What is the best treatment for hypotension in healthy dogs during anaesthesia maintained with isoflurane?

Hypotension is a common and potentially life-threatening complication of general anaesthesia in dogs. Due to the combination of cardiovascular side effects of many anaesthetic, sedative and analgesic drugs used peri-operatively hypotension is frequently reported even in healthy dogs undergoing elective procedures. Several treatment options for hypotension have been advocated. Potential treatments include rapid administration of either crystalloid or colloid fluids; pharmacological treatments to increase cardiac output and/or systemic vascular resistance; or reduction in the delivery of the volatile anaesthetic agents. This critical appraisal considers the current evidence for which treatment is the best option for treating hypotension in healthy euvolemic dogs undergoing general anaesthesia maintained with isoflurane. Fourteen relevant studies were appraised, including 12 laboratory studies and two small clinical trials. One study demonstrated that reduction in the delivery of isoflurane may correct hypotension, but this treatment may not always be feasible. In general, rapid administration of fluids did not increase blood pressure and failed to correct hypotension. Synthetic colloids demonstrated some efficacy, but results were inconsistent between studies and large volumes may be required. Infusion of dopamine appears to be the most reliable pharmacological option consistently increasing blood pressure, cardiac output and correcting hypotension.

Assessing resuscitation in burn patients with varying degrees of liver disease

We find minimal literature and lack of consensus among burn practitioners over how to resuscitate thermally injured patients with pre-existing liver disease. Our objective was to assess burn severity in patients with a previous history of liver disease. We attempted to stratify resuscitation therapy utilised, using it as an indicator of burn shock severity. We hypothesized that as severity of liver disease increased, more fluid therapy is needed. We retrospectively studied adult patients with a total body surface area (TBSA) of burn greater than or equal to 20% (n = 314). We determined the severity of liver disease by calculating admission Model for End-Stage Liver Disease (MELD) scores and measured resuscitation adequacy via urine output within the first 24 h. We performed stepwise, multivariable linear regression with backward selection to test our hypothesis with α = 0.05 defined a priori. After controlling for important confounders including age, TBSA, baseline serum albumin, total crystalloids, colloids, blood products, diuretics, and steroids given in first 24 h, we found a statistically significant reduction in urine output as MELD score increased (p < 0.000). In our study, severity of liver disease correlated with declining urine output during first 24-hour resuscitation more so than burn size or burn depth. While resuscitation is standardized for all patients, lack of urine output with increased liver disease suggests a new strategy is of benefit. This may involve investigation of alternate markers of adequacy of resuscitation, or developing modified resuscitation protocols for use in patients with liver disease. More investigation is necessary into how resuscitation protocols may best be modified.

Goal-directed colloid versus crystalloid therapy and microcirculatory blood flow following ischemia/reperfusion

OBJECTIVE

Ischemia/reperfusion can impair microcirculatory blood flow. It remains unknown whether colloids are superior to crystalloids for restoration of microcirculatory blood flow during ischemia/reperfusion injury. We tested the hypothesis that goal-directed colloid - compared to crystalloid - therapy improves small intestinal, renal, and hepatic microcirculatory blood flow in pigs with ischemia/reperfusion injury.

METHODS

This was a randomized trial in 32 pigs. We induced ischemia/reperfusion by supra-celiac aortic-cross-clamping. Pigs were randomized to receive either goal-directed isooncotic hydroxyethyl-starch colloid or balanced isotonic crystalloid therapy. Microcirculatory blood flow was measured using Laser-Speckle-Contrast-Imaging. The primary outcome was small intestinal, renal, and hepatic microcirculatory blood flow 4.5 h after ischemia/reperfusion. Secondary outcomes included small intestinal, renal, and hepatic histopathological damage, macrohemodynamic and metabolic variables, as well as specific biomarkers of tissue injury, renal, and hepatic function and injury, and endothelial barrier function.

RESULTS

Small intestinal microcirculatory blood flow was higher in pigs assigned to isooncotic hydroxyethyl-starch colloid therapy than in pigs assigned to balanced isotonic crystalloid therapy (768.7 (677.2-860.1) vs. 595.6 (496.3-694.8) arbitrary units, p = .007). There were no important differences in renal (509.7 (427.2-592.1) vs. 442.1 (361.2-523.0) arbitrary units, p = .286) and hepatic (604.7 (507.7-701.8) vs. 548.7 (444.0-653.3) arbitrary units, p = .376) microcirculatory blood flow between groups. Pigs assigned to colloid - compared to crystalloid - therapy also had less small intestinal, but not renal and hepatic, histopathological damage.

CONCLUSIONS

Goal-directed isooncotic hydroxyethyl-starch colloid - compared to balanced isotonic crystalloid - therapy improved small intestinal, but not renal and hepatic, microcirculatory blood flow in pigs with ischemia/reperfusion injury. Whether colloid therapy improves small intestinal microcirculatory blood flow in patients with ischemia/reperfusion needs to be investigated in clinical trials.

Cost-effectiveness analysis of intralesional and perilesional recombinant human epidermal growth factor vs hydrocolloid therapy in venous ulcer treatment in the Colombian context

OBJECTIVE

To perform a comparative analysis of health care expenses and outcomes in response to the question: What is the cost-effectiveness of intralesional and perilesional recombinant human epidermal growth factor (rhEGF) compared with hydrocolloid therapy in patients diagnosed with chronic venous insufficiency without infection in Colombia?

METHODS

A Markov model was used to determine cost effectiveness over a 5-year period, considering the perspective of the health system in Colombia. The study included patients aged >18 years diagnosed with chronic venous insufficiency and used clinical studies to calculate the probabilities of epithelialization, infection, recurrence, and mortality.

RESULTS

RhEGF is more expensive per unit than hydrocolloids, but it is proven to be effective at healing ulcers in 8 to 12 weeks, even in complex cases. Hydrocolloids, in contrast, typically require 29.5 weeks on average, and ≤46 weeks for complex cases. Despite the cost, rhEGF is more cost effective because it achieves results comparable with hydrocolloid therapy at a lower cost per additional quality-adjusted life-year.

CONCLUSIONS

Based on cost-effectiveness analysis, rhEGF is a superior alternative to hydrocolloids for treating venous ulcers in Colombia. Not only is it more affordable, but it also enhances patients' quality of life and streamlines the health care system's resource use.

The Evolution of Colloid Administration in Burn Resuscitation

ABSTRACT

Colloid administration in acute resuscitation of burn injuries is being increasingly recognized as an important part of fluid management for these injuries. Such clinical experience, along with possibilities of endothelial preservation by colloid solutions, could lead to a major reconsideration of early colloid administration in burn resuscitation.

Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients

OBJECTIVE

Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management.

METHODS

PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists.

RESULTS

Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy.

CONCLUSIONS

Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section

BACKGROUND

Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury).

OBJECTIVES

To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (9 August 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data from eligible studies. We report 'Summary of findings' tables using GRADE.

MAIN RESULTS

We included 125 studies involving 9469 women. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review's primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit. Crystalloid versus control (no fluids) Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence). Colloid versus crystalloid Fewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.69, 95% CI 0.58 to 0.81; 2009 women; 27 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women; very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.98, 95% CI 0.54 to 1.78, 5 studies, 413 women; very low-quality evidence), nausea and/or vomiting (average RR 0.89, 95% CI 0.66 to 1.19, 14 studies, 1058 women, I² = 29%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 10 studies, 730 babies; very low-quality evidence). Ephedrine versus phenylephrine There were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence). Ondansetron versus control Ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence). Lower limb compression versus control Lower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42, 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence). Walking versus lying There was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence). Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections. External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration.

AUTHORS' CONCLUSIONS

While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.

Clinical practice on intra-operative fluid therapy in Poland: A point prevalence study

Intra-operative fluid therapy (IFT) is the cornerstone of peri-operative management as it may significantly influence the treatment outcome. Therefore, we sought to evaluate nationwide clinical practice regarding IFT in Poland.A cross-sectional, multicenter, point-prevalence study was performed on April 5, 2018, in 31 hospitals in Poland. Five hundred eighty-seven adult patients undergoing non-cardiac surgery were investigated. The volume and type of fluids transfused with respect to the patient and procedure risk were assessed.The study group consisted of 587 subjects, aged 58 (interquartile range [IQR] 40-67) years, including 142 (24%) American Society of Anesthesiology Physical Status (ASA-PS) class III+ patients. The median total fluid dose was 8.6 mL kg h (IQR 6-12.5), predominantly including balanced crystalloids (7.0 mL kg h, IQR 4.9-10.6). The dose of 0.9% saline was low (1.6 mL kg h, IQR 0.8-3.7). Synthetic colloids were used in 66 (11%) subjects. The IFT was dependent on the risk involved, while the transfused volumes were lower in ASA-PS III+ patients, as well as in high-risk procedures (P < .05).The practice of IFT is liberal but is adjusted to the preoperative risk. The consumption of synthetic colloids and 0.9% saline is low.

Development and validation of a clinical model to predict intraoperative hemodynamic instability in patients with pheochromocytomas surgery

Although currently the primary strategy for the treatment of pheochromocytomas is surgery, it is associated with a high risk of intraoperative hemodynamic instability (IHD), even with adequate preoperative medical preparation, which may result in life-threatening situations. The aim of this study was to develop and validate a nomogram for preoperative prediction of IHD related to pheochromocytoma surgery. The development cohort consisted of 283 patients with pheochromocytoma who underwent unilateral laparoscopic or open adrenaletomy at our center between January 1, 2007 and December 31, 2016. The clinicopathological characteristics of each patient were recorded. The least absolute shrinkage and selection operator binary logistic regression model was used for data dimension reduction and feature selection, while multivariable logistic regression analysis was used to develop the prediction model. An independent cohort consisting of 119 consecutive patients from January 1, 2017 to December 31, 2018 was used for validation. The performance of the prediction model was assessed in regards to discrimination, calibration, and clinical usefulness. The predictors of this model included body mass index, coronary heart disease, tumor size, and preoperative use of crystal/colloid fluid. For the validation cohort, the model showed good discrimination with an area under the receiver operating characteristic of 0.767 (95% CI, 0.667-0.857) and good calibration (unreliability test, p = 0.852; Hosmer-Lemeshow test, p = 0.9309). Decision curve analysis demonstrated that the model was clinically useful. This nomogram to facilitate preoperative individualized prediction of IHD in patients with pheochromocytoma may help to improve the perioperative strategy and treatment outcome.

Silica solutions (SL) is efficacy in the treatment of chronic periodontitis: a case control study

AIM

The objective of this study was to compare the efficacy of supportive periodontal therapy (i.e. scaling and rooth planning, SRP) alone versus a chemical device silica dioxide (SiO2) colloidal solutions (SL) used in association with SRP in the treatment of chronic periodontitis in adult patients.

MATERIALS AND METHODS

A total of 20 patients with a diagnosis of chronic periodontitis (40 localized chronic periodontitis sites) in the age group of 35 to 55 were selected. None of these patients have previously received any surgical or non-surgical periodontal therapy and demonstrated radiographic evidence of moderate bone loss. Two non-adjacent sites in separate quadrants were selected in each patient to monitorize treatment efficacy (split mouth design). Clinical pocket depth (PD) and microbial analysis (MA) were analyzed at baseline and 15th day. SPSS program and paired simple statistic T-test were used to detect significant differences.

RESULTS

Total bacteria loading, Tannerella Forsitia and Treponema Denticola loading were statistically reduced when SiO2 is locally delivered.

CONCLUSIONS

SL gel is an adiuvant therapy which should be added to SRP in the management of moderate to severe chronic periodontitis.

Silica dioxide colloidal solutions is efficient in the treatment of chronic periodontitis: a case control study

The objective of this study was to compare the efficacy of supportive periodontal therapy (i.e. scaling and rooth planning, SRP) alone versus a chemical device silica dioxide (SiO2) colloidal solutions (SDCS) used in association with SRP in the treatment of chronic periodontitis in adult patients. A total of 20 patients with a diagnosis of chronic periodontitis (40 localized chronic periodontitis sites) in the age group of 35 to 55 were selected. None of these patients have previously received any surgical or non-surgical periodontal therapy and demonstrated radiographic evidence of moderate bone loss. Two non-adjacent sites in separate quadrants were selected in each patient to monitorize treatment efficacy (split mouth design). Clinical pocket depth (PD) and microbial analysis (MA) were analyzed at baseline and 15th day. SPSS program and paired simple statistic T-test were used to detect significant differences. Total bacteria loading, Tannerella Forsitia and Treponema Denticola loading were statistically reduced when SiO2 is locally delivered. SDCS gel is an adjuvant therapy which should be added to SRP in the management of moderate to severe chronic periodontitis.

Colloids versus crystalloids for fluid resuscitation in critically ill people

BACKGROUND

Critically ill people may lose fluid because of serious conditions, infections (e.g. sepsis), trauma, or burns, and need additional fluids urgently to prevent dehydration or kidney failure. Colloid or crystalloid solutions may be used for this purpose. Crystalloids have small molecules, are cheap, easy to use, and provide immediate fluid resuscitation, but may increase oedema. Colloids have larger molecules, cost more, and may provide swifter volume expansion in the intravascular space, but may induce allergic reactions, blood clotting disorders, and kidney failure. This is an update of a Cochrane Review last published in 2013.

OBJECTIVES

To assess the effect of using colloids versus crystalloids in critically ill people requiring fluid volume replacement on mortality, need for blood transfusion or renal replacement therapy (RRT), and adverse events (specifically: allergic reactions, itching, rashes).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two other databases on 23 February 2018. We also searched clinical trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of critically ill people who required fluid volume replacement in hospital or emergency out-of-hospital settings. Participants had trauma, burns, or medical conditions such as sepsis. We excluded neonates, elective surgery and caesarean section. We compared a colloid (suspended in any crystalloid solution) versus a crystalloid (isotonic or hypertonic).

DATA COLLECTION AND ANALYSIS

Independently, two review authors assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We included 69 studies (65 RCTs, 4 quasi-RCTs) with 30,020 participants. Twenty-eight studied starch solutions, 20 dextrans, seven gelatins, and 22 albumin or fresh frozen plasma (FFP); each type of colloid was compared to crystalloids.Participants had a range of conditions typical of critical illness. Ten studies were in out-of-hospital settings. We noted risk of selection bias in some studies, and, as most studies were not prospectively registered, risk of selective outcome reporting. Fourteen studies included participants in the crystalloid group who received or may have received colloids, which might have influenced results.We compared four types of colloid (i.e. starches; dextrans; gelatins; and albumin or FFP) versus crystalloids.Starches versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using starches or crystalloids in mortality at: end of follow-up (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.86 to 1.09; 11,177 participants; 24 studies); within 90 days (RR 1.01, 95% CI 0.90 to 1.14; 10,415 participants; 15 studies); or within 30 days (RR 0.99, 95% CI 0.90 to 1.09; 10,135 participants; 11 studies).We found moderate-certainty evidence that starches probably slightly increase the need for blood transfusion (RR 1.19, 95% CI 1.02 to 1.39; 1917 participants; 8 studies), and RRT (RR 1.30, 95% CI 1.14 to 1.48; 8527 participants; 9 studies). Very low-certainty evidence means we are uncertain whether either fluid affected adverse events: we found little or no difference in allergic reactions (RR 2.59, 95% CI 0.27 to 24.91; 7757 participants; 3 studies), fewer incidences of itching with crystalloids (RR 1.38, 95% CI 1.05 to 1.82; 6946 participants; 2 studies), and fewer incidences of rashes with crystalloids (RR 1.61, 95% CI 0.90 to 2.89; 7007 participants; 2 studies).Dextrans versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using dextrans or crystalloids in mortality at: end of follow-up (RR 0.99, 95% CI 0.88 to 1.11; 4736 participants; 19 studies); or within 90 days or 30 days (RR 0.99, 95% CI 0.87 to 1.12; 3353 participants; 10 studies). We are uncertain whether dextrans or crystalloids reduce the need for blood transfusion, as we found little or no difference in blood transfusions (RR 0.92, 95% CI 0.77 to 1.10; 1272 participants, 3 studies; very low-certainty evidence). We found little or no difference in allergic reactions (RR 6.00, 95% CI 0.25 to 144.93; 739 participants; 4 studies; very low-certainty evidence). No studies measured RRT.Gelatins versus crystalloidsWe found low-certainty evidence that there may be little or no difference between gelatins or crystalloids in mortality: at end of follow-up (RR 0.89, 95% CI 0.74 to 1.08; 1698 participants; 6 studies); within 90 days (RR 0.89, 95% CI 0.73 to 1.09; 1388 participants; 1 study); or within 30 days (RR 0.92, 95% CI 0.74 to 1.16; 1388 participants; 1 study). Evidence for blood transfusion was very low certainty (3 studies), with a low event rate or data not reported by intervention. Data for RRT were not reported separately for gelatins (1 study). We found little or no difference between groups in allergic reactions (very low-certainty evidence).Albumin or FFP versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using albumin or FFP or using crystalloids in mortality at: end of follow-up (RR 0.98, 95% CI 0.92 to 1.06; 13,047 participants; 20 studies); within 90 days (RR 0.98, 95% CI 0.92 to 1.04; 12,492 participants; 10 studies); or within 30 days (RR 0.99, 95% CI 0.93 to 1.06; 12,506 participants; 10 studies). We are uncertain whether either fluid type reduces need for blood transfusion (RR 1.31, 95% CI 0.95 to 1.80; 290 participants; 3 studies; very low-certainty evidence). Using albumin or FFP versus crystalloids may make little or no difference to the need for RRT (RR 1.11, 95% CI 0.96 to 1.27; 3028 participants; 2 studies; very low-certainty evidence), or in allergic reactions (RR 0.75, 95% CI 0.17 to 3.33; 2097 participants, 1 study; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Using starches, dextrans, albumin or FFP (moderate-certainty evidence), or gelatins (low-certainty evidence), versus crystalloids probably makes little or no difference to mortality. Starches probably slightly increase the need for blood transfusion and RRT (moderate-certainty evidence), and albumin or FFP may make little or no difference to the need for renal replacement therapy (low-certainty evidence). Evidence for blood transfusions for dextrans, and albumin or FFP, is uncertain. Similarly, evidence for adverse events is uncertain. Certainty of evidence may improve with inclusion of three ongoing studies and seven studies awaiting classification, in future updates.

Fluid resuscitation management in patients with burns: update

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.

Clinical Improvements in Very Dry Skin from a Natural Ingredient-Based Moisturizing Cream Compared With a Leading Colloidal Oatmeal Control

The objective of this 6-week clinical study was to demonstrate the effectiveness of a natural ingredient-based moisturizing cream versus a colloidal oatmeal moisturizing cream in improving the hydration, barrier function, appearance, and feel of dry leg skin. Thirty-two subjects completed the study. After a 5-day washout, subjects used the natural ingredient-based moisturizing cream and oatmeal-containing cream on randomly-assigned legs twice a day for a period of three weeks. For the following two weeks subjects did not use any moisturizer on their legs. Skin moisture measurements showed a statistically significant increase in hydration for both products at all time points during the treatment phase of the study. Both products reduced transepidermal water loss measurements during the treatment phase of the study, showing their abilities to improve stratum corneum barrier function. Clinical evaluations showed that both products significantly decreased visual dryness and tactile roughness during the treatment phase. Improvements in the assessed clinical parameters persisted even after treatment cessation. In conclusion, the natural ingredient-based moisturizing cream was highly effective in providing moisturization and improving the skin barrier of subjects with very dry leg skin. It also produced significant improvements in visual dryness and tactile roughness that persisted during regression. Overall, these results show that the natural ingredient-based moisturizing cream delivers comparable benefits to that of a colloidal oatmeal-containing benchmark product and is an option for health care providers and consumers who seek relief from dry skin and prefer a product with all-natural ingredients. J Drugs Dermatol. 2018;17(7):758-764.

Prevention of Acute Renal Failure - Fluid Repletion and Colloids

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.

Comparison of intraoperative basal fluid requirements in distal pancreatectomy: Laparotomy vs. laparoscopy: A retrospective cohort study

There has been recent progress in intraoperative fluid therapy. However, little is known about intraoperative fluid therapy in laparoscopic surgery. The purpose of this study is to determine whether there are differences in the basal fluid requirements during surgery between laparotomy and laparoscopic distal pancreatectomy.This retrospective cohort study analyzed the electronic medical records of 253 patients who underwent distal pancreatectomy via either laparotomy (73 patients) or laparoscopy (180 patients) between June 2006 and March 2016. The volume of intraoperative fluid administered, postoperative complications, length of hospital stay, and readmission rate were evaluated. The total volume of fluids was calculated as the sum of the volume of crystalloid plus the volume of colloid multiplied by 1.5 or 2.0.Patients who had laparotomy were older and had higher American Society of Anesthesiologists classes. Anesthesia time was longer and estimated blood loss was larger in laparotomy. More colloid (1.8 mL/kg per h vs. 1.2 mL/kg per h, P < .001) and more total calculated fluid (1.5 times: 11.7 mL/kg per h vs. 10.6 mL/kg per h, P = .002; 2.0 times: 12.6 mL/kg per h vs. 11.2 mL/kg per h, P = .001) were infused in laparotomy. Crystalloid (9.0 mL/kg per h vs. 8.9 mL/kg per h, P = .203) did not show significant difference. Postoperative complications were more frequent (63% vs. 45%, P = .008), the hospital stay was longer (18 days vs. 13.4 days, P < .001), and readmission rate was higher (15% vs. 5.6%, P = .02) in laparotomy. By logistic regression analysis, we could find that operation type (laparotomy vs. laparoscopy, odds ratio 1.900, 95% confidence interval 1.072-3.368) and operation time (P = .004) had effect on complications.In patients undergoing distal pancreatectomy, basal fluid requirements were larger in laparotomy compared with laparoscopy. Operation time and estimated blood loss had effects on fluid administration. Postoperative complications were more frequent in laparotomy but we could not find relationships with infused colloid or total calculated fluid volumes. Operation type (laparotomy vs. laparoscopy) and operation time were the only related factors to postoperative complications.

Haemodynamic response to crystalloids or colloids in shock: an exploratory subgroup analysis of a randomised controlled trial

OBJECTIVE

To compare the haemodynamic effect of crystalloids and colloids during acute severe hypovolaemic shock.

DESIGN

Exploratory subgroup analysis of a multicentre randomised controlled trial (Colloids Versus Crystalloids for the Resuscitation of the Critically Ill, CRISTAL, ClinicalTrials.gov NCT00318942).

SETTING

CRISTAL was conducted in intensive care units in Europe, North Africa and Canada.

PARTICIPANTS

Current analysis included all patients who had a pulmonary artery catheter in place at randomisation. 220 patients (117 received crystalloids vs 103 colloids) underwent pulmonary artery catheterisation.

INTERVENTION

Crystalloids versus colloids for fluid resuscitation in hypovolaemic shock.

OUTCOME MEASURES

Haemodynamic data were collected at the time of randomisation and subsequently on days 1, 2, 3, 4, 5, 6 and 7.

RESULTS

Median cumulative volume of fluid administered during the first 7 days was higher in the crystalloids group than in the colloids group (3500 (2000-6000) vs 2500 (1000-4000) mL, p=0.01). Patients in the colloids arm exhibited a lower heart rate over time compared with those allocated to the crystalloids arm (p=0.014). There was no significant difference in Cardiac Index (p=0.053), mean blood pressure (p=0.4), arterial lactates (p=0.9) or global Sequential Organ Failure Assessment score (p=0.3) over time between arms.

CONCLUSIONS

During acute severe hypovolaemic shock, patients monitored by a pulmonary artery catheter achieved broadly similar haemodynamic outcomes, using lower volumes of colloids than crystalloids. The heart rate was lower in the colloids arm.

Fluid Creep and Over-resuscitation

Fluid creep is the term applied to a burn resuscitation, which requires more fluid than predicted by standard formulas. Fluid creep is common today and is linked to several serious edema-related complications. Increased fluid requirements may accompany the appropriate resuscitation of massive injuries but dangerous fluid creep is also caused by overly permissive fluid infusion and the lack of colloid supplementation. Several strategies for recognizing and treating fluid creep are presented.

Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01--2 June 2014

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Multicountry survey of emergency and critical care medicine physicians' fluid resuscitation practices for adult patients with early septic shock

OBJECTIVES

Evidence to guide fluid resuscitation evidence in sepsis continues to evolve. We conducted a multicountry survey of emergency and critical care physicians to describe current stated practice and practice variation related to the quantity, rapidity and type of resuscitation fluid administered in early septic shock to inform the design of future septic shock fluid resuscitation trials.

METHODS

Using a web-based survey tool, we invited critical care and emergency physicians in Canada, the UK, Scandinavia and Saudi Arabia to complete a self-administered electronic survey.

RESULTS

A total of 1097 physicians' responses were included. 1 L was the most frequent quantity of resuscitation fluid physicians indicated they would administer at a time (46.9%, n=499). Most (63.0%, n=671) stated that they would administer the fluid challenges as quickly as possible. Overall, normal saline and Ringer's solutions were the preferred crystalloid fluids used 'often' or 'always' in 53.1% (n=556) and 60.5% (n=632) of instances, respectively. However, emergency physicians indicated that they would use normal saline 'often' or 'always' in 83.9% (n=376) of instances, while critical care physicians said that they would use saline 'often' or 'always' in 27.9% (n=150) of instances. Only 1.0% (n=10) of respondents indicated that they would use hydroxyethyl starch 'often' or 'always'; use of 5% (5.6% (n=59)) or 20-25% albumin (1.3% (n=14)) was also infrequent. The majority (88.4%, n=896) of respondents indicated that a large randomised controlled trial comparing 5% albumin to a crystalloid fluid in early septic shock was important to conduct.

CONCLUSIONS

Critical care and emergency physicians stated that they rapidly infuse volumes of 500-1000 mL of resuscitation fluid in early septic shock. Colloid use, specifically the use of albumin, was infrequently reported. Our survey identifies the need to conduct a trial on the efficacy of albumin and crystalloids on 90-day mortality in patients with early septic shock.

Fluid management in sepsis: The potential beneficial effects of albumin

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.

Colloids Versus Albumin in Large Volume Paracentesis to Prevent Circulatory Dysfunction: Evidence-based Case Report

Large volume paracentesis may cause paracentesis induced circulatory dysfunction (PICD). Albumin is recommended to prevent this abnormality. Meanwhile, the price of albumin is too expensive and there should be another alternative that may prevent PICD. This report aimed to compare albumin to colloids in preventing PICD. Search strategy was done using PubMed, Scopus, Proquest, dan Academic Health Complete from EBSCO with keywords of "ascites", "albumin", "colloid", "dextran", "hydroxyethyl starch", "gelatin", and "paracentesis induced circulatory dysfunction". Articles was limited to randomized clinical trial and meta-analysis with clinical question of "In hepatic cirrhotic patient undergone large volume paracentesis, whether colloids were similar to albumin to prevent PICD". We found one meta-analysis and four randomized clinical trials (RCT). A meta analysis showed that albumin was still superior of which odds ratio 0.34 (0.23-0.51). Three RCTs showed the same results and one RCT showed albumin was not superior than colloids. We conclude that colloids could not constitute albumin to prevent PICD, but colloids still have a role in patient who undergone paracentesis less than five liters.

[CLINICAL CASES-TREATED WITH TECHNOLOGY LIPID COLLOIDAL (TLC)]

INTRODUCTION

This study presents clinical cases collecting etiologies that are more frequent in the field of complex wounds. All require a specific approach, as well as the interdisciplinary participation of different members of the team. But in general, established local cure plans may be quite similar. Applies them technology lipid colloidal (TLC) which consists of the combination of particles of hydrocolloid (carboxymethylcellulose) with lipid components. Products with a technology designed for every moment of healing.

OBJECTIVE

Show our experience in the use of products with TLC in patients with ulcers of different etiologies.

METHOD

The following products depending on the case have been used to treat: UrgoTul Absorb Border, Urgoclean (rope or plate), UrgoStart, UrgoK2 and UrgoK2 LITE. These products were applied in patients presenting four different etiologies of ulcer: hypertensive, traumatic, venous and ischemic ulcer. The use of Urgoclean rope favored cleaning the bed ulceral and applied Urgoclean plate with reinforced alginate to control the abundant exudates, with coverage of UrgoTul ABsorb Border. Once clean beds pass UrgoStart and at all times UrgoK2 bandage, cases that required compressive therapy. Intolerance to that kind of compression applied to patients presenting bandage UrgoK2 LITE (which tolerated without problem) which significantly reduced edema, favoring the control of exudate. Patients with ulcer of long evolution, at the start were reluctant to the application of new technologies, but after the first cures and sensing a good evolution, we get their confidence and commitment to the resolution.

RESULTS

Are displayed clinical cases of different etiologic and personal contexts that an integral and interdisciplinary approach together with the application of products with TLC, managed to solve the problem.

CONCLUSION

The materials used have been satisfactory in all cases, with a direct involvement in the resolution of lesions which carries a long unresolved, and in any of them, even with a diagnosis of poor prognosis. In the clinical practice of the wound care knowledge and research of new materials that improve the quality of life of patients, reducing the time evolution of the lesions is very important. Not to mention that education for the prevention of their health should be one of the objectives to prevent recurrences.

Prolonged Field Care Working Group Fluid Therapy Recommendations

The Prolonged Field Care Working Group concurs that fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock, and the capability to transfuse FWB should be a basic skill set for Special Operations Forces (SOF) Medics. Prolonged field care (PFC) must also address resuscitative and maintenance fluid requirements in nonhemorrhagic conditions.

Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery

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.

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Multifunctional Fluorescent-Magnetic Polymeric Colloidal Particles: Preparations and Bioanalytical Applications

Fluorescent-magnetic particles (FMPs) play important roles in modern materials, especially as nanoscale devices in the biomedical field. The interesting features of FMPs are attributed to their dual detection ability, i.e., fluorescent and magnetic modes. Functionalization of FMPs can be performed using several types of polymers, allowing their use in various applications. The synergistic potentials for unique multifunctional, multilevel targeting nanoscale devices as well as combination therapies make them particularly attractive for biomedical applications. However, the synthesis of FMPs is challenging and must be further developed. In this review article, we summarized the most recent representative works on polymer-based FMP systems that have been applied particularly in the bioanalytical field.

Colloids versus crystalloids in the prevention of hypotension induced by spinal anesthesia in elective cesarean section. A systematic review and meta-analysis

The incidence of hypotension associated to spinal anesthesia in elective cesarean section is high. To determine the effects of colloids and crystalloids in the incidence of hypotension induced by spinal anesthesia in elective cesarean section, an attempt was made to define which type of fluid and what total volume should be administered. Following the PRISMA methodology a systematic review and meta-analysis were carried out. A systematic Medline/PubMed, EMBASE and Cochrane Library search was made to identify trials where women were scheduled for elective cesarean section with spinal anesthesia and volume loading (preload or co-load). The primary outcome was the incidence of hypotension. Stratification into subgroups was made for the primary outcome according to the type of colloid administered, differentiating those studies employing new generation colloids (HES 6% 130/0.4) from those not using such colloids, based on the volume of colloid administered and the combination of a vasopressor. The secondary outcome was the incidence of intraoperative nausea and vomiting. Two-hundred and twenty-seven controlled clinical trials were analyzed; eleven randomized clinical trials including 990 patients were included. A significative decrease of incidence of hypotension associated to spinal anesthesia was observed with the use of colloids compared to crystalloids (RR [95% CI] 0.70 [0.53-0.92], P=0.01). However, there was no difference between crystalloid and colloid in the risk of intraoperative nausea and vomiting (RR [95% CI] 0.75 [0.41-1.38]; P=0.33). This meta-analysis shows colloid administration to significantly reduce the incidence of hypotension associated to spinal anesthesia in elective cesarean section compared with of crystalloid use.

Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013

INTRODUCTION

Recent evidence indicates that the choice of intravenous fluids may affect outcomes in critically ill patients.

METHODS

We recorded the administration of resuscitation fluids in patients admitted to Australian and New Zealand adult intensive care units (ICUs) for a 24-h period at 6 time points between 2007 and 2013. Changes in patterns of fluid use over this period were determined using regression analyses.

RESULTS

Of the 2825 patients admitted to the 61 ICUs on the 6 study days, 754 (26.7%) patients received fluid resuscitation. Of those receiving fluid resuscitation, the proportion of patients receiving crystalloid significantly increased from 28.9% (41/142) in 2007 to 50.5% (48/95) in 2013 (adjusted odds ratio (OR) 2.93; 95% confidence intervals (CI) 1.35-6.33; p = 0.006); of these, the proportion of patients receiving buffered salt solutions significantly increased from 4.9% (7/142) in 2007 to 31.6% (30/95) in 2013 (OR 7.00; 95% CI 2.14-22.92; p = 0.001). The use of colloids significantly decreased from 59.9% (85/142) in 2007 to 42.1% (40/95) in 2013 (adjusted OR 0.34; 95% CI 0.16-0.74; p = 0.007) due to a significant decrease in the proportion of patients receiving gelatin; 28.9% (41/142) to 2.1% (2/95) (OR 0.10; 95% CI 0.03-0.29; p ≤ 0.001).

CONCLUSION

Fluid resuscitation practice in Australia and New Zealand adult ICUs has changed over the 6-year study period. Crystalloid use increased primarily due to an increase in the use of buffered salt solutions while overall the use of colloid has decreased.

Individual goal-directed intraoperative fluid management of initially hypovolemic patients for elective major urological surgery

BACKGROUND

The impact of different approaches to fluid management during intraoperative volume resuscitation in patients undergoing major elective surgery is poorly defined. We compared volume effectiveness of crystalloid and colloid substitution aimed to maintain the cardiac index (CI) between 2.6 and 3.8 l/min/m(2) as measured by transesophageal Doppler (TED).

METHODS

A total of 115 urological patients were enrolled in the prospective randomized trial and then randomized into 2 groups, one with volume therapy based on crystalloids (n = 57) and the other with colloids (n = 58). A TED probe was inserted and then hemodynamic optimization (therapy with Ringer's solution or hydroxyethyl starch 6 % 130/0.4 and administration of vasoactive drugs) was started according to TED variables to maintain the CI between 2.6 and 3.8 l/min/m(2).

RESULTS

We observed high incidence of CI < 2.6 l/min/m(2) after induction of anesthesia (75 %) in both groups. There were no significant differences in demographic characteristics, ASA classification, length of surgery, estimated blood loss and the CI during surgery. To maintain the CI within the requested interval, significantly different amounts of crystalloids were needed as compared to colloid (median: 5000 ml vs 1500 ml). In the CRY group, more patients were treated by vasodilatators (40.4 vs 20.7 %).

CONCLUSIONS

The study confirmed that crystalloids and colloids are effective in correcting flow-related perfusion abnormalities. The significant difference between volumes of crystalloids and colloids proved their different characteristics such as unequal distribution between compartments. The expansion of therapeutic algorithm by using vasoactive drugs allows us to avoid adverse events resulting from fluid overload (Tab. 1, Fig. 5, Ref. 35).

Influence of Two Colloidal Extracorporeal Primes on Coagulation of Cardiac Surgical Patients: A Prospectively Randomized Open-Label Pilot Trial

The search for the ideal priming fluid continues as more evidence is discovered about side effects of volume expanders. With the availability of modern, balanced hydroxyethyl starch (HES) solutions with less side effects than former HES solutions, we considered to replace our gelatin- (modified gelatin) based extracorporeal circuit prime for a HES (130/.42) prime. Therefore, we studied the influence of two colloidal priming fluids on postoperative coagulation in patients undergoing cardiac surgery. The primary endpoint was to compare clot formation time between the HES group and the gelatin group with rotational thromboelastometry (ROTEM). Additionally we compared colloid osmotic pressure and fluid balance of both groups. Forty patients, undergoing elective first time coronary artery bypass grafting or single-valve surgery, were included in this prospectively randomized open-label pilot study. Laboratory data and ROTEM data were collected and analyzed for differences between the two groups. ROTEM data show significantly more prolongation in Extem clot formation time and significant more decrease in Extem alpha in the HES group. Fibtem maximum clot firmness was significantly smaller in the HES group; this was consistent with fibrinogen concentration measurement, which decreased more in the HES group than in the gelatin group and recovered more over time in the gelatin group. We found no significant difference in colloid. osmotic pressure between the groups. In this trial, HES (130/.42) impairs coagulation significantly more compared with gelatin. These differences in influence on coagulation did not lead to a difference in blood loss or fluid balance, so clinical relevance could not be proven.

Colloids for fluid resuscitation: what is their role in patients with shock?

BACKGROUND

Fluid therapy is widely used in critically ill patients to restore effective intravascular volume and improve organ perfusion. Recent studies have questioned the administration of colloid-based solutions, especially if containing hydroxyethyl starch (HES), in different ICU populations; however, there is still uncertainty on the use of colloids as initial fluid therapy for early resuscitation.

METHODS

The aim of this study was to investigate the effect of two different resuscitation fluid strategies on the mortality of patients with shock. In a multicentric (57 ICUs), controlled, open-label trial (from February 2003 to August 2012), the authors randomized patients with signs of acute hypovolemia, defined by the combination of hypotension, evidence of low filling pressures or cardiac index and at least two signs of tissue hypoperfusion (such as altered consciousness, mottled skin, oliguria, lactate levels > 2 mmol/L), to received either a colloid- or crystalloid-based therapy. Both cohorts received maintenance fluids consisting in isotonic crystalloids and albumin in case of severe hypoalbuminemia (<2 g/dL). Exclusion criteria included previous fluid therapy, pregnancy, brain death, extended burns, chronic hemodialysis or liver disease, known coagulopathy, acute anaphylaxis, dehydration and hypotension due to sedative drugs.

RESULTS

Among the 6498 eligible patients, 2857 were eventually randomized in one of the two groups. The 28-day mortality was 25.4% in the colloid and 27.0% in the crystalloid group (P=0.26). In the sub-group analysis, similar mortality rates were reported for shock due to hypovolemia, sepsis or trauma. Also, the use of continuous renal replacement therapy was similar between groups (11.0% vs. 12.5%, P=0.19). There were more days alive without mechanical ventilation or vasopressors during the first 7 and 28 days and a lower 90-day mortality in the colloid group.

CONCLUSION

These data suggest that mortality was not increased and probably decreased with the use of colloids in different forms of shock requiring early fluid resuscitation. We discussed herein some methodological issues that may explain the discrepancies of this trial with the other studies developed in the same field.

The inhibitory and apoptotic effects of docetaxel-loaded mesoporous magnetic colloidal nanocrystal clusters on bladder cancer T24 cells in vitro

Mesoporous magnetic colloidal nanocrystal clusters (MCNCs) are featured with high magnetization, adequate surface area, excellent colloidal stability, good biocompatibility, and acid degradability. It is thus highly anticipated that MCNCs can serve as vehicles for target drug delivery. Herein, the mesoporous MCNCs stabilized by poly(gamma-glutamic acid) (PGA) were fabricated by the modified solvothermal route, showing a high specific surface area (126.4 m2/g), strong magnetic response (63 emu/g) and appropriate mesoporosity including a large pore volume (0.27 cm3/g) and accessible pore size (8.1 nm). Docetaxel (DOC) was then loaded in the resultant MCNCs using the nanoprecipitation method, and a high drug loading capacity was achieved up to 24 wt%. The chemotherapeutic effect and mechanism of DOC-MCNC conjugates in bladder cancer was evaluated in vitro. A series of analyses for cell uptake, cell viability, cell cycle, cell apoptosis and some cell proteins were performed by transmission electron microscopy, MTT assay, flow cytometry, cell nuclei staining, Annexin V staining assay, western blot assay and caspase-3 activity assay, respectively. The results demonstrated that DOC-MCNC conjugates enhanced the inhibitory effect by hampering mitoschisis and increased the apoptotic effect by changing the expression of apoptosis-related proteins in T24 cells, substantially proving their remarkable efficiency in treatment of bladder cancer.

Crystalloids versus colloids for fluid resuscitation in critically-ill patients

The choice of crystalloid or colloid for fluid resuscitation has been debated for the last few years. Although colloids seems to be more interesting when taking into account their physiological properties, their effect on mortality is not better than crystalloids if they are used in an adequate amount. Moreover, colloids' side effects are far more important than those of crystalloids. Several randomised studies pointed out the renal effects of colloids including acute renal injury with an increased need of renal replacement therapy. An unacceptably high rate of renal side effects has resulted in premature termination of some clinical trials. In addition, homeostatic and anaphylactoid effects of colloids on coagulation and on anaphylaxis may increase the risk of death associated with their use. Finally, colloids are much more expensive than crystalloids. For all these reasons, we conclude that crystalloids should be preferred to colloids for fluid resuscitation.

Efficacy of some colloidal silver preparations and silver salts against Proteus bacteria, one possible cause of rheumatoid arthritis

There has been increased interest in the role of anti-Proteus antibodies in the aetiology of rheumatoid arthritis (RA) and whether chemotherapeutic agents active against Proteus species might reduce the risk and/or exacerbations of RA. We examined the in vitro antibacterial effects of ten different silver preparations which were either ionic silver [Ag(I)] solutions or nanoparticulate silver (NPS) (Ag(0)) suspensions against ATCC and two wild (clinical) strains of Proteus. The data establish the low minimum inhibitory concentration and minimum bactericidal concentration of all the silver formulations tested against these four Proteus strains. In a pilot study, a potent NPS preparation ex vivo showed long-lasting anti-Proteus activity in a normal human volunteer.

Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial

IMPORTANCE

Evidence supporting the choice of intravenous colloid vs crystalloid solutions for management of hypovolemic shock remains unclear.

OBJECTIVE

To test whether use of colloids compared with crystalloids for fluid resuscitation alters mortality in patients admitted to the intensive care unit (ICU) with hypovolemic shock.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, randomized clinical trial stratified by case mix (sepsis, trauma, or hypovolemic shock without sepsis or trauma). Therapy in the Colloids Versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was open label but outcome assessment was blinded to treatment assignment. Recruitment began in February 2003 and ended in August 2012 of 2857 sequential ICU patients treated at 57 ICUs in France, Belgium, North Africa, and Canada; follow-up ended in November 2012.

INTERVENTIONS

Colloids (n = 1414; gelatins, dextrans, hydroxyethyl starches, or 4% or 20% of albumin) or crystalloids (n = 1443; isotonic or hypertonic saline or Ringer lactate solution) for all fluid interventions other than fluid maintenance throughout the ICU stay.

MAIN OUTCOMES AND MEASURES

The primary outcome was death within 28 days. Secondary outcomes included 90-day mortality; and days alive and not receiving renal replacement therapy, mechanical ventilation, or vasopressor therapy.

RESULTS

Within 28 days, there were 359 deaths (25.4%) in colloids group vs 390 deaths (27.0%) in crystalloids group (relative risk [RR], 0.96 [95% CI, 0.88 to 1.04]; P = .26). Within 90 days, there were 434 deaths (30.7%) in colloids group vs 493 deaths (34.2%) in crystalloids group (RR, 0.92 [95% CI, 0.86 to 0.99]; P = .03). Renal replacement therapy was used in 156 (11.0%) in colloids group vs 181 (12.5%) in crystalloids group (RR, 0.93 [95% CI, 0.83 to 1.03]; P = .19). There were more days alive without mechanical ventilation in the colloids group vs the crystalloids group by 7 days (mean: 2.1 vs 1.8 days, respectively; mean difference, 0.30 [95% CI, 0.09 to 0.48] days; P = .01) and by 28 days (mean: 14.6 vs 13.5 days; mean difference, 1.10 [95% CI, 0.14 to 2.06] days; P = .01) and alive without vasopressor therapy by 7 days (mean: 5.0 vs 4.7 days; mean difference, 0.30 [95% CI, -0.03 to 0.50] days; P = .04) and by 28 days (mean: 16.2 vs 15.2 days; mean difference, 1.04 [95% CI, -0.04 to 2.10] days; P = .03).

CONCLUSIONS AND RELEVANCE

Among ICU patients with hypovolemia, the use of colloids vs crystalloids did not result in a significant difference in 28-day mortality. Although 90-day mortality was lower among patients receiving colloids, this finding should be considered exploratory and requires further study before reaching conclusions about efficacy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00318942.

[Treatment of infected diabetic foot ulcers clinical effectiveness of a dressing of alginate and hydrocolloid, with silver fiber. Analysis of results of a series of cases]

INTRODUCTION

High levels of bacterial load have shown a deleterious influence on wound healing. Using antimicrobial dressings can control ulcers' bioburden. The aim of our study was to evaluate the improving of infected diabetic foot ulcers due an alginate's fiber and hydrocolloid silver dressing.

MATERIAL AND METHODS

We analysed a case series of 6 patients with diabetic foot ulcers without peripheral vascular disease and diagnosed from critical colonization and/or local infection according the presence of inflammation clinical signs. Patients were treated for a minimum period of two weeks. We analysed the percentage reduction in ulcer area from the day of enrolment to antimicrobial dressing removal.

RESULTS

The duration of treatment had a median of 5 weeks with a minimum of 2 weeks and up to 6. The median percentage of area reduction of the wounds was 47.7% (range: 0.5%-90%). The mean percentage reduction on the lesion was 58% from 2 weeks and 67.14% at 3 weeks. All patients had reduced significantly their size at 3 weeks from beginning of treatment (p < 0.05).

CONCLUSION

The use of an alginate's fiber and hydrocolloid silver dressing promotes healing on diabetic foot ulcers with local infection, reducing the inflammatory clinical signs significantly over a period of three weeks.

Patient-specific dosimetry for intracavitary 32P-chromic phosphate colloid therapy of cystic brain tumours

PURPOSE

(32)P-chromic phosphate colloid treatments of astrocytoma and craniopharyngioma cystic brain tumours in paediatric patients are conventionally based on a sphere model under the assumption of uniform uptake. The aims of this study were to determine the distribution of the absorbed dose delivered by (32)P on a patient-specific basis and to evaluate the accuracy with which this can be predicted from a pretherapy administration of (99m)Tc-Sn colloid.

METHODS

Three patients were treated with (32)P-chromic phosphate colloid following (99m)Tc-Sn colloid administrations. Convolution dosimetry was performed using pretherapy and posttherapy sequential SPECT imaging, and verified with EGSnrc Monte Carlo radiation transport simulations. Mean absorbed doses to the cyst wall and dose-volume histograms were also calculated and compared with those obtained by the sphere model approach.

RESULTS

Highly nonuniform uptake distributions of both the (99m)Tc and (32)P colloids were observed and characterized by dose-volume histograms to the cyst wall. Mean absorbed doses delivered to the cyst wall, obtained with the convolution method, were on average 21 % (SD 18 %) and 50 % (SD 30 %) lower than those predicted by the (99m)Tc distribution and the uniform assumption of the sphere model, respectively.

CONCLUSION

Absorbed doses delivered to the cyst wall by (32)P are more accurately predicted from image-based patient-specific convolution dosimetry than from simple sphere models. These results indicate the necessity to perform personalized treatment planning and verification for intracavitary irradiation of cystic brain tumours treated with radiocolloids. Patient-specific dosimetry can be used to guide the frequency and levels of repeated administrations and would facilitate data collection and comparison to support the multicentre trials necessary to progress this therapy.

The care of a child with multiple trauma and severe anemia who was a Jehovah's Witness

Jehovah's Witness followers do not accept blood derived transfusions and available methods for avoiding transfusion have been used with degrees of success, demonstrating that the probability of death after trauma in these patients may not be significantly different from religious groups. In this report, we describe the case of a child victim of a multiple trauma with severe anemia due to blood loss, whose family would not authorize blood transfusion because of their Jehovah's Witness faith. We discuss the current indications for restricting transfusion, as well as highlighting new tools that contribute to the success of minimizing blood loss, thus avoiding transfusion.