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.

[Meningococcal purpura fulminans: treatment with recombinant protein C activator in 3 cases]

Purpura fulminans is a serious disease associated with high rates of morbidity and mortality. It usually leads to disseminated intravascular coagulation and septic shock related to reduced levels of protein C. Recombinant protein C (rPC) activator has been used successfully to inhibit this process. Intracranial hemorrhages are the most important, life-threatening adverse effects of treatment with rPC activator. We report 3 cases of patients with meningococcal purpura fulminans who developed septic shock and multiorgan dysfunction. They were treated with the protocol for septic shock, antibiotics and rPC activator from the time of admission, and improvement in hemodynamic dysfunction was observed within hours in all patients. All received platelet replacement transfusions. Subarachnoid bleeding complications occurred in 2 patients. One patient died 5 days after admission and 2 were discharged from the intensive recovery care unit 28 days after admission.

[Evaluation of "hidden" renal insufficiency by abbreviated-MDRD equation]

BACKGROUND

Early detection of renal insufficiency (RI) allows to start therapies in order to slow renal disease progression and modify associated risk factors. Serum creatinine (Cr) is not a good marker of renal insufficiency. Some patients with significant renal failure can show Cr values in the normal range. Cr derived equations can help us to estimate glomerular filtration rate (GFR) more precisely. The aim of this study has been to know the utility of abbreviated-MDRD equation to detect "hidden" (non detected by Cr) renal insufficiency in patients attending general practices.

MATERIAL AND METHODS

Patients with blood samples attending general practices in two localities were studied during one year. In all, one thousand patients were included. Collected data were: age, sex, creatinine, haemoglobin, previous diagnosis of arterial hypertension or diabetes mellitus and chronic abuse of analgesic. Abbreviated MDRD equation was used to know GFR. "Hidden" RI was defined when GFR was lower than 60 ml/min/1.73 m2 and Cr was in the normal range.

RESULTS

104 (10.4%) patients showed "hidden" RI. Patients with "hidden" RI were older (70.7 +/- 12.5 vs. 52.4 +/- 18.6 years, p < 0.001), were more frequently women (86.5% vs 62.4%, p < 0.001) and hypertensive (46.1% vs. 23.6%, p < 0.001) and showed lower levels of haemoglobin (13.8 +/- 1.3 vs 14.2 +/- 1.3 g/dl, p = 0.001).

CONCLUSIONS

In patients attending general practices abbreviated-MDRD allows to recognise a significant number of patients with "hidden" renal insufficiency, but with normal range creatinine. Patientes with "hidden" renal insufficiency are more frequently older, women and hypertensive.