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Çekmen N, Uslu A. Anaesthesia management for liver transplantation: A narrative review. J Perioper Pract 2023:17504589231193551. [PMID: 37970678 DOI: 10.1177/17504589231193551] [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] [Indexed: 11/17/2023]
Abstract
Orthotopic liver transplantation is the definitive standard treatment for end-stage liver disease. Orthotopic liver transplantation anaesthesia management is a complex procedure that requires a multidisciplinary team approach. Understanding the complex pathophysiology of end-stage liver disease and its complications in the affected systems is essential for proper anaesthesia management in orthotopic liver transplantation. Orthotopic liver transplantation is a dynamic process, and preoperative optimisation is essential in these patients. Therefore, anaesthesiologists should focus on rapidly fluctuating physiology, haemodynamics, metabolic, and coagulation status in the anaesthesia management of these patients. Perioperative care and anaesthesia for orthotopic liver transplantation can be divided into preoperative evaluation, anaesthesia induction and management, dissection, anhepatic, neo-hepatic, and postoperative care, with essential anaesthetic considerations at each point. Considering the clinical situation, haemodynamic changes, misapplications, knowledge, attitude, and multimodal and multidisciplinary approach are vital in anaesthesia and the perioperative period. In our review, in line with the literature, we aimed to present the perioperative and anaesthesia management in orthotopic liver transplantation patients.
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Affiliation(s)
- Nedim Çekmen
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Ahmed Uslu
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Baskent University, Ankara, Turkey
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2
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Abdelhamid BM, Matta M, Rady A, Adel G, Gamal M. Conventional fluid management versus plethysmographic variability index-based goal directed fluid management in patients undergoing spine surgery in the prone position - a randomised control trial. Anaesthesiol Intensive Ther 2023; 55:186-195. [PMID: 37728446 PMCID: PMC10496101 DOI: 10.5114/ait.2023.130792] [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: 12/15/2022] [Accepted: 05/08/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION The plethysmographic variability index (PVI) is a dynamic approach for assessing volume status. This study aims to compare conventional fluid management and PVI based goal-directed fluid management (GDFM) during elective spine surgery in the prone position. MATERIAL AND METHODS Sixty-six adult patients, ASA I-II, scheduled for elective lumbar spine procedures under general anaesthesia in the prone position were included. Patients were randomly divided into either the Conventional Group with the conventional fluid management protocol or the PVI Group with the PVI-based GDFM protocol. The total amount of intraoperative crystalloid administered was set as a primary outcome. Intraoperative PVI and perfusion index (PI), mean arterial pressure (MAP), heart rate (HR), the incidence of hypotension after prone positioning in both groups and data from arterial blood gas samples (immediately after induction of anaesthesia [T1] and immediately postoperatively [T2]) were set as secondary outcomes. RESULTS The total amount of intraoperative crystalloids, blood transfusion, urine output, and fluid balance were similar in the two groups ( P -values 0.443, 0.317 and 0.273, respectively). The perioperative MAP and HR values showed no significant differences between the two groups at all time points of measurements. The values of pH, PaO 2 , PaCO 2 , HCO 3 , lactate and haemoglobin showed no statistically significant difference between the two groups. The blood lactate value at T2 was significantly increased when compared to T1 values in the two groups. CONCLUSIONS PVI dependent goal-directed fluid management (GDFM) therapy did not reduce the intraoperative total crystalloid administration or requirements for blood transfusion when compared to conventional fluid management using a fixed fluid rate in patients undergoing spine surgery in a prone position. Clinical trial registration: The study was registered at clinicaltrials.gov (NCT05239286).
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Affiliation(s)
- Bassant Mohamed Abdelhamid
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
- Department of Anaesthesiology, Armed Forces College of Medicine, Egypt
| | - Marina Matta
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
| | - Ashraf Rady
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
| | - George Adel
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
| | - Medhat Gamal
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
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Pérez-Moreno J, Gutiérrez-Vélez A, Torres Soblechero L, González Martínez F, Toledo Del Castillo B, Vierge Hernán E, Rodríguez-Fernández R. Do we overestimate intravenous fluid therapy needs? Adverse effects related to isotonic solutions during pediatric hospital admissions. Nefrologia 2022; 42:688-695. [PMID: 36907718 DOI: 10.1016/j.nefroe.2023.02.006] [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: 03/04/2020] [Accepted: 06/21/2021] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Maintenance intravenous fluids are frequently used in hospitalised pediatric patients. The aim of the study was to describe the adverse effects of isotonic fluid therapy in hospitalised patients, and its prevalence based on the rate of infusion. MATERIALS AND METHODS A prospective clinical observational study was designed. We included hospitalised patients between 3 months-old and 15-years-old were included with 0,9% isotonic solutions with 5% glucose within the first 24 h of administration. They were divided into two groups, depending on the quantity of liquid they received (restricted <100% vs 100% maintenance needs). Clinical data and laboratory findings were recorded in two different times (T0 when they were admitted to hospital and T1 within the first 24 h of administration). RESULTS The study included 84 patients, 33 received <100% maintenance needs and 51 patients received around 100%. The main adverse effects notified in the first 24 h of administration were hyperchloremia >110 mEq/L (16.6%) and oedema (19%). Oedema was more frequent in patients with lower age (p < 0,01). The hyperchloremia at 24 h of intravenous fluids was an independent risk factor of developing oedema (OR 1,73 (1,0-3,8), p = 0,06). CONCLUSION The use of isotonic fluids is not free from adverse effects, probably related to the rate of infusion and more likely to appear in infants. It`s necessary more studies that review the correct estimation of intravenous fluid needs in hospitalized children.
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Affiliation(s)
- Jimena Pérez-Moreno
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ana Gutiérrez-Vélez
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Torres Soblechero
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe González Martínez
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Blanca Toledo Del Castillo
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Eva Vierge Hernán
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Rodríguez-Fernández
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Walters K, Brearley J, Baptista A, Po E. Suspected pulmonary oedema development in a pig following general anaesthesia and the associated complications encountered during a subsequent general anaesthetic. Vet Record Case Reports 2022. [DOI: 10.1002/vrc2.333] [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: 11/09/2022]
Affiliation(s)
- Kate Walters
- Queen's Veterinary School Hospital University of Cambridge Cambridge UK
| | | | - Andre Baptista
- Cambridge Farm Vets University of Cambridge Cambridge UK
| | - Eleonora Po
- Cambridge Farm Vets University of Cambridge Cambridge UK
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Wang M, Zhu B, Jiang L, Luo X, Wang N, Zhu Y, Xi X. Association between Latent Trajectories of Fluid Balance and Clinical Outcomes in Critically Ill Patients with Acute Kidney Injury: A Prospective Multicenter Observational Study. Kidney Dis (Basel) 2022; 8:82-92. [PMID: 35224009 PMCID: PMC8820145 DOI: 10.1159/000515533] [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] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 02/26/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION We aimed to identify different trajectories of fluid balance (FB) and investigate the effect of FB trajectories on clinical outcomes in intensive care unit (ICU) patients with acute kidney injury (AKI) and the dose-response association between fluid overload (FO) and mortality. METHODS We derived data from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 1,529 critically ill patients with AKI were included. The primary outcome was 28-day mortality, and hospital mortality, ICU mortality and AKI stage were the secondary outcomes. A group-based trajectory model was used to identify the trajectory of FB during the first 7 days. Multivariable logistic regression was performed to examine the relationship between FB trajectories and clinical outcomes. A logistic regression model with restricted cubic splines was used to examine the dose relationship between FO and 28-day mortality. RESULTS Three distinct trajectories of FB were identified: low FB (1,316, 86.1%), decreasing FB (120, 7.8%), and high FB (93, 6.1%). Compared with low FB, high FB was associated with increased 28-day mortality (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.17-3.19) and AKI stage (OR 2.04, 95% CI 1.23-3.37), whereas decreasing FB was associated with a reduction in 28-day mortality by approximately half (OR 0.53, 95% CI 0.32-0.87). Similar results were found for the outcomes of ICU mortality and hospital mortality. We observed a J-shaped relationship between maximum FO and 28-day mortality, with the lowest risk at a maximum FO of 2.8% L/kg. CONCLUSION Different trajectories of FB in critically ill patients with AKI were associated with clinical outcomes. An FB above or below a certain range was associated with an increased risk of mortality. Further studies should explore this relationship and search for the optimal fluid management strategies for critically ill patients with AKI.
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Affiliation(s)
- Meiping Wang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Bo Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Li Jiang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuying Luo
- Department of Critical Care Medicine, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Na Wang
- Emergency Department, China Rehabilitation Research Center, Capital Medical University, Beijing, China
| | - Yibing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
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Pérez-Moreno J, Gutiérrez-Vélez A, Torres Soblechero L, González Martínez F, Toledo del Castillo B, Vierge Hernán E, Rodríguez-Fernández R. ¿Sobreestimamos las necesidades de líquidos? Complicaciones del uso de sueros isotónicos de mantenimiento en plantas de hospitalización pediátrica. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.06.013] [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: 10/20/2022] Open
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7
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Yiew XT, Bateman SW, Hahn RG, Bersenas AME, Muir WW. Understanding Volume Kinetics: The Role of Pharmacokinetic Modeling and Analysis in Fluid Therapy. Front Vet Sci 2020; 7:587106. [PMID: 33330713 PMCID: PMC7714761 DOI: 10.3389/fvets.2020.587106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Fluid therapy is a rapidly evolving yet imprecise clinical practice based upon broad assumptions, species-to-species extrapolations, obsolete experimental evidence, and individual preferences. Although widely recognized as a mainstay therapy in human and veterinary medicine, fluid therapy is not always benign and can cause significant harm through fluid overload, which increases patient morbidity and mortality. As with other pharmaceutical substances, fluids exert physiological effects when introduced into the body and therefore should be considered as "drugs." In human medicine, an innovative adaptation of pharmacokinetic analysis for intravenous fluids known as volume kinetics using serial hemoglobin dilution and urine output has been developed, refined, and investigated extensively for over two decades. Intravenous fluids can now be studied like pharmaceutical drugs, leading to improved understanding of their distribution, elimination, volume effect, efficacy, and half-life (duration of effect) under various physiologic conditions, making evidence-based approaches to fluid therapy possible. This review article introduces the basic concepts of volume kinetics, its current use in human and animal research, as well as its potential and limitations as a research tool for fluid therapy research in veterinary medicine. With limited evidence to support our current fluid administration practices in veterinary medicine, a greater understanding of volume kinetics and body water physiology in veterinary species would ideally provide some evidence-based support for safer and more effective intravenous fluid prescriptions in veterinary patients.
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Affiliation(s)
- Xiu Ting Yiew
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shane W. Bateman
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Robert G. Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden
- Karolinska Institutet, Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Alexa M. E. Bersenas
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - William W. Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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8
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Yiew XT, Bateman SW, Hahn RG, Bersenas AME. Evaluation of the Distribution and Elimination of Balanced Isotonic Crystalloid, 5% Hypertonic Saline, and 6% Tetrastarch 130/0.4 Using Volume Kinetic Modeling and Analysis in Healthy Conscious Cats. Front Vet Sci 2020; 7:587564. [PMID: 33313076 PMCID: PMC7703656 DOI: 10.3389/fvets.2020.587564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
This prospective, randomized, blinded, interventional cross-over study investigated the distribution, elimination, plasma volume expansion, half-life, comparative potency, and ideal fluid prescription of three commonly prescribed intravenous (IV) fluids in 10 healthy conscious cats using volume kinetic analysis that is novel to veterinary medicine. Each cat received 20 mL/kg of balanced isotonic crystalloid (PLA), 3.3 mL/kg of 5% hypertonic saline (HS), and 5 mL/kg of 6% tetrastarch 130/0.4 (HES) over 15 min on separate occasions. Hemoglobin concentration, red blood cell count, hematocrit, heart rate, and blood pressure were measured at baseline, 5, 10, 15, 20, 30, 40, 50, 60, and every 15 min until 180 min. Urine output was estimated every 30 min using point-of-care bladder ultrasonography. Plasma dilution derived from serial hemoglobin concentration and red blood cell count served as input variables for group and individual fluid volume kinetic analyses using a non-linear mixed effects model. In general, the distribution of all IV fluids was rapid, while elimination was slow. The half-lives of PLA, HS, and HES were 49, 319, and 104 min, respectively. The prescribed fluid doses for PLA, HS, and HES resulted in similar peak plasma volume expansion of 27–30%. The potency of HS was 6 times higher than PLA and 1.7 times greater than HES, while HES was 3.5 times more potent than PLA. Simulation of ideal fluid prescriptions to achieve and maintain 15 or 30% plasma volume expansion revealed the importance of a substantial reduction in infusion rates following initial IV fluid bolus. In conclusion, volume kinetic analysis is a feasible research tool that can provide data on IV fluid kinetics and body water physiology in cats. The rapid distribution but slow elimination of IV fluids in healthy conscious cats is consistent with anecdotal reports of fluid overload susceptibility in cats and warrants further investigation.
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Affiliation(s)
- Xiu Ting Yiew
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shane W Bateman
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Robert G Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden.,Karolinska Institutet Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Alexa M E Bersenas
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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9
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Affiliation(s)
- Stefano Romagnoli
- Health Science Department, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Zaccaria Ricci
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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10
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Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, Basu RK, Conway EE, Fehr JJ, Hawkins C, Kaplan RL, Rowe EV, Waseem M, Moritz ML. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics 2018; 142:peds.2018-3083. [PMID: 30478247 DOI: 10.1542/peds.2018-3083] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).
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Affiliation(s)
- Leonard G Feld
- Retired, Nicklaus Children's Health System, Miami, Florida;
| | | | | | - Michael G Leu
- School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Matthew D Garber
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | | | - Rajit K Basu
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Edward E Conway
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Jacobi Medical Center, Bronx, New York
| | - James J Fehr
- Departments of Anesthesiology and Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Clare Hawkins
- Department of Family Medicine, Houston Methodist Hospital, Houston, Texas
| | | | - Echo V Rowe
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and
| | | | - Michael L Moritz
- Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Cesur S, Çardaközü T, Kuş A, Türkyılmaz N, Yavuz Ö. Comparison of conventional fluid management with PVI-based goal-directed fluid management in elective colorectal surgery. J Clin Monit Comput 2018; 33:249-257. [PMID: 29948666 PMCID: PMC6420438 DOI: 10.1007/s10877-018-0163-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 02/06/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I–II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I–II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.
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Affiliation(s)
- Sevim Cesur
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey.
| | - Tülay Çardaközü
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Alparslan Kuş
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Neşe Türkyılmaz
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Ömer Yavuz
- Department of General Surgery, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
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Ramchandran S, Day LM, Line B, Buckland AJ, Passias P, Protopsaltis T, Bendo J, Huncke T, Errico TJ, Bess S. The Impact of Different Intraoperative Fluid Administration Strategies on Postoperative Extubation Following Multilevel Thoracic and Lumbar Spine Surgery: A Propensity Score Matched Analysis. Neurosurgery 2018; 85:31-40. [DOI: 10.1093/neuros/nyy226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 05/01/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Subaraman Ramchandran
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Louis M Day
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Breton Line
- Department of Orthopedic surgery, Rocky Mountain Scoliosis and spine center, Denver, Colorado
| | - Aaron J Buckland
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Peter Passias
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - John Bendo
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Tessa Huncke
- Department of Anesthesiology, NYU Hospital for Joint Diseases, New York, New York
| | - Thomas J Errico
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shay Bess
- Department of Orthopedic surgery, Rocky Mountain Scoliosis and spine center, Denver, Colorado
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Malbrain MLNG, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, Teboul JL, Rice TW, Mythen M, Monnet X. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care 2018; 8:66. [PMID: 29789983 PMCID: PMC5964054 DOI: 10.1186/s13613-018-0402-x] [Citation(s) in RCA: 269] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/23/2018] [Indexed: 02/07/2023] Open
Abstract
In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose and timing of intravenous fluid administration. There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications and for parenteral nutrition. In this paradigm-shifting review, we discuss different fluid management strategies including early adequate goal-directed fluid management, late conservative fluid management and late goal-directed fluid removal. In addition, we expand on the concept of the “four D’s” of fluid therapy, namely drug, dosing, duration and de-escalation. During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase and the evacuation phase. The four questions are “When to start intravenous fluids?”, “When to stop intravenous fluids?”, “When to start de-resuscitation or active fluid removal?” and finally “When to stop de-resuscitation?” In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.
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Affiliation(s)
- Manu L N G Malbrain
- Intensive Care Unit, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium. .,Faculteit Geneeskunde en Farmacie, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Niels Van Regenmortel
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | - Bernd Saugel
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Brecht De Tavernier
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | - Pieter-Jan Van Gaal
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | | | - Jean-Louis Teboul
- Medical Intensive Care Unit, Hopitaux universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicetre, France
| | - Todd W Rice
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Monty Mythen
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Xavier Monnet
- Medical Intensive Care Unit, Hopitaux universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicetre, France
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15
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Codes L, Souza YGD, D’Oliveira RAC, Bastos JLA, Bittencourt PL. Cumulative positive fluid balance is a risk factor for acute kidney injury and requirement for renal replacement therapy after liver transplantation. World J Transplant 2018; 8:44-51. [PMID: 29696105 PMCID: PMC5915376 DOI: 10.5500/wjt.v8.i2.44] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/12/2018] [Accepted: 04/01/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To analyze whether fluid overload is an independent risk factor of adverse outcomes after liver transplantation (LT).
METHODS One hundred and twenty-one patients submitted to LT were retrospectively evaluated. Data regarding perioperative and postoperative variables previously associated with adverse outcomes after LT were reviewed. Cumulative fluid balance (FB) in the first 12 h and 4 d after surgery were compared with major adverse outcomes after LT.
RESULTS Most of the patients were submitted to a liberal approach of fluid administration with a mean cumulative FB over 5 L and 10 L, respectively, in the first 12 h and 4 d after LT. Cumulative FB in 4 d was independently associated with occurrence of both AKI and requirement for renal replacement therapy (RRT) (OR = 2.3; 95%CI: 1.37-3.86, P = 0.02 and OR = 2.89; 95%CI: 1.52-5.49, P = 0.001 respectively). Other variables on multivariate analysis associated with AKI and RRT were, respectively, male sex and Acute Physiology and Chronic Health Disease Classification System (APACHE II) levels and sepsis or septic shock. Mortality was shown to be independently related to AST and APACHE II levels (OR = 2.35; 95%CI: 1.1-5.05, P = 0.02 and 2.63; 95%CI: 1.0-6.87, P = 0.04 respectively), probably reflecting the degree of graft dysfunction and severity of early postoperative course of LT. No effect of FB on mortality after LT was disclosed.
CONCLUSION Cumulative positive FB over 4 d after LT is independently associated with the development of AKI and the requirement of RRT. Survival was not independently related to FB, but to surrogate markers of graft dysfunction and severity of postoperative course of LT.
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Affiliation(s)
- Liana Codes
- Unit of Gastroenterology and Hepatology, Portuguese Hospital of Salvador, Bahia 40140-901, Brazil
| | - Ygor Gomes de Souza
- Unit of Gastroenterology and Hepatology, Portuguese Hospital of Salvador, Bahia 40140-901, Brazil
| | | | | | - Paulo Lisboa Bittencourt
- Unit of Gastroenterology and Hepatology, Portuguese Hospital of Salvador, Bahia 40140-901, Brazil
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16
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Weinberg L, Li MHG, Churilov L, Armellini A, Gibney M, Hewitt T, Tan CO, Robbins R, Tremewen D, Christophi C, Bellomo R. Associations of Fluid Amount, Type, and Balance and Acute Kidney Injury in Patients Undergoing Major Surgery. Anaesth Intensive Care 2018; 46:79-87. [DOI: 10.1177/0310057x1804600112] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Fluid administration has been reported to be associated with an increased risk of acute kidney injury (AKI). We assessed whether, after correction for fluid balance, amount and chloride content of fluids administered have an independent association with AKI. We performed an observational study in patients after major surgery assessing the independent association of AKI with volume, chloride content and fluid balance, after adjustment for Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) score, age, elective versus emergency surgery, and duration of surgery. We studied 542 consecutive patients undergoing major surgery. Of these, 476 patients had renal function tested as part of routine clinical care and 53 patients (11.1%) developed postoperative AKI. After adjustments, a 100 ml greater mean daily fluid balance was artificially associated with a 5% decrease in the instantaneous hazard of AKI: adjusted Hazard Ratio (aHR) 0.951, 95% confidence intervals (CI) 0.935 to 0.967, P <0.001. However, after adjustment for the proportion of chloride-restrictive fluids, mean daily fluid amounts and balances, POSSUM morbidity, age, duration and emergency status of surgery, and the confounding effect of fluid balance, every 5% increase in the proportion of chloride-liberal fluid administered was associated with an 8% increase in the instantaneous hazard of AKI (aHR 1.079, 95% CI 1.032 to 1.128, P=0.001), and a 100 ml increase in mean daily fluid amount given was associated with a 6% increase in the instantaneous hazard of AKI (aHR 1.061, 95% CI 1.047 to 1.075, P <0.001). After adjusting for key risk factors and for the confounding effect of fluid balance, greater fluid administration and greater administration of chloride-rich fluid were associated with greater risk of AKI.
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Affiliation(s)
- L. Weinberg
- Director of Anaesthesia, Austin Hospital, A/Professor, Departments of Surgery and Anaesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria
| | - M. H. G. Li
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria
| | - L. Churilov
- Head, Statistics and Decision Analysis Academic Platform, Florey Institute of Neuroscience & Mental Health; Honorary Professorial Fellow, Florey Department of Neuroscience & Mental Health, The University of Melbourne; Adjunct Professor, Mathematical Sciences, School of Science, RMIT University, Melbourne, Victoria
| | - A. Armellini
- Department of Surgery, University of Melbourne, Melbourne, Victoria
| | - M. Gibney
- Department of Surgery, Austin Health, Melbourne, Victoria
| | - T. Hewitt
- Department of Surgery, Austin Health, Melbourne, Victoria
| | - C. O. Tan
- Department of Anaesthesia, Austin Health, Melbourne, Victoria
| | - R. Robbins
- Senior Data Analyst, Clinical Informatics and Governance Unit, Austin Hospital, Melbourne, Victoria
| | - D. Tremewen
- Deputy Director, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria
| | | | - R. Bellomo
- Head of Research, Department of Intensive Care, Austin Hospital, Professor, The University of Melbourne, Melbourne, Victoria
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17
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Abstract
Fluid resuscitation in the acutely ill must take into consideration numerous elements, including the intravenous solution itself, the phase of resuscitation, and the strategies toward volume management which are paramount. With the advancement in the understanding and implementation of aggressive fluid resuscitation has also come a greater awareness of the resultant fluid toxicity, especially in those that suffer acute kidney injury, and the realization that there is continued ambiguity with regard to volume mitigation and removal in the resuscitated patient. As such, the discussion regarding intravenous solutions continues to evolve especially as it pertains to their effect on kidney and metabolic function, electrolytes, and ultimately patient outcome. In the section below, we review the foundations of fluid resuscitation in the critically ill patient and the different solutions available in this context, including their composition, physiologic properties, and safety and efficacy including the available data regarding "renal-safe" options.
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18
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Abstract
OBJECTIVE Intravenous fluids are broadly categorized into colloids and crystalloids. The aim of this review is to present under a clinical point of view the characteristics of intravenous fluids that make them more or less appropriate either for maintaining hydration when enteral intake is contraindicated or for treating hypovolemia. METHODS We considered randomized trials and meta-analyses as well as narrative reviews evaluating the effects of colloids or crystalloids in patients with hypovolemia or as maintenance fluids published in the PubMed and Cochrane databases. RESULTS Clinical studies have not shown a greater clinical benefit of albumin solutions compared with crystalloid solutions. Furthermore, albumin and colloid solutions may impair renal function, while there is no evidence that the administration of colloids reduces the risk of death compared with resuscitation with crystalloids in patients with trauma, burns or following surgery. Among crystalloids, normal saline is associated with the development of hyperchloremia-induced impairment of kidney function and metabolic acidosis. On the other hand, the other commonly used crystalloid solution, the Ringer's Lactate, has certain indications and contraindications. These matters, along with the basic principles of the administration of potassium chloride and bicarbonate, are meticulously discussed in the review. CONCLUSIONS Intravenous fluids should be dealt with as drugs, as they have specific clinical indications, contraindications and adverse effects.
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Affiliation(s)
- N El Gkotmi
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
| | - C Kosmeri
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
| | - T D Filippatos
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
| | - M S Elisaf
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
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19
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Abstract
Since its original description in 1832, fluid resuscitation has become the cornerstone of early and aggressive treatment of severe sepsis and septic shock. However, questions remain about optimal fluid composition, dose, and rate of administration for critically ill patients. This article reviews pertinent physiology of the circulatory system, pathogenesis of septic shock, and phases of sepsis resuscitation, and then focuses on the type, rate, and amount of fluid administration for severe sepsis and septic shock, so providers can choose the right fluid, for the right patient, at the right time.
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Affiliation(s)
- Rob Loflin
- University of Rochester Medical Center, Rochester, NY, USA
| | - Michael E Winters
- Critical Care Program, Internal Medicine, Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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20
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Sharma A, Yadav M, Kumar BR, Lakshman PS, Iyenger R, Ramchandran G. A comparative study of Sterofundin and Ringer lactate based infusion protocol in scoliosis correction surgery. Anesth Essays Res 2016; 10:532-537. [PMID: 27746547 PMCID: PMC5062242 DOI: 10.4103/0259-1162.181425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: A major change in anesthesia practice as regards to intraoperative infusion therapy is the present requirement. Switching over to balanced fluids can substantially decrease the incidence of lactic acidosis and hyperchloremic acidosis. The deleterious effects of unbalanced fluids are more recognizable during major surgeries. We prospectively studied the influence of Sterofundin (SF) and Ringer lactate (RL) on acid–base changes, hemodynamics, and readiness for extubation during scoliosis surgery. Subjects and Methods: Thirty consecutive children posted for scoliosis surgery were randomized to receive either RL (n = 15) or SF (n = 15) as intraoperative fluid at 10 mg/kg/h. Fluid boluses were added according to the study fluid algorithm. Arterial blood was sampled and analyzed at hourly intervals during surgery. Red blood cell transfusion was guided by hematocrit below 27. Patients were followed for 24 h postoperatively in the Intensive Care Unit. Results: There was no statistically significant difference in the volume of infused fluid (2400 ± 512 ml in Group RL and 2200 ± 640 ml in Group SF. There were no significant changes in pH of patients infused with SF. Statistically, significant higher lactate levels were seen in RL-infused group. The strong ion difference was decreased in both groups, but it normalized earlier with SF. Conclusions: SF-infused patients had nonremarkable changes in acid–base physiology in scoliosis surgery.
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Affiliation(s)
- Ashima Sharma
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Monu Yadav
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - B Rajesh Kumar
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - P Sai Lakshman
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Raju Iyenger
- Department of Orthopedics, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Gopinath Ramchandran
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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21
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Miller TE, Bunke M, Nisbet P, Brudney CS. Fluid resuscitation practice patterns in intensive care units of the USA: a cross-sectional survey of critical care physicians. Perioper Med (Lond) 2016; 5:15. [PMID: 27313844 PMCID: PMC4910257 DOI: 10.1186/s13741-016-0035-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [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: 03/03/2016] [Accepted: 05/09/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA. METHODS We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume. RESULTS Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices. CONCLUSIONS Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg. 4101, Research Triangle Park, NC 27709 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungry Neck Blvd., Suite C-303, Charleston, SC 29464 USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
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22
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Vincent JL, De Backer D, Wiedermann CJ. Fluid management in sepsis: The potential beneficial effects of albumin. J Crit Care 2016; 35:161-7. [PMID: 27481753 DOI: 10.1016/j.jcrc.2016.04.019] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [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: 12/21/2015] [Revised: 03/22/2016] [Accepted: 04/19/2016] [Indexed: 12/22/2022]
Abstract
Fluid administration is a key intervention in hemodynamic resuscitation. Timely expansion (or restoration) of plasma volume may prevent tissue hypoxia and help to preserve organ function. In septic shock in particular, delaying fluid resuscitation may be associated with mitochondrial dysfunction and may promote inflammation. Ideally, infused fluids should remain in the plasma for a prolonged period. Colloids remain in the intravascular space for longer periods than do crystalloids, although their hemodynamic effect is affected by the usual metabolism of colloid substances; leakage through the endothelium in conditions with increased permeability, such as sepsis; and/or external losses, such as with hemorrhage and burns. Albumin has pleiotropic physiological activities including antioxidant effects and positive effects on vessel wall integrity. Its administration facilitates achievement of a negative fluid balance in hypoalbuminemia and in conditions associated with edema. Fluid resuscitation with human albumin is less likely to cause nephrotoxicity than with artificial colloids, and albumin infusion has the potential to preserve renal function in critically ill patients. These properties may be of clinical relevance in circulatory shock, capillary leak, liver cirrhosis, and de-escalation after volume resuscitation. Sepsis is a candidate condition in which human albumin infusion to preserve renal function should be substantiated.
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Affiliation(s)
- Jean Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium.
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, B-1420 Braine L'Alleud, Brussels, Belgium.
| | - Christian J Wiedermann
- Department of Internal Medicine, Central Hospital of Bolzano, 39100 Bolzano, Bozen, Italy.
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23
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Abstract
Sepsis is a systemic inflammatory response to severe infection causing significant morbidity and mortality that costs the health care system $20.3 billion annually within the United States. It is well established that fluid resuscitation is a central component of sepsis management; however, to date there is no consensus as to the ideal composition of fluid used for resuscitation. In this review, we discuss the progression of clinical research comparing various fluids, as well as the historical background behind fluid selection for volume resuscitation. We conclude that the use of balanced fluids, such as Ringer's Lactate, seems very promising but further research is needed to confirm their role.
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24
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Larsen TR, Singh G, Velocci V, Nasser M, McCullough PA. Frequency of fluid overload and usefulness of bioimpedance in patients requiring intensive care for sepsis syndromes. Proc (Bayl Univ Med Cent) 2016; 29:12-5. [PMID: 26722156 DOI: 10.1080/08998280.2016.11929342] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Guideline-directed therapy for sepsis calls for early fluid resuscitation. Often patients receive large volumes of intravenous fluids. Bioimpedance vector analysis (BIVA) is a noninvasive technique useful for measuring total body water. In this prospective observational study, we enrolled 18 patients admitted to the intensive care unit for the treatment of sepsis syndromes. Laboratory data, clinical parameters, and BIVA were recorded daily. All but one patient experienced volume overload during the course of treatment. Two patients had >20 L of excess volume. Volume overload is clinically represented by tissue edema. Edema is not a benign condition, as it impairs tissue oxygenation, obstructs capillary blood flow, disrupts metabolite clearance, and alters cell-to-cell interactions. Specifically, volume overload has been shown to impair pulmonary, cardiac, and renal function. A positive fluid balance is a predictor of hospital mortality. As septic patients recover, volume excess should be aggressively treated with the use of targeted diuretics and renal replacement therapies if necessary.
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Affiliation(s)
- Timothy R Larsen
- Department of Internal Medicine, Section of Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia (Larsen); Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, Michigan (Singh, Velocci, Nasser); and Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital and Baylor University Medical Center, Dallas, Texas, and The Heart Hospital, Plano, Texas (McCullough)
| | - Gurbir Singh
- Department of Internal Medicine, Section of Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia (Larsen); Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, Michigan (Singh, Velocci, Nasser); and Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital and Baylor University Medical Center, Dallas, Texas, and The Heart Hospital, Plano, Texas (McCullough)
| | - Victor Velocci
- Department of Internal Medicine, Section of Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia (Larsen); Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, Michigan (Singh, Velocci, Nasser); and Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital and Baylor University Medical Center, Dallas, Texas, and The Heart Hospital, Plano, Texas (McCullough)
| | - Mohamed Nasser
- Department of Internal Medicine, Section of Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia (Larsen); Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, Michigan (Singh, Velocci, Nasser); and Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital and Baylor University Medical Center, Dallas, Texas, and The Heart Hospital, Plano, Texas (McCullough)
| | - Peter A McCullough
- Department of Internal Medicine, Section of Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia (Larsen); Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, Michigan (Singh, Velocci, Nasser); and Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital and Baylor University Medical Center, Dallas, Texas, and The Heart Hospital, Plano, Texas (McCullough)
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25
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Basora M, Colomina MJ, Moral V, Asuero de Lis MS, Boix E, Jover JL, Llau JV, Rodrigo MP, Ripollés J, Calvo Vecino JM. Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery. Rev Esp Anestesiol Reanim 2016; 63:29-47. [PMID: 26343809 DOI: 10.1016/j.redar.2015.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 06/08/2015] [Revised: 06/24/2015] [Accepted: 06/26/2015] [Indexed: 06/05/2023]
Abstract
The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.
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Affiliation(s)
- M Basora
- Anestesiología y Reanimación, Hospital Clínic, Barcelona, España.
| | - M J Colomina
- Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - V Moral
- Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, España
| | - M S Asuero de Lis
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Boix
- Anestesiología y Reanimación, Hospital Universitario del Vinalopó, Elche, Alicante, España
| | - J L Jover
- Anestesiología y Reanimación, Hospital Verge dels Lliris, Alcoi, Alicante, España
| | - J V Llau
- Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España
| | - M P Rodrigo
- Anestesiología y Reanimación, Hospital de Basurto, Bilbao, España
| | - J Ripollés
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, España
| | - J M Calvo Vecino
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Universidad Complutense, Madrid, España
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26
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Abstract
Fluid therapy is the most common intervention received by acutely ill hospitalized patients; however, important questions on its optimal use remain. Its prescription should be patient and context specific, with clear indications and contradictions, and have the type, dose, and rate specified. Any fluid therapy, if provided inappropriately, can contribute unnecessary harm to patients. The quantitative toxicity of fluid therapy contributes to worse outcomes; this should prompt greater bedside attention to fluid prescription, fluid balance, development of avoidable complications attributable to fluid overload, and for the timely deresuscitation of patients whose clinical status and physiology allow active fluid mobilization.
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Affiliation(s)
- Oleksa Rewa
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440-112 Street Northwest, Edmonton, Alberta T6G 2B7, Canada
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440-112 Street Northwest, Edmonton, Alberta T6G 2B7, Canada.
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27
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Besen BAMP, Gobatto ALN, Melro LMG, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: An overview. World J Crit Care Med 2015; 4:116-129. [PMID: 25938027 PMCID: PMC4411563 DOI: 10.5492/wjccm.v4.i2.116] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [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: 09/29/2014] [Revised: 12/24/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.
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