively. No patient developed hypernatraemia (serum sodium concentrations >150 mEq/L) or other adverse outcomes. The relative risk in the hypotonic group was 3.7 (95% CI 2.3 to 5.9), almost four times the risk of developing hyponatraemia than those who received isotonic fluids. There were also no significant differences between the groups with regard to the development of metabolic acidosis. Hypotonic solution, age <12 months and postoperative abdominal surgery were risk factors associated with hyponatraemia. CONCLUSIONS The incidence of iatrogenic hyponatraemia was greater with the administration of hypotonic fluids compared with that of isotonic fluids. There were no significant differences in the incidence of metabolic acidosis between the groups.
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Affiliation(s)
- Silvio Fabio Torres
- Department of Pediatrics, Hospital Universitario Austral, Pilar, Argentina.,IRB, Universidad Austral, Pilar, Argentina
| | - Thomas Iolster
- Department of Pediatrics, Hospital Universitario Austral, Pilar, Argentina
| | | | | | - Nicolás A Sticco
- Department of Pediatrics, Hospital Universitario Austral, Pilar, Argentina
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13
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Odor PM, Bampoe S, Dushianthan A, Bennett-Guerrero E, Cro S, Gan TJ, Grocott MPW, James MFM, Mythen MG, O'Malley CMN, Roche AM, Rowan K, Burdett E. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures: a Cochrane systematic review. Perioper Med (Lond) 2018; 7:27. [PMID: 30559961 PMCID: PMC6291967 DOI: 10.1186/s13741-018-0108-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/14/2018] [Indexed: 12/12/2022] Open
Abstract
Background Buffered intravenous fluid preparations contain substrates to maintain acid-base status. The objective of this systematic review was to compare the effects of buffered and non-buffered fluids administered during the perioperative period on clinical and biochemical outcomes. Methods We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library until May 2017 and included all randomised controlled trials that evaluated buffered versus non-buffered fluids, whether crystalloid or colloid, administered to surgical patients. We assessed the selected studies for risk of bias and graded the level of evidence in accordance with Cochrane recommendations. Results We identified 19 publications of 18 randomised controlled trials, totalling 1096 participants. Mean difference (MD) in postoperative pH was 0.05 units lower immediately following surgery in the non-buffered group (12 studies of 720 participants; 95% confidence interval (CI) 0.04 to 0.07; I2 = 61%). This difference did not persist on postoperative day 1. Serum chloride concentration was higher in the non-buffered group at the end of surgery (10 trials of 530 participants; MD 6.77 mmol/L, 95% CI 3.38 to 10.17). This effect persisted until postoperative day 1 (5 trials of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). Quality of this evidence was moderate. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Outcome data was variably reported at disparate time points and with heterogeneous patient groups. Consequently, the effect size and overall confidence interval was reduced, despite the relatively low inherent risk of bias. There was insufficient evidence on the effect of fluid composition on mortality and organ dysfunction. Confidence intervals of this outcome were wide and the quality of evidence was low (3 trials of 276 participants for mortality; odds ratio (OR) 1.85, 95% CI 0.37 to 9.33; I2 = 0%). Conclusions Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Buffered fluid may have biochemical benefits, including a significant reduction in postoperative hyperchloraemia and metabolic acidosis. Electronic supplementary material The online version of this article (10.1186/s13741-018-0108-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter M Odor
- 1Department of Anaesthesia and Critical Care, University College London, Gower St, London, WC1E 6BT UK
| | - Sohail Bampoe
- 2Centre for Anaesthesia and Perioperative Medicine, University College London, London, UK
| | - Ahilanandan Dushianthan
- 3General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Suzie Cro
- 5Medical Research Council Clinical Trials Unit, London, UK
| | - Tong J Gan
- 4Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY USA
| | - Michael P W Grocott
- 6Critical Care Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael F M James
- 7Department of Anaesthesia, University of Cape Town, Cape Town, South Africa
| | - Michael G Mythen
- 1Department of Anaesthesia and Critical Care, University College London, Gower St, London, WC1E 6BT UK
| | | | - Anthony M Roche
- 9Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA USA
| | - Kathy Rowan
- 10Intensive Care National Audit & Research Centre, London, UK
| | - Edward Burdett
- 11Department of Anaesthesia, UCL Centre for Anaesthesia, London, UK
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14
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Abstract
Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.
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Affiliation(s)
| | - G Usúa
- Anesthesia and Critical Care Department
| | - N Martín
- Anesthesia and Critical Care Department
| | - L Abarca
- Anesthesia and Critical Care Department
| | - J P Barret
- Plastic Surgery Department and Burn Centre, Hospital Universitari Vall d'Hebron, Barcelona 08035, Spain
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15
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Abstract
PURPOSE OF REVIEW The past decade has seen more advances in our understanding of fluid therapy than the preceding decades combined. What was once thought to be a relatively benign panacea is increasingly being recognized as a potent pharmacological and physiological intervention that may pose as much harm as benefit. RECENT FINDINGS Recent studies have clearly indicated that the amount, type, and timing of fluid administration have profound effects on patient morbidity and outcomes. The practice of aggressive volume resuscitation for 'renal protection' and 'hemodynamic support' may in fact be contributing to end organ dysfunction. The practice of early goal-directed therapy for patients suffering from critical illness or undergoing surgery appears to offer no benefit over conventional therapy and may in fact be harmful. A new conceptual model for fluid resuscitation of critically ill patients has recently been developed and is explored here. SUMMARY The practice of giving more fluid early and often is being replaced with new conceptual models of fluid resuscitation that suggest fluid therapy be 'personalized' to individual patient pathophysiology.
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16
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Abstract
Metabolic acidosis is considered deleterious but is common in post-surgical patients admitted to intensive care unit. We evaluated the prevalence and time course of metabolic acidosis in elective major surgery, and generated hypotheses about causes, by hourly arterial blood sampling in 92 patients. Metabolic acidosis began before incision and most had occurred by the next hour. Seventy-eight per cent of patients had a significant metabolic acidosis post-operatively. Two overlapping phases were observed. The early phase started before incision, characterised by a rising chloride and falling anion gap, unrelated to saline use. The late phase was partly associated with lactate, related to surgery type, and early fluids appeared protective. There was a trend towards longer intensive care unit (+1.3 days) and hospital (+3.2 days) stay with metabolic acidosis. This is the first large study of the evolution of this common finding, demonstrating a pre-incision component. The early phase appears unavoidable or unpredictable, but the late phase might be modified by early fluid administration. It remains unclear whether acidosis of this type should be avoided.
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Affiliation(s)
- T O Lawton
- Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - A Quinn
- Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - S J Fletcher
- Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
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17
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Gurajala I, Nikhar SA, Jayaram K, Gopinath R. Regional anesthesia is safe and effective for lower limb orthopedic surgery in patient with renal tubular acidosis and hypokalemia. J Anaesthesiol Clin Pharmacol 2018; 34:117-119. [PMID: 29643635 PMCID: PMC5885426 DOI: 10.4103/0970-9185.168203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Renal tubular acidosis (RTA) with hypokalemia may precipitate acute respiratory failure and potentially fatal arrhythmias like ventricular fibrillation. Though there are random reports of respiratory failure needing mechanical ventilation and sudden death in patients with RTA and hypokalemia, the anesthetic management of these patients has not been clearly elucidated. Acidosis and hypokalemia have significant interactions with both general and local anesthetics and alter their effect substantially. Proper preoperative planning and optimization are required for the safe conduct of anesthesia in this subset of patients. We describe a case of distal RTA, hypokalemia, and metabolic bone disease in whom central neuraxial anesthesia was effectively used for lower limb orthopedic surgery with no complications.
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Affiliation(s)
- Indira Gurajala
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sapna Annaji Nikhar
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Kavitha Jayaram
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ramachandran Gopinath
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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18
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Pfortmueller CA, Kabon B, Schefold JC, Fleischmann E. Crystalloid fluid choice in the critically ill : Current knowledge and critical appraisal. Wien Klin Wochenschr 2018; 130:273-282. [PMID: 29500723 DOI: 10.1007/s00508-018-1327-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
Abstract
Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.
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Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Barbara Kabon
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
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19
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Abstract
Hypovolemia alone or in conjunction with other factors is a main reason for acute renal failure in critically ill patients. Various crystalloid and colloid solutions are available to correct hypovolemia. Some of them have been implicated in impairment of renal function. Infusion of large amounts of sodium chloride is associated with increased incidence of nausea, vomiting and hyperchloremic metabolic acidosis. While gelatins and HES are preferred colloids in patients with normal kidney function, there is some evidence that the latter are associated with impaired renal function in patients with pre-existing kidney disease. Any hyperoncotic colloid given in large amounts may decrease glomerular filtration, and should therefore be combined with crystalloids.
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Affiliation(s)
- S M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, Bern, Switzerland.
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20
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Huang L, Zhou X, Yu H. Balanced crystalloids vs 0.9% saline for adult patients undergoing non-renal surgery: A meta-analysis. Int J Surg 2018; 51:1-9. [PMID: 29339230 DOI: 10.1016/j.ijsu.2018.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid maintenance and resuscitation is an important strategy during major surgeries. There has been a debate on the choice of crystalloids over the past decades. 0.9% saline (normal saline) is more likely to cause hyperchloremic acidosis when compared to balanced crystalloids with low chloride content. Meta-analyses comparing these two kinds of crystalloids have been performed in renal transplantations. We aim to compare the safety of balanced crystalloids to normal saline among adult patients undergoing non-renal surgery. METHODS Relevant articles were searched through PubMed, Embase and the Cochrane Library. Nine randomized controlled trials (including 871 participants) comparing balanced crystalloids to normal saline on adult patients undergoing non-renal surgery were finally included. Possible effects were calculated using meta-analysis. RESULTS Patients in the normal saline group had significantly lower postoperative pH (MD: 0.05; 95% CI: 0.04-0.06; p < .001; I2 = 82%) and base excess (MD: 2.04; 95% CI: 1.44-2.65; p < .001; I2 = 87%). The postoperative serum chloride level was significantly higher in the normal saline group (MD: -4.79; 95% CI: -8.13∼-1.45; p = .005; I2 = 95%). CONCLUSION Comparing to normal saline, balanced crystalloids are more beneficial in keeping postoperative electrolytes and acid-base balance among adult patients undergoing non-renal surgery. Future researches should pay more attention to meaningful clinical outcomes concerning the safety of balanced crystalloids and normal saline.
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Affiliation(s)
- Lili Huang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, PR China.
| | - Xiaoshuang Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, PR China.
| | - Hai Yu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, PR China.
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21
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Abstract
The survival of a child with severe volume depletion at the emergency department depends on the competency of the first responder to recognize and promptly treat hypovolemic shock. Although the basic principles on fluid and electrolytes therapy have been investigated for decades, the topic remains a challenge, as consensus on clinical management protocol is difficult to reach, and more adverse events are reported from fluid administration than for any other drug. While the old principles proposed by Holliday and Segar, and Finberg have stood the test of time, recent systematic reviews and meta-analyses have highlighted the risk of hyponatraemia, and hyponatraemic encephalopathy in some children treated with hypotonic fluids. In the midst of conflicting literature on fluid and electrolytes therapy, it would appear that isotonic fluids are best suitable for the correction of hypotonic, isonatraemic, and hypernatraemic dehydration. Although oral rehydration therapy is adequate to correct mild to moderate isonatraemic dehydration, parenteral fluid therapy is safer for the child with severe dehydration and those with changes in serum sodium. The article reviews the pathophysiology of water and sodium metabolism and, it uses the clinical case examples to illustrate the bed-side approach to the management of three different types of dehydration using a pre-mixed isotonic fluid solution (with 20 or 40 mmol/L of potassium chloride added depending on the absence or presence of hypokalemia, respectively). When 3% sodium chloride is unavailable to treat hyponatraemic encephalopathy, 0.9% sodium chloride becomes inevitable, albeit, a closer monitoring of serum sodium is required. The importance of a keen and regular clinical and laboratory monitoring of a child being rehydrated is emphasized. The article would be valuable to clinicians in less-developed countries, who must use pre-mixed fluids, and who often cannot get some suitable rehydrating solutions.
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Affiliation(s)
- Emmanuel Ademola Anigilaje
- Nephrology Unit, Department of Paediatrics, College of Health Sciences, University of Abuja, Abuja, Nigeria
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22
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Hassan MH, Hassan WMNW, Zaini RHM, Shukeri WFWM, Abidin HZ, Eu CS. Balanced Fluid Versus Saline-Based Fluid in Post-operative Severe Traumatic Brain Injury Patients: Acid-Base and Electrolytes Assessment. Malays J Med Sci 2017; 24:83-93. [PMID: 29386975 DOI: 10.21315/mjms2017.24.5.9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/22/2017] [Indexed: 01/17/2023] Open
Abstract
Background Normal saline (NS) is a common fluid of choice in neurosurgery and neuro-intensive care unit (ICU), but it does not contain other electrolytes and has the potential to cause hyperchloremic metabolic acidosis with prolonged infusion. These problems may be reduced with the availability of balanced fluid (BF), which becomes a more physiological isotonic solution with the presence of complete electrolyte content. This study aimed to compare the changes in electrolytes and acid-base between NS and BF (Sterofundin® ISO) therapy for post-operative severe traumatic brain injury (TBI) patients in neuro-ICU. Methods Sixty-six severe TBI patients who required emergency craniotomy or craniectomy and were planned for post-operative ventilation were randomised into NS (n = 33) and BF therapy groups (n = 33). The calculation of maintenance fluid given was based on the Holliday-Segar method. The electrolytes and acid-base parameters were assessed at an 8 h interval for 24 h. The data were analysed using repeated measures ANOVA. Results The NS group showed a significant lower base excess (-3.20 versus -1.35, P = 0.049), lower bicarbonate level (22.03 versus 23.48 mmol/L, P = 0.031), and more hyperchloremia (115.12 versus 111.74 mmol/L, P < 0.001) and hypokalemia (3.36 versus 3.70 mmol/L, P < 0.001) than the BF group at 24 h of therapy. The BF group showed a significantly higher level of calcium (1.97 versus 1.79 mmol/L, P = 0.003) and magnesium (0.94 versus 0.80 mmol/L, P < 0.001) than the NS group at 24 h of fluid therapy. No significant differences were found in pH, pCO2, lactate, and sodium level. Conclusion BF therapy showed better effects in maintaining higher electrolyte parameters and reducing the trend toward hyperchloremic metabolic acidosis than the NS therapy during prolonged fluid therapy for postoperative TBI patients.
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Affiliation(s)
- Mohamad Hasyizan Hassan
- Department of Neurosciences, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Rhendra Hardy Mohd Zaini
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Fadzlina Wan Muhd Shukeri
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Huda Zainal Abidin
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Chong Soon Eu
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.,Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Bertam, Pulau Pinang, Malaysia
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23
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Yoshino O, Perini MV, Christophi C, Weinberg L. Perioperative fluid management in major hepatic resection: an integrative review. Hepatobiliary Pancreat Dis Int 2017; 16:458-469. [PMID: 28992877 DOI: 10.1016/s1499-3872(17)60055-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 04/10/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms "surgery", "anesthesia", "starch", "hydroxyethyl starch derivatives", "albumin", "gelatin", "liver resection", "hepatic resection", "fluids", "fluid therapy", "crystalloid", "colloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "acetate", and "lactate". Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed. CONCLUSIONS Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.
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Affiliation(s)
- Osamu Yoshino
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia.
| | - Marcos Vinicius Perini
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia; Anaesthesia Perioperative Pain Medicine Unit, University of Melbourne, Melbourne, Victoria, Australia
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Bampoe S, Odor PM, Dushianthan A, Bennett‐Guerrero E, Cro S, Gan TJ, Grocott MPW, James MFM, Mythen MG, O'Malley CMN, Roche AM, Rowan K, Burdett E. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures. Cochrane Database Syst Rev 2017; 9:CD004089. [PMID: 28933805 PMCID: PMC6483610 DOI: 10.1002/14651858.cd004089.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Perioperative fluid strategies influence clinical outcomes following major surgery. Many intravenous fluid preparations are based on simple solutions, such as normal saline, that feature an electrolyte composition that differs from that of physiological plasma. Buffered fluids have a theoretical advantage of containing a substrate that acts to maintain the body's acid-base status - typically a bicarbonate or a bicarbonate precursor such as maleate, gluconate, lactate, or acetate. Buffered fluids also provide additional electrolytes, including potassium, magnesium, and calcium, more closely matching the electrolyte balance of plasma. The putative benefits of buffered fluids have been compared with those of non-buffered fluids in the context of clinical studies conducted during the perioperative period. This review was published in 2012, and was updated in 2017. OBJECTIVES To review effects of perioperative intravenous administration of buffered versus non-buffered fluids for plasma volume expansion or maintenance, or both, on clinical outcomes in adults undergoing all types of surgery. SEARCH METHODS We electronically searched the Clinicaltrials.gov major trials registry, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 6) in the Cochrane Library, MEDLINE (1966 to June 2016), Embase (1980 to June 2016), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to June 2016). We handsearched conference abstracts and, when possible, contacted leaders in the field. We reran the search in May 2017. We added one potential new study of interest to the list of 'Studies awaiting classification' and will incorporate this trial into formal review findings when we prepare the review update. SELECTION CRITERIA Only randomized controlled trials that compared buffered versus non-buffered intravenous fluids for surgical patients were eligible for inclusion. We excluded other forms of comparison such as crystalloids versus colloids and colloids versus different colloids. DATA COLLECTION AND ANALYSIS Two review authors screened references for eligibility, extracted data, and assessed risks of bias. We resolved disagreements by discussion and consensus, in collaboration with a third review author. We contacted trial authors to request additional information when appropriate. We presented pooled estimates for dichotomous outcomes as odds ratios (ORs) and for continuous outcomes as mean differences (MDs), with 95% confidence intervals (CIs). We analysed data via Review Manager 5.3 using fixed-effect models, and when heterogeneity was high (I² > 40%), we used random-effects models. MAIN RESULTS This review includes, in total, 19 publications of 18 randomized controlled trials with a total of 1096 participants. We incorporated five of those 19 studies (330 participants) after the June 2016 update. Outcome measures in the included studies were thematically similar, covering perioperative electrolyte status, renal function, and acid-base status; however, we found significant clinical and statistical heterogeneity among the included studies. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Trial authors variably reported outcome data at disparate time points and with heterogeneous patient groups. Consequently, many outcome measures are reported in small group sizes, reducing overall confidence in effect size, despite relatively low inherent bias in the included studies. Several studies reported orphan outcome measures. We did not include in the results of this review one large, ongoing study of saline versus Ringer's solution.We found insufficient evidence on effects of fluid therapies on mortality and postoperative organ dysfunction (defined as renal insufficiency leading to renal replacement therapy); confidence intervals were wide and included both clinically relevant benefit and harm: mortality (Peto OR 1.85, 95% CI 0.37 to 9.33; I² = 0%; 3 trials, 6 deaths, 276 participants; low-quality evidence); renal insufficiency (OR 0.82, 95% CI 0.34 to 1.98; I² = 0%; 4 trials, 22 events, 276 participants; low-quality evidence).We noted several metabolic differences, including a difference in postoperative pH measured at end of surgery of 0.05 units - lower in the non-buffered fluid group (12 studies with a total of 720 participants; 95% CI 0.04 to 0.07; I² = 61%). However, this difference was not maintained on postoperative day one. We rated the quality of evidence for this outcome as moderate. We observed a higher postoperative serum chloride level immediately after operation, with use of non-buffered fluids reported in 10 studies with a total of 530 participants (MD 6.77 mmol/L, 95% CI 3.38 to 10.17), and this difference persisted until day one postoperatively (five studies with a total of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). We rated the quality of evidence for this outcome as moderate. AUTHORS' CONCLUSIONS Current evidence is insufficient to show effects of perioperative administration of buffered versus non-buffered crystalloid fluids on mortality and organ system function in adult patients following surgery. Benefits of buffered fluid were measurable in biochemical terms, particularly a significant reduction in postoperative hyperchloraemia and metabolic acidosis. Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Larger studies are needed to assess these relevant clinical outcomes.
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Affiliation(s)
- Sohail Bampoe
- University College LondonCentre for Anaesthesia and Perioperative MedicineLondonUKNW1 2BU
| | - Peter M Odor
- University College LondonDepartment Anaesthesia and Critical Care235 Euston Rd, FitzroviaLondonUKNW1 2BU
| | - Ahilanandan Dushianthan
- University Hospital Southampton NHS Foundation TrustGeneral Intensive Care UnitTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Elliott Bennett‐Guerrero
- Stony Brook MedicineDepartment of AnesthesiologyHealth Science Tower, Level 4 (Rm 060)Stony BrookNYUSA
| | - Suzie Cro
- Medical Research Council Clinical Trials Unit222 Euston RoadLondonUKNW1 2DA
| | - Tong J Gan
- Stony Brook MedicineDepartment of AnesthesiologyHealth Science Tower, Level 4 (Rm 060)Stony BrookNYUSA
| | - Michael PW Grocott
- Faculty of Medicine, University of SouthamptonCritical Care Group, Clinical and Experimental SciencesTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Michael FM James
- University of Cape TownDepartment of AnaesthesiaAnzio RoadObservatory 7925Cape TownWestern CapeSouth Africa7925
| | - Michael G Mythen
- University College LondonDepartment Anaesthesia and Critical Care235 Euston Rd, FitzroviaLondonUKNW1 2BU
| | | | - Anthony M Roche
- University of WashingtonDepartment of Anesthesiology and Pain MedicineBox 359724SeattleWAUSA98104
| | - Kathy Rowan
- Intensive Care National Audit & Research CentreNapier House24 High HolbornLondonUKWC1V 6AZ
| | - Edward Burdett
- UCL Centre for AnaesthesiaDepartment of Anaesthesia3rd floor PodiumUniversity College Hospital, 235 Euston RoadLondonUKNW1 2BU
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Serpa Neto A, Martin Loeches I, Klanderman RB, Freitas Silva R, Gama de Abreu M, Pelosi P, Schultz MJ. Balanced versus isotonic saline resuscitation-a systematic review and meta-analysis of randomized controlled trials in operation rooms and intensive care units. Ann Transl Med 2017; 5:323. [PMID: 28861420 DOI: 10.21037/atm.2017.07.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Fluid resuscitation is the cornerstone in treatment of shock, and intravenous fluid administration is the most frequent intervention in operation rooms and intensive care units (ICUs). The composition of fluids used for fluid resuscitation gained interest over the past decade, with recent focus on whether balanced solutions should be preferred over isotonic saline. METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing fluid resuscitation with a balanced solution versus isotonic saline in adult patients in operation room or ICUs. Primary outcome was in-hospital mortality, secondary outcomes included occurrence of acute kidney injury (AKI) and need for renal replacement therapy (RRT). RESULTS The search identified 11 RCTs involving 2,703 patients; 8 trials were conducted in operation room and 3 in ICU. In-hospital mortality, as well as the occurrence of AKI and need for RRT was not different between resuscitation with balanced solutions versus isotonic saline, neither in operation room nor in ICU patients. Serum chloride levels, but not arterial pH, were significantly lower in patients resuscitated with balanced solutions. CONCLUSIONS Currently evidence insufficiently supports the use of balanced over isotonic saline for fluid resuscitation to improve outcome of operation room and ICU patients.
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Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ignacio Martin Loeches
- Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Robert B Klanderman
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Pagel JI, Hulde N, Kammerer T, Schwarz M, Chappell D, Burges A, Hofmann-Kiefer K, Rehm M. The impact of phosphate-balanced crystalloid infusion on acid-base homeostasis (PALANCE study): study protocol for a randomized controlled trial. Trials 2017; 18:313. [PMID: 28693594 PMCID: PMC5504754 DOI: 10.1186/s13063-017-2051-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 06/13/2017] [Indexed: 11/16/2022] Open
Abstract
Background This study aims to investigate the effects of a modified, balanced crystalloid including phosphate in a perioperative setting in order to maintain a stable electrolyte and acid-base homeostasis in the patient. Methods/design This is a single-centre, open-label, randomized controlled trial involving two parallel groups of female patients comparing a perioperative infusion regime with sodium glycerophosphate and Jonosteril® (treatment group) or Jonosteril® (comparator) alone. The primary endpoint is to maintain a stable concentration of weak acids [A-] according to the Stewart approach of acid-base balance. Secondary endpoints are measurement of serum phosphate levels, other acid-base parameters such as the strong ion difference (SID), the onset and severity of postoperative nausea and vomiting (PONV), electrolyte levels and their excretion in the urine, monitoring of renal function and glycocalyx components, haemodynamics, amounts of catecholamines and other vasopressors used and the safety of the infusion regime. Discussion Perioperative fluid replacement with the use of currently available crystalloid preparations still fail to maintain a stable acid-base balance and experts agree that common balanced solutions are still not ideal. This study aims to investigate the effectivity and safety of a new crystalloid solution by adding sodium glycerophosphate to a standardized crystalloid preparation in order to maintain a balanced perioperative acid-base homeostasis. Trial registration EudraCT number 201002422520. Registered on 30 November 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2051-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Judith-Irina Pagel
- Department of Anaesthesiology, Hospital of the University of Munich LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | - Nikolai Hulde
- Department of Anaesthesiology, Hospital of the University of Munich LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, Hospital of the University of Munich LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Michaela Schwarz
- Department of Anaesthesiology, Surgical Clinic of Munich-Bogenhausen, Munich, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, Hospital of the University of Munich LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Alexander Burges
- Department of Gynaecology, Hospital of the University of Munich, LMU, Munich, Germany
| | - Klaus Hofmann-Kiefer
- Department of Anaesthesiology, Hospital of the University of Munich LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Markus Rehm
- Department of Anaesthesiology, Hospital of the University of Munich LMU, Marchioninistr. 15, 81377, Munich, Germany
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Corrêa TD, Cavalcanti AB, Assunção MSCD. Balanced crystalloids for septic shock resuscitation. Rev Bras Ter Intensiva 2017; 28:463-471. [PMID: 28099643 PMCID: PMC5225922 DOI: 10.5935/0103-507x.20160079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/08/2016] [Indexed: 01/14/2023] Open
Abstract
Timely fluid administration is crucial to maintain tissue perfusion in septic
shock patients. However, the question concerning which fluid should be used for
septic shock resuscitation remains a matter of debate. A growing body of
evidence suggests that the type, amount and timing of fluid administration
during the course of sepsis may affect patient outcomes. Crystalloids have been
recommended as the first-line fluids for septic shock resuscitation.
Nevertheless, given the inconclusive nature of the available literature, no
definitive recommendations about the most appropriate crystalloid solution can
be made. Resuscitation of septic and non-septic critically ill patients with
unbalanced crystalloids, mainly 0.9% saline, has been associated with a higher
incidence of acid-base balance and electrolyte disorders and might be associated
with a higher incidence of acute kidney injury. This can result in greater
demand for renal replacement therapy and increased mortality. Balanced
crystalloids have been proposed as an alternative to unbalanced solutions in
order to mitigate their detrimental effects. Nevertheless, the safety and
effectiveness of balanced crystalloids for septic shock resuscitation need to be
further addressed in a well-designed, multicenter, pragmatic, randomized
controlled trial.
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Affiliation(s)
- Thiago Domingos Corrêa
- Unidade de Terapia Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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Ali JM, Catarino P, Dunning J, Giele H, Vrakas G, Parmar J. Could Sentinel Skin Transplants Have Some Utility in Solid Organ Transplantation? Transplant Proc. 2017;48:2565-2570. [PMID: 27788782 DOI: 10.1016/j.transproceed.2017.06.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/16/2017] [Indexed: 01/07/2023]
Abstract
Accurate diagnosis of allograft rejection can be hazardous and challenging. A strategy that has emerged from experience with vascularized composite allografts (VCAs) is the use of sentinel skin transplants (SSTs)-portions of donor skin transplanted synchronously to an allograft. Work in nonhuman animal models and experience with VCAs suggest concordance between rejection occurring in the primary allograft and the SST, and that appearance of rejection in the SST may precede rejection in the primary allograft, permitting early therapeutic intervention that may improve outcomes with lower rates of chronic rejection. The encouraging findings reported in VCA transplantation raise the possibility that SST may also be useful in solid organ transplantation. Some evidence is provided by experience with abdominal wall transplantation in some intestinal and multivisceral transplant recipients. Results from those reports raise the possibility that rejection may manifest in the skin component before emergence in the intestinal allograft, providing a "lead time" during which treatment of rejection of the abdominal wall could prevent the emergence of intestinal rejection. It is plausible that these findings may be extrapolated to other solid organ allografts, especially those for which obtaining an accurate diagnosis of acute rejection can be hazardous and challenging, such as the lung or pancreas. However, more data are required to support widespread adoption of this technique.
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Uña Orejón R, Gisbert de la Cuadra L, Garríguez Pérez D, Díez Sebastián J, Ureta Tolsada MP. Maintenance fluid therapy in a tertiary hospital: A prevalence study. Rev Esp Anestesiol Reanim 2017; 64:306-312. [PMID: 28214096 DOI: 10.1016/j.redar.2016.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the types of maintenance fluids used in our hospital, comparing their volume and composition to the standards recommended by the guidelines. MATERIAL AND METHODS Observational, cross-sectional study. Volume and type of fluid therapy administered during 24h to patients admitted to various hospital departments were recorded. Patients receiving fluid therapy because of water-electrolyte imbalance were excluded. RESULTS Out of 198 patients registered, 74 (37.4%) were excluded because they did not meet the criteria for inclusion. Mean administered volume was 2,500cc/day. Mean daily glucose dose was 36g per 24h (SD: 31.4). The most frequent combination included normal saline solution (NSS) and glucose 5% (64.4%). Mean daily dose of sodium and chlorine was, respectively, 173mEq (SD: 74.8) and 168mEq (SD: 75), representing a surplus daily dose of +87.4mEq and +85mEq. Potassium, magnesium and calcium daily deficit was, respectively, -50mEq, -22mEq and -21mEq per day. Buffer administration was exceptional, bicarbonate (2.29%), acetate (1.29%), lactate (1.15%) and gluconate (1.10%) being the buffering agents most frequently used. CONCLUSION NNS is the most frequently used solution. In contrast to excess doses of sodium and chlorine, there is a great deficit of other ions, buffering agents and caloric intake in the fluid therapy regimens that are usually prescribed.
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Affiliation(s)
- R Uña Orejón
- Sección de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España.
| | | | - D Garríguez Pérez
- Sección de Anestesiología y Reanimación, Universidad Autónoma de Madrid, Madrid, España
| | - J Díez Sebastián
- Servicio de Medicina Preventiva, Hospital Universitario La Paz, Madrid, España
| | - M P Ureta Tolsada
- Sección de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
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Spoelstra–de Man AME, Smorenberg A, Groeneveld ABJ. Different effects of fluid loading with saline, gelatine, hydroxyethyl starch or albumin solutions on acid-base status in the critically ill. PLoS One 2017; 12:e0174507. [PMID: 28380062 PMCID: PMC5381890 DOI: 10.1371/journal.pone.0174507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 03/01/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction Fluid administration in critically ill patients may affect acid-base balance. However, the effect of the fluid type used for resuscitation on acid-base balance remains controversial. Methods We studied the effect of fluid resuscitation of normal saline and the colloids gelatine 4%, hydroxyethyl starch (HES) 6%, and albumin 5% on acid-base balance in 115 clinically hypovolemic critically ill patients during a 90 minute filling pressure-guided fluid challenge by a post-hoc analysis of a prospective randomized clinical trial. Results About 1700 mL was infused per patient in the saline and 1500 mL in each of the colloid groups (P<0.001). Overall, fluid loading slightly decreased pH (P<0.001) and there was no intergroup difference. This mildly metabolic acidifying effect was caused by a small increase in chloride concentration and decrease in strong ion difference in the saline- and HES-, and an increase in (uncorrected) anion gap in gelatine- and albumin-loaded patients, independent of lactate concentrations. Conclusion In clinically hypovolemic, critically ill patients, fluid resuscitation by only 1500–1700 mL of normal saline, gelatine, HES or albumin, resulted in a small decrease in pH, irrespective of the type of fluid used. Therefore, a progressive metabolic acidosis, even with increased anion gap, should not be erroneously attributed to insufficient fluid resuscitation. Trial registration ISRCTN Registry ISRCTN19023197
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Affiliation(s)
| | - Annemieke Smorenberg
- Department of Internal Medicine, Ziekenhuis Amstelland, Amstelveen, The Netherlands
- * E-mail:
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Abstract
AIM We aimed to determine whether using a balanced salt solution, Hartmann's solution (HS), in diabetic ketoacidosis (DKA) shortens the time to normalise acid-base status through the avoidance of hyperchloremic metabolic acidosis compared with 0.9% normal saline (NS). METHODS We conducted a double-blind, randomised controlled trial comparing HS to NS as the initial intravenous fluid in children with DKA. Patients were stratified by severity (pH < 7.1) and known or new diabetes. Electrolytes, venous blood gases and glucose were measured every 2 h until intravenous fluids were ceased. The primary outcome was the time for the plasma bicarbonate to reach 15 mmol/L. Secondary outcomes included time to normalise pH (7.3), time to receive subcutaneous (SC) insulin, change in sodium and insulin requirement. RESULTS A total of 77 children were enrolled. The groups were similar at baseline. There was no difference in the time to reach a bicarbonate of 15 mmol/L: geometric mean (SD) 8.6 (2.3) h for NS versus 6.2 (4.7) h for HS, ratio 1.4 (95% confidence interval 0.8-2.5), and no difference in time to normalise pH: NS 8.5 (2.3) h versus HS group 7.5 (1.8) h, ratio 1.1 (0.8-1.6). Kaplan-Meier survival estimates showed shorter times for these end-points in the severe subgroup: log-rank test P = 0.0277 and 0.0024, respectively. There was no difference in time to SC insulin, NS: 15.2 (2.4) h versus HS 14.3 (1.6) h, ratio 1.1 (0.8-1.5). Patients treated with HS received significantly less total fluids/kg. CONCLUSIONS HS is an acceptable alternative to NS in DKA and may benefit those with severe DKA.
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Affiliation(s)
- Michael Yung
- Department of Paediatric Critical Care, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Georgia Letton
- Department of Paediatric Critical Care, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Steve Keeley
- Department of Paediatric Critical Care, Women's and Children's Hospital, Adelaide, South Australia, Australia
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Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med 2016; 5:235-250. [PMID: 27896148 PMCID: PMC5109922 DOI: 10.5492/wjccm.v5.i4.235] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 07/06/2016] [Accepted: 10/09/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative medicine.
METHODS We performed an electronic literature search from Medline and PubMed (via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: “surgery”, “anaesthesia”, “anesthesia”, “anesthesiology”, “anaesthesiology”, “fluids”, “fluid therapy”, “crystalloid”, “saline”, “plasma-Lyte”, “plasmalyte”, “hartmann’s”, “ringers”“acetate”, “gluconate”, “malate”, “lactate”. All relevant articles were accessed in full. We summarized the data and reported the data in tables and text.
RESULTS We retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and text.
CONCLUSION Plasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of Plasma-Lyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.
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Allen CH, Goldman RD, Bhatt S, Simon HK, Gorelick MH, Spandorfer PR, Spiro DM, Mace SE, Johnson DW, Higginbotham EA, Du H, Smyth BJ, Schermer CR, Goldstein SL. A randomized trial of Plasma-Lyte A and 0.9 % sodium chloride in acute pediatric gastroenteritis. BMC Pediatr 2016; 16:117. [PMID: 27480410 PMCID: PMC4969635 DOI: 10.1186/s12887-016-0652-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 07/19/2016] [Indexed: 01/16/2023] Open
Abstract
Background Compare the efficacy and safety of Plasma-Lyte A (PLA) versus 0.9 % sodium chloride (NaCl) intravenous (IV) fluid replacement in children with moderate to severe dehydration secondary to acute gastroenteritis (AGE). Methods Prospective, randomized, double-blind study conducted at eight pediatric emergency departments (EDs) in the US and Canada (NCT#01234883). The primary outcome measure was serum bicarbonate level at 4 h. Secondary outcomes included safety and tolerability. The hypothesis was that PLA would be superior to 0.9 % NaCl in improvement of 4-h bicarbonate. Patients (n = 100) aged ≥6 months to <11 years with AGE-induced moderate-to-severe dehydration were enrolled. Patients with a baseline bicarbonate level ≤22 mEq/L formed the modified intent to treat (mITT) group. Results At baseline, the treatment groups were comparable except that the PLA group was older. At hour 4, the PLA group had greater increases in serum bicarbonate from baseline than did the 0.9 % NaCl group (mean ± SD at 4 h: 18 ± 3.74 vs 18.0 ± 3.67; change from baseline of 1.6 and 0.0, respectively; P = .004). Both treatment groups received similar fluid volumes. The PLA group had less abdominal pain and better dehydration scores at hour 2 (both P = .03) but not at hour 4 (P = 0.15 and 0.08, respectively). No patient experienced clinically relevant worsening of laboratory findings or physical examination, and hospital admission rates were similar. One patient in each treatment group developed hyponatremia. Four patients developed hyperkalemia (PLA:1, 0.9 % NaCl:3). Conclusion In comparison with 0.9 % NaCl, PLA for rehydration in children with AGE was well tolerated and led to more rapid improvement in serum bicarbonate and dehydration score. Trial registration NCT#01234883 (Registration Date: November 3, 2010). Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0652-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Coburn H Allen
- Department of Pediatrics, Dell Medical School at University of Texas at Austin, 4900 Mueller Blvd, Austin, TX, 78746, USA.
| | - Ran D Goldman
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Seema Bhatt
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Harold K Simon
- Departments of Pediatrics and Emergency Medicine, Emory University/Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Marc H Gorelick
- Pediatric Emergency Medicine, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Philip R Spandorfer
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - David M Spiro
- Pediatric Emergency Services, Oregon Health and Science University, Portland, OR, USA
| | - Sharon E Mace
- Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - David W Johnson
- Departments of Pediatrics, Pharmacology and Physiology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Eric A Higginbotham
- Department of Pediatrics, Dell Medical School at University of Texas at Austin, 4900 Mueller Blvd, Austin, TX, 78746, USA
| | - Hongyan Du
- Research and Development, Baxter Healthcare Corporation, Deerfield, IL, USA
| | | | - Carol R Schermer
- Research and Development, Baxter Healthcare Corporation, Deerfield, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Abstract
For many years there has been a debate about whether crystalloids or colloids should be used for resuscitation. Some years ago, albumin was the gold standard against which all other solutions were compared. This continues to be the case, despite the fact that other solutions are as effective for volume replacement. This paper stresses the need for a proper understanding of the properties of solutions that may influence the choice for volume replacement. Different classes of solutions are discussed in detail, with special reference to their effects on cardiovascular and oxygen transport parameters. Other important properties such as side-effects and effect on coagulation are also considered.
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Pfortmueller CA, Fleischmann E. Acetate-buffered crystalloid fluids: Current knowledge, a systematic review. J Crit Care 2016; 35:96-104. [PMID: 27481742 DOI: 10.1016/j.jcrc.2016.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/24/2016] [Accepted: 05/04/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The concept of fluid resuscitation with balanced solutions containing acetate is relatively new. The knowledge about acetate mostly originates from nephrological research, as acetate was primarily used as a dialysis buffer where much higher doses of acetate are infused. The aim of this review is to give an overview of the advantages and disadvantages of an acetate-buffered crystalloid fluid when compared with other crystalloid infusates. METHODS We report trials with the primary object of comparing an acetate-buffered infusion solute to another crystalloid infusate. A systematic literature search of MEDLINE and the Cochrane Controlled Clinical trials register was conducted to identify suitable studies. RESULTS The search strategy used produced 1205 potential titles. After eliminating doubles, 312 titles and abstracts were screened, and 31 references were retrieved for full-text analysis. A total of 27 scientific studies were included in the study. CONCLUSION Acetate-buffered crystalloid solutes do have a favorable influence on microcirculation. To what extent the acetate-buffered crystalloids influence kidney function is controversially discussed and not yet clear. Metabolic alkalosis did not occur in a single study in humans after an acetate-buffered infusate; potassium levels stayed stable in all studies. Cardiac output and contractility seem to be positively influenced; nonetheless, data on maintenance of a target blood pressure remain inconclusive. Whether acetate-buffered crystalloid fluids lead to lower rates of acute kidney injury and increased survival when compared with normal saline is yet unclear and may depend on the amount of fluid administered.
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Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria.
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria.
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Affiliation(s)
- Ying Wei Yau
- Emergency Medicine Department, National University Hospital, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, Singapore
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Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. DATA SOURCES Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HUMAN DATA SYNTHESIS HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. VETERINARY DATA SYNTHESIS The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. CONCLUSIONS Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.
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Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Galm B, Bagshaw SM. 0.9% Saline or Balanced Crystalloid Fluids for Critically Ill Patients: SPLIT Decision? Am J Kidney Dis 2016; 68:11-4. [PMID: 26896899 DOI: 10.1053/j.ajkd.2016.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
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Abstract
Intravenous fluids are frequently used in paediatrics but have been associated with significant adverse outcomes. Understanding the composition of fluid prescribed and administering an appropriate rate is essential for safe fluid administration, along with regular monitoring. Recent evidence has shown that using an isotonic fluid with a sodium concentration similar to plasma can decrease the risk of hyponatraemia without an increase in adverse effects. This should lead to a change in guidelines: isotonic fluid should now be used as the primary maintenance intravenous fluid given to the majority of children.
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Affiliation(s)
- Sarah McNab
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Smith CA, Gosselin RC, Utter GH, Galante JM, Young JB, Scherer LA, Schermer CR. Does saline resuscitation affect mechanisms of coagulopathy in critically ill trauma patients? An exploratory analysis. Blood Coagul Fibrinolysis. 2015;26:250-254. [PMID: 25803514 DOI: 10.1097/mbc.0000000000000154] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Metabolic acidosis has been implicated in the development of coagulopathy, although the specific mechanisms have not been well characterized. We sought to explore whether resuscitation of injured patients with a balanced crystalloid solution affects coagulation, as measured by endogenous thrombin potential (ETP) and thromboelastography (TEG). We performed an exploratory analysis of a subset of subjects enrolled in a randomized trial comparing the effect of resuscitation with isotonic saline versus Plasma-Lyte A (PLA) on acidosis and electrolyte abnormalities. We collected plasma at admission and 6 h later for subsequent ETP and TEG analysis and compared subjects receiving isotonic saline to those receiving PLA. Among 18 evaluated subjects, baseline characteristics, including ETP and TEG parameters, were similar between the two arms. At 6 h, subjects receiving isotonic saline were more acidemic. At 6 h, there were no differences in ETP parameters between groups; however, TEG results showed the time from initial clot formation to an amplitude of 20 mm (K) was shorter (3.8 ± 2.1 vs. 7.2 ± 2.8 s) and the rapidity of fibrin build-up and cross-linking (α angle) was significantly greater (41 ± 8 vs. 24 ± 15 deg) for the PLA group than in the isotonic saline group. Relative to PLA, isotonic saline does not alter thrombin generation, but isotonic saline and PLA may differentially impact clotting factor availability. The shorter time to reach prespecified clot amplitude and the increased rate of fibrin generation imply faster amplification of clotting factors with PLA without effect on latency time or clot strength.
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Kim MY, Jeon NY, Hyun SK, Kim HT, Cho WH, Park UJ. The Effects of Normal Saline Solution versus Hartmann's Solution on the Acid-base and Electrolytes Status and Renal Function after Kidney Transplantation. Korean J Transplant 2015. [DOI: 10.4285/jkstn.2015.29.4.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Min Young Kim
- Department of Nursing, Ulsan University College of Medicine, Ulsan, Korea
| | - Na Yeon Jeon
- Division of Transplant and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Seul Ki Hyun
- Division of Transplant and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Hyoung Tae Kim
- Division of Transplant and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Won Hyun Cho
- Division of Transplant and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Ui Jun Park
- Division of Transplant and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Abstract
Nearly 2 centuries have passed since the use of intravenous fluid became a foundational component of clinical practice. Despite a steady stream of published investigations on the topic, questions surrounding the choice, dose, timing, targets, and cost-effectiveness of various fluid options remain insufficiently answered. In recent years, 2 of the most debated topics reference the role of albumin in acute care and the safety of normal saline. Although albumin has a place in therapy for specific patient populations, its high cost relative to other fluids makes it a less desirable option for hospitals and health systems with escalating formulary scrutiny. Pharmacists bear responsibility for reconciling this disparity and supporting the rational use of albumin in acute care through a careful evaluation of recently published literature. In parallel, it has become clear that crystalloids should no longer be considered a homogenous class of fluids. The past reliance on normal saline has been questioned due to recent findings of renal dysfunction attributable to the solution's supraphysiologic chloride concentration. These safety concerns with 0.9% sodium chloride may result in a practice shift toward more routine use of "balanced crystalloids," such as lactated Ringer's or Plasma-Lyte, that mimic the composition of extracellular fluid. The purpose of this review is to summarize the evidence regarding these 2 important fluid controversies that are likely to affect hospital pharmacists in the coming decades - the evidence-based use of human albumin and the rising role of balanced salt solutions in clinical practice.
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Affiliation(s)
- Erin N Frazee
- Hospital Pharmacy Services, Mayo Clinic , Rochester, Minnesota
| | - David D Leedahl
- Hospital Pharmacy Services, Sanford Health , Fargo, North Dakota
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota ; Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota
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Wong YC, Lai YY, Tan MH, Tan CS, Wu J, Zeng LZ, Lu J, Moochhala S. Potential biomarker panel for predicting organ dysfunction and acute coagulopathy in a polytrauma porcine model. Shock 2015; 43:157-65. [PMID: 25347751 DOI: 10.1097/SHK.0000000000000279] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traumatic injury remains a major cause of morbidity and mortality worldwide, and patients who survived the initial insult are susceptible to an overwhelming inflammatory dysfunction that will lead to acute coagulopathy of trauma (ACOT) and subsequently multiple organ dysfunction syndrome (MODS). Multiple organ dysfunction syndrome-related scoring systems, although they measure organ dysfunction, present clinical markers, and single-cytokine estimates are unable to predict accurately the events of MODS in the clinical setting to aid risk stratification. In this study, a pig model comprising the lethal triad of trauma was used to determine prognostic patterns of early circulating trauma markers so as to predict the development of MODS and ACOT. We measured early expression of several biomarkers (neutrophil gelatinase-associated protein, high-mobility group box 1, C-reactive protein, tumor necrosis factor-α, heart-type fatty acid binding protein, and D-dimers) and clinical parameters for various organ injuries and abnormalities (creatinine, creatine kinase myocardial band, aspartate aminotransferase, and maximum clot firmness) at later time points. The strength of association between the early expression of several biomarkers to the development of MODS and ACOT in polytraumatized pigs was tested using the Spearman correlation coefficient. These biomarkers were found useful to predict the onset of renal, cardiac, hepatic, and hemostatic abnormalities. The findings show that these biomarkers could help to identify, guide, and streamline damage control surgery and earlier intervention to reverse the detrimental outcomes of MODS and ACOT.
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Shaw AD, Schermer CR, Lobo DN, Munson SH, Khangulov V, Hayashida DK, Kellum JA. Impact of intravenous fluid composition on outcomes in patients with systemic inflammatory response syndrome. Crit Care 2015; 19:334. [PMID: 26370823 PMCID: PMC4570151 DOI: 10.1186/s13054-015-1045-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/21/2015] [Indexed: 01/09/2023]
Abstract
Introduction Intravenous (IV) fluids may be associated with complications not often attributed to fluid type. Fluids with high chloride concentrations such as 0.9 % saline have been associated with adverse outcomes in surgery and critical care. Understanding the association between fluid type and outcomes in general hospitalized patients may inform selection of fluid type in clinical practice. We sought to determine if the type of IV fluid administered to patients with systemic inflammatory response syndrome (SIRS) is associated with outcome. Methods This was a propensity-matched cohort study in hospitalized patients receiving at least 500 mL IV crystalloid within 48 hours of SIRS. Patient data was extracted from a large multi-hospital electronic health record database between January 1, 2009, and March 31, 2013. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay, readmission, and complications measured by ICD-9 coding and clinical definitions. Outcomes were adjusted for illness severity using the Acute Physiology Score. Of the 91,069 patients meeting inclusion criteria, 89,363 (98 %) received 0.9 % saline whereas 1706 (2 %) received a calcium-free balanced solution as the primary fluid. Results There were 3116 well-matched patients, 1558 in each cohort. In comparison with the calcium-free balanced cohort, the saline cohort experienced greater in-hospital mortality (3.27 % vs. 1.03 %, P <0.001), length of stay (4.87 vs. 4.38 days, P = 0.016), frequency of readmission at 60 (13.54 vs. 10.91, P = 0.025) and 90 days (16.56 vs. 12.58, P = 0.002) and frequency of cardiac, infectious, and coagulopathy complications (all P <0.002). Outcomes were defined by administrative coding and clinically were internally consistent. Patients in the saline cohort received more chloride and had electrolyte abnormalities requiring replacement more frequently (P <0.001). No differences were found in acute renal failure. Conclusions In this large electronic health record, the predominant use of 0.9 % saline in patients with SIRS was associated with significantly greater morbidity and mortality compared with predominant use of balanced fluids. The signal is consistent with that reported previously in perioperative and critical care patients. Given the large population of hospitalized patients receiving IV fluids, these differences may confer treatment implications and warrant corroboration via large clinical trials. Trial registration NCT02083198 clinicaltrials.gov; March 5, 2014 Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1045-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrew D Shaw
- Dept of Anesthesiology, Vanderbilt University Medical Center, 1215 21st Avenue S., Suite 5160 MCE NT, Office 5163, Campus Box 8274, Nashville, TN, 37232-8274, USA.
| | - Carol R Schermer
- Former Employee Baxter Healthcare Corporation, 1 Baxter Parkway, Deerfield, IL, 60015, USA.
| | - Dileep 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, Derby Road, Nottingham, NG7 2UH, UK.
| | - Sibyl H Munson
- Boston Strategic Partners, Inc., 4 Wellington Street, Boston, MA, 02118, USA.
| | - Victor Khangulov
- Boston Strategic Partners, Inc., 4 Wellington Street, Boston, MA, 02118, USA.
| | - David K Hayashida
- Boston Strategic Partners, Inc., 4 Wellington Street, Boston, MA, 02118, USA.
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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Trujillo-zea JA, Aristizábal-henao N, Fonseca-ruiz N. Lactato de Ringer versus solución salina normal para trasplante renal. Revisión sistemática y metaanálisis. ACTA ACUST UNITED AC 2015; 43:194-203. [DOI: 10.1016/j.rca.2015.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Trujillo-Zea JA, Aristizábal-Henao N, Fonseca-Ruiz N. Lactated Ringer's vs. normal saline solution for renal transplantation: Systematic review and meta-analysis. Colombian Journal of Anesthesiology 2015. [DOI: 10.1016/j.rcae.2015.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Song JW, Shim JK, Kim NY, Jang J, Kwak YL. The effect of 0.9% saline versus plasmalyte on coagulation in patients undergoing lumbar spinal surgery; a randomized controlled trial. Int J Surg 2015; 20:128-34. [PMID: 26123384 DOI: 10.1016/j.ijsu.2015.06.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/05/2015] [Accepted: 06/15/2015] [Indexed: 01/12/2023]
Abstract
INTRODUCTION In multi-level lumbar spinal fusion surgery yielding a large amount of blood loss, choice of fluid for volume resuscitation is an important issue since it can influence acid-base status, coagulation, and patients' outcome. This study compared the effect of plasmalyte to 0.9% saline on coagulation assessed by rotation thromboelastometry (ROTEM) and acid-base balance in the aforementioned patients. METHODS Fifty patients were randomly allocated to receive either 0.9% saline or plasmalyte during operation and until postoperative 12 h. ROTEM was performed at 10 min after anesthetic induction and end of surgery. Arterial blood gas analyses were serially performed from 10 min after anesthetic induction until postoperative 12 h. Fluid balance, blood loss, and transfusion requirement were assessed. RESULTS ROTEM variables showed sporadic deterioration in both groups after surgery without intergroup differences. Intraoperatively, arterial pH, base excess, and bicarbonate concentrations were lower and serum chloride concentrations were higher in the 0.9% saline group compared with the plasmalyte group. The differences in base excess and bicarbonate concentrations persisted until postoperative 12 h. Fluid balance, blood loss, and transfusion requirement were similar between the groups while urine output was greater in the plasmalyte group compared with the 0.9% saline group (3.2 ± 1.6 ml/kg/h vs. 1.8 ± 1.1 ml/kg/h, p = 0.001). CONCLUSION In contrast to plasmalyte, fluid therapy with 0.9% saline resulted in transient hyperchloremic acidosis in patients undergoing multi-level lumbar spinal fusion, while coagulation assessed by ROTEM analysis and the amount of blood loss were similar between the groups.
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Affiliation(s)
- Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Jaewon Jang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
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Severs D, Rookmaaker MB, Hoorn EJ. Intravenous solutions in the care of patients with volume depletion and electrolyte abnormalities. Am J Kidney Dis 2015; 66:147-53. [PMID: 25921718 DOI: 10.1053/j.ajkd.2015.01.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 01/05/2015] [Indexed: 01/28/2023]
Abstract
Infusion fluids are often given to restore blood pressure (volume resuscitation), but may also be administered to replace ongoing losses, match insensible losses, correct electrolyte or acid-base disorders, or provide glucose. The development of new infusion fluids has provided clinicians with a wide range of products. Although the choice for a certain infusion fluid is often driven more by habit than by careful consideration, we believe it is useful to approach infusion fluids as drugs and consider their pharmacokinetic and pharmacodynamic characteristics. This approach not only explains why infusion fluids may cause electrolyte and acid-base disturbances, but also why they may compromise kidney function or coagulation. In this teaching case, we present a 19-year-old patient in whom severe hypernatremia developed as a result of normal saline solution infusion and explore the pharmacokinetic and pharmacodynamic effects of frequently used infusion fluids. We review clinical evidence to guide the selection of the optimal infusion fluid.
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Affiliation(s)
- David Severs
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Maarten B Rookmaaker
- Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, the Netherlands
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Klemz K, Ho L, Bellomo R. Daily Intravenous Chloride Load and the Acid-Base and Biochemical Status of Intensive Care Unit Patients. Journal of Pharmacy Practice and Research 2015. [DOI: 10.1002/j.2055-2335.2008.tb00393.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Katja Klemz
- Ernst-Moritz-Arndt University; Greifswald Germany
| | - Lisa Ho
- Intensive Care Department; Austin Hospital; Heidelberg Victoria
| | - Rinaldo Bellomo
- Intensive Care Department; Austin Hospital; Heidelberg Victoria
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Trujillo-zea JA, Aristizábal-henao N, Fonseca-ruiz N. Lactated Ringerʼs vs. normal saline solution for renal transplantation: Systematic review and meta-analysis☆. Colombian Journal of Anesthesiology 2015; 43:194-203. [DOI: 10.1097/01819236-201543030-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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