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PubMed1979

Correlation of changes in body weight and pulmonary vascular pressures with lung water accumulation during fluid overload.

The accumulation of excess lung water is a major concern after the infusion of large amounts of crystalloid solution. The parameters used to monitor total body and lung water balance include changes in body weight, and the measurement of pulmonary vascular and plasma colloid osmotic pressures. We studied the reliability of these parameters in predicting lung water during severe fluid overload in nephrectomized sheep. We found that the normal lung appeared resistant to excess fluid accumulation, particularly when compared to the splanchnic circulation. Body weight change was an unreliable index of lung water with a correlation coefficient of 0.43. Pulmonary vascular pressures were the best index (r = 0.83) with lung water accumulating rapidly after capillary pressure exceeded 30 cm H2O. The difference between pulmonary capillary pressure and plasma colloid osmotic pressure was not as reliable (r = 0.72) as was capillary pressure alone.

Animals↗
PubMed1990

Fluid therapy and the resuscitation of traumatic shock.

Fluid management of the traumatized patient begins with assessment of volume status via palpation of pulses; evaluation of mental status; and measurement of urine output, arterial blood pressure, and central pressures. Intravascular line placement and choice of initial resuscitation fluids should be individualized to the clinical situation, although in most situations a crystalloid solution continues to be the initial fluid of choice. Following initial stabilization, the intravenous fluid administered can be tailored to a given situation, chosen only after the deranged fluid balance is sequentially classified according to alterations of volume, concentration, and composition. Parenteral fluids may be divided into two groups: crystalloids and colloids. The indications, complications, and controversies surrounding various resuscitation modalities have been reviewed.

Colloids↗
PubMed1986

Free radical scavengers and myocardial preservation during transplantation.

The efficacy of oxygen radical scavengers in preservation of left ventricular (LV) function after prolonged hypothermic global ischemia was investigated in a model of orthotopic cardiac transplantation in sheep. Group 1 hearts (N = 8) received hypothermic crystalloid cardioplegic solution, and were harvested and stored at 4 degrees C in balanced electrolyte solution for six hours prior to transplantation. Group 2 (N = 9) received identical treatment with the addition of 30,000 units of superoxide dismutase to the cardioplegic solution and the administration of 60,000 units of superoxide dismutase coincident with reperfusion. All animals were weaned from cardiopulmonary bypass. Preischemic and postischemic LV function was determined using sonomicrometry and a micromanometer-tipped LV catheter. Coronary blood flow was determined using standard microsphere techniques, and platelet deposition was assayed with autologous platelets labeled with indium 111. Lipid peroxidation products were measured using thiobarbituric acid assay. LV performance was significantly better (p less than .05) in Group 2 hearts when assessed by the slope of the end-systolic pressure-volume relationship and the stroke work versus end-diastolic volume relationship. There was better preservation of endocardial blood flow in the group receiving superoxide dismutase compared with controls (p less than .05). Platelet deposition, as determined by the tissue to blood ratio of scintigraphic counts, was greater (p less than .05) in controls compared with the group receiving superoxide dismutase. In addition, thiobarbituric acid reactive species were significantly less (p less than .05) in Group 2 versus Group 1 hearts.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMedDate not supplied

The effects of low flow, low pressure pulsatile bypass.

The effects of low flow low pressure pulsatile bypass were studied in 90 consecutive patients undergoing coronary artery surgery. Overall pump flow rate (OFR) was 19-49 (mean 31 +/- 7) ml/kg/min at all temperatures. Moderate (28 degrees C) hypothermia was used. When cross-clamped flow was 17-49 (mean 27 +/- 7) ml/kg/min and mean perfusion pressure 50-60 mmHg. Priming volume (PV) was reduced to 1.45 +/- 0.02 L (range 1.2-2.0 L) PV, cardioplegia and volume additions were considered as total bypass crystalloid (TBC) and this correlated positively with increased post-operative positive water balance (r = 0.58, P less than 0.001). Bypass urine output averaged 135 +/- 24 ml (range 0-1,000 ml) was unrelated to OFR and correlated only with TBC (r=0.47, P less than 0.001). In 86 a single cardioplegia dose of 0.7 L (range 0.4-0.8 L) sufficed for this ischaemic period (mean 46 +/- 16 min). Four required a further 0.2-0.3 L. Their ischemic times were 44-74 min (mean 59 +/- 13 PNS). Inotropes were used in only 3 patients. Post-operatively 7 required diuretics for low hourly urine flow. Of the 76 with normal pre-operative renal function urea rose transiently in 15. Three had raised urea for over 9 days. Creatinine rose transiently in 7 but persisted in only one. Plasma cortisol (n=78) rose in 67 and fell in 11, indicating, overall, an adequate metabolic response. Plasma free haemoglobin before and after bypass varied widely and did not correlate with flow rate or perfusion time.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1984

Vasopressin supplementation in a porcine model of brain-dead potential organ donors.

The use of vasopressin to limit the polyuria of the brain-dead organ donor is a controversial subject. It is held that the associated vasoconstriction may result in ischemic damage to transplantable organs. However, the derangements in the intravascular--and thereby interstitial and intracellular--fluid and electrolyte balances associated with diabetes insipidus may lead to gross fluid shifts in the organ donor. Aggressive resuscitation with crystalloid solutions may aggravate these fluid shifts, contribute to the development of interstitial and intracellular edema, and ultimately result in cardiovascular failure and the rejection of the organs for transplantation. Theoretically, a minute amount of vasopressin is required for the maintenance of normal intravascular fluid and electrolyte balance, and it is best administered as a continuous i.v. infusion. We report on our study of an animal model of a brain-dead organ donor, in which polyuria, hypernatremia, and hyperosmolality developed. The administration of low-dose (2-10 microU/kg/min) vasopressin by continuous infusion maintained plasma sodium and osmolality in the normal range over the course of the experiments (24 hr) in the experimental group. Cardiovascular function remained stable in both control and experimental vasopressin-infusion) groups, with the only significant difference being a moderate rise in pulmonary artery pressure. It would appear that early low-dose vasopressin supplementation by continuous i.v. infusion may improve donor management. The maintenance of intravascular homeostasis may contribute to the quality and number of organs for transplantation.

Animals↗
PubMed1996

Burn resuscitation: crystalloid versus colloid versus hypertonic saline hyperoncotic colloid in sheep.

OBJECTIVES: The present study was undertaken to assess the fluid balance and hemodynamic effects during the first 8 hrs of resuscitation in animals with a large body surface area burn, using lactated Ringer's solution, 6% hetastarch, and hypertonic saline dextran. DESIGN: A prospective, blinded, controlled, terminal study, using anesthetized animals. The initial baseline period was followed by scald injury, and three different treatment regimens were administered from coded bags to achieve a physiologic end point. SETTING: University laboratory. SUBJECTS: Eighteen female sheep (35 to 45 kg) were anesthetized with isoflurane. INTERVENTIONS: Test solutions (10 mL/kg of either lactated Ringer's solution, hetastarch, or hypertonic saline dextran) were infused 30 mins after the scald injury at a rate to restore and maintain the baseline oxygen delivery (DO2) value. MEASUREMENTS AND MAIN RESULTS: Cardiovascular hemodynamics, plasma sodium concentration, plasma colloid osmotic pressure, and fluid balance were measured before and after scalding and resuscitation. After the initial 10-mL/kg test solution dose was given, lactated Ringer's solution was infused to achieve the same end point of baseline DO2 for the remainder of the 8 hrs. The scald caused an initial 30% reduction in cardiac output, a 20% reduction in mean arterial pressure, and 10% to 15% increase in hematocrit. All three test solutions restored and maintained baseline DO2 within 1 hr. However, hetastarch and hypertonic saline dextran reduced the net fluid volume over 8 hrs by 48% and 74%, respectively, compared with lactated Ringer's solution. Edema in the burn wound was not affected by treatment, while hypertonic saline dextran reduced edema in nonburned skin compared with both lactated Ringer's solution and hypertonic saline dextran. Plasma colloid osmotic pressure was significantly higher in the hetastarch and hypertonic saline dextran groups. A continuous decrease in plasma sodium concentrations from baseline values (140 to 145 mmol/L) was measured in the lactated Ringer's solution and hetastarch groups (130 to 133 mmol/L) over 8 hrs. Plasma sodium concentrations in the group receiving hypertonic saline dextran were increased (150 to 155 mmol/L) at 4 hrs, but returned toward baseline by 8 hrs. CONCLUSIONS: Net volume loading can be reduced markedly by initial resuscitation of large body surface area burn injury using a colloid (hetastarch), and can be further reduced by use of hypertonic saline colloid. Hyponatremia was apparent in the isotonic crystalloid- and colloid-treated animals, but not in those animals treated with hypertonic saline colloid.

Animals↗
PubMed1995

A comparison of albumin, polygeline and crystalloid priming solutions for cardiopulmonary bypass in patients having coronary artery bypass graft surgery.

This study was designed to assess the effect of different prime solution compositions on a patient's fluid balance, transfusion requirements, renal function and haemodynamic stability over the first 24 hours postbypass. Ninety-three patients presenting for first-time coronary artery bypass graft (CABG) surgery were randomly allocated to receive one of three prime solutions for the CPB pump: albumin (4.6%) + Plasmalyte (Group A, n = 32), polygeline (Hemaccel) + Plasmalyte (Group P, n = 29), or crystalloid (Plasmalyte) alone (Group C, n = 32). Patients, anaesthetists, surgeons and intensive care unit (ICU) staff were all blinded as to the solution type. The groups were demographically and haemodynamically similar. There were no differences between the groups with respect to white cell or platelet counts during the study. There was a significant difference in haemoglobin levels between the groups on weaning from CPB and on arrival in the ICU (Group C > Groups P and A, p < 0.001 for both times). There was no difference in blood transfusion requirements between any of the groups. During CPB, Group C required significantly more crystalloid than the other groups (p < 0.001). Urine output was significantly higher in Group C compared with Groups P and A at all time periods up to and including ICU 12 hours (p < 0.05). The use of frusemide was significantly higher in the ICU in Groups P and A (p < 0.01). There was a net gain of 3132 +/- 412 ml in Group C in 24 hour fluid balance, which was significantly higher than Group A (2166 +/- 223 ml, p = 0.04). Our results show that, in this patient population, there is no advantage in using a colloid-based prime solution over a purely crystalloid solution from a haemotologic or haemodynamic point of view for the first 24 hours after CPB. There appears to be an increase in extracellular fluid (ECF) retention in Group C, but this caused no related problems in the study period. On the other hand, diuretics (frusemide) needed to be given significantly less often in these patients to offset oliguria.

Albumins↗
PubMed2006

Risk factors for postoperative nausea and vomiting.

Knowledge of postoperative nausea and vomiting (PONV) risk factors allows anesthesiologists to optimize the use of prophylactic regimens. Modern PONV risk research began in the 1990s with publication of studies using logistic regression analysis to simultaneously identify multiple independent PONV predictors and publication of meta-analyses and systematic reviews. This literature shows that female gender post-puberty, nonsmoking status, history of PONV or motion sickness, childhood after infancy and younger adulthood, increasing duration of surgery, and use of volatile anesthetics, nitrous oxide, large-dose neostigmine, or intraoperative or postoperative opioids are well established PONV risk factors. Possible risk factors include history of migraine, history of PONV or motion sickness in a child's parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration, increasing duration of anesthesia, general versus regional anesthesia or sedation, balanced versus total IV anesthesia, and use of longer-acting versus shorter-acting opioids. Early-phase menstruation, obesity and lack of supplemental oxygen are disproved risk factors. Current risk scoring systems have approximately 55%-80% accuracy in predicting which patient groups will suffer PONV. Further research examining genetic and under-investigated clinical patient characteristics as potential risk factors, and involving outpatients and children, should improve predictive systems.

Humans↗
PubMed1981

Balanced salt solution in blood loss replacement.

This is a review article of the debated massive use of balance electrolyte solutions in the replacement of blood loss. We cannot directly apply the results and conclusions of American reviews on this subject as there are significant differences between USA and Finland in the use and availability of alternative fluids. Electrolyte solutions pass freely across the capillary membrane and are distributed in the extracellular compartment and as such poorly restore and maintain blood volume. In order to be effective they have to be infused in volumes trice the blood loss. Efficient protective mechanisms in the pulmonary capillary membranes prevent the appearance of pulmonary interstitial edema even when crystalloids are used in massive amounts. There is however significant water retention and edema in the periphery which results in impaired tissue oxygenation. The optimum anion composition of balanced electrolyte solutions is unsettled. In blood loss replacement electrolyte solutions without dextrose are preferred. The minimal amounts of potassium in balanced electrolyte solutions is of no practical value. Even though crystalloid solutions can be tolerated in massive amounts, marked blood loss is replaced more physiologically and effectively using natural or artificial colloids in iso-oncotic concentrations together with red cell concentrates and fresh blood.

Blood Volume↗
PubMed1989

Does the addition of albumin to the prime solution in cardiopulmonary bypass affect clinical outcome? A prospective randomized study.

Colloid solution is commonly used to increase the oncotic pressures of priming solutions used in the cardiopulmonary bypass circuit. To study the effectiveness of this practice, we prospectively randomized 100 adult patients undergoing cardiac operations to receive Ringer's lactate solution plus 50 gm of albumin (group A) or Ringer's lactate solution alone (group B) as the prime solution for the bypass circuit. Personnel involved in the management of these patients were blinded concerning the group to which the patients had been randomized. Forty clinical parameters related to perioperative fluid balance, cardiopulmonary function, and renal function were studied. Although group B received a larger volume of crystalloid solution intraoperatively (p less than 0.05), had a lower mean cardiac filling pressure (p less than 0.05), and had a higher hematocrit value (p less than 0.05) in the immediate postoperative period, all mean values for both groups were within the normal range. There were no differences between the two groups with regard to postoperative clinical parameters of cardiopulmonary and renal function, nor was outcome affected by the addition of albumin to the prime solution. We conclude that there is no clinically detectable advantage for the practice of adding 50 gm of albumin to the priming solution of bypass circuits in adults undergoing cardiac operations. Routinely supplementing the bypass prime solution with albumin adds significant cost, estimated to be approximately $10,000 per 100 cases, without demonstrable clinical benefits. Whether this practice can be of value in selected cases needs to be further studied.

Albumins↗
PubMed1982

The effect of a new branched chain--enriched amino acid solution on postoperative catabolism.

Branched-chain amino acids (BCAAs) may regulate muscle amino acid flux. Metabolic studies of both experimental animals and humans utilizing comparatively large amounts of BCAAs infused with hypocaloric glucose have shown that catabolism and proteolysis can be blunted. These studies suggested that the nitrogen-sparing properties of amino acid solutions used in postoperative trauma or sepsis might be improved by increasing the amount of BCAAs. This hypothesis was tested on ten patients undergoing operations of moderate severity utilizing a peripheral amino acid mixture with a branched-chain:non-branched-chain ratio of 45:55% given in 5% dextrose. The patients received 1.7 gm of protein equivalent/kg of ideal body weight in 5% dextrose-crystalloid solution with a concentration of 3.5% amino acids for the first 5 postoperative days. Nitrogen balance, 3-methylhistidine excretion, blood chemistries, and plasma amino acid profile tests were done daily. The results showed that nitrogen equilibrium was maintained for 5 postoperative days without any untoward effects on patients, their surgical wounds, or hepatic function. Plasma amino acids showed no significant changes from baseline with the exception of elevations of the BCAAs. We conclude that this 45% BCAA-enriched solution may be safely administered to patients with postoperative traumatic injury and results in nitrogen equilibrium over a 5-day period.

Adolescent↗
PubMed2005

Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery.

Fluid therapy is one of the most controversial topics in perioperative management. There is continuing debate with regard to the quantity and the type of fluid resuscitation during elective major surgery. However, there are increasing reports of perioperative excessive intravascular volume leading to increased postoperative morbidity and mortality. Recent evidence suggests that judicious perioperative fluid therapy improves outcome after major elective gastrointestinal surgery. The observed benefits may not be solely attributable to crystalloid restriction but also to the use of colloids instead. Some clinically useful guidelines based on the studies discussed in this review include avoidance of deep general anesthesia and elimination of preload for patients who receive epidural analgesia. A balanced approach to fluid management is recommended, with colloids administered to provide hemodynamic stability and maintain urine output of 0.5 mL x kg(-1) x h(-1) and crystalloids administered only for maintenance. In addition, blood loss may be replaced with colloid on a volume-to-volume basis. Furthermore, predetermined algorithms that suggest replacement of third space losses and losses through diuresis are unnecessary. Significant reduction in crystalloid volume can be achieved without encountering intraoperative hemodynamic instability or reduced (i.e., < 0.5 mL x kg(-1) x h(-1)) urinary output just by avoiding replacement of third space losses and preloading. Finally, there is a need for well-controlled studies in a well-defined patient population using clear criteria or end-points for perioperative fluid therapy.

Blood Volume↗
PubMed2004

The effect of bloodless pump prime on cerebral oxygenation in paediatric patients.

BACKGROUND: In paediatric patients, crystalloid prime for cardiopulmonary bypass (CPB) causes further haemodilution in comparison with blood-containing prime. Thus it may affect the cerebral oxygen supply/demand balance. The purpose of the study was to compare the effect of bloodless pump prime with that of blood-containing prime on cerebral oxygenation in children. METHODS: Thirty-six paediatric patients scheduled for elective repair of atrial or ventricular septal defect were enrolled. In Group C (n = 18), the CPB circuit was primed only with crystalloid. In Group B (n = 18), red blood cells were added to achieve a haematocrit (Hct) of 20% during CPB. The regional cerebral oxygen saturation (rSO(2)) value measured by near-infrared spectroscopy was compared between the two groups. RESULTS: In both groups, rSO(2) decreased below baseline at the start of CPB and during rewarming (P < 0.001, for both groups during each period). At the start of CPB, haemodilution was greater in Group C than in Group B (Hct 16.1 +/- 0.7% vs. 20.7 +/- 0.5%; P < 0.01), and there was a greater reduction in rSO(2) in Group C (49.0 +/- 5.4% vs. 59.2 +/- 7.0%; P < 0.01). During rewarming, rSO(2) was significantly lower in Group C than in Group B (57.8 +/- 5.3% vs. 62.8 +/- 6.2%; P < 0.01). CONCLUSIONS: In paediatric patients, the haemodilution associated with crystalloid priming causes a greater reduction in rSO(2) than with blood-containing prime at the starting period of CPB and the rewarming period.

Analysis of Variance↗
PubMed1987

Effect of irrigation fluids on arterial and venous endothelium after ischemia.

This study examines the extent of endothelial damage following a period of irrigation with various crystalloid irrigation fluids. Both arteries and veins were evaluated after irrigation with normal saline, lactated Ringer's, Balanced Salt Solution (BSS), and Balanced Salt Solution Plus (BSS+). The arterial and venous endothelia were examined with the scanning electron microscope. Using a randomized blind observer scoring system, micrographs were evaluated for changes in nuclear shape, cell junction integrity, cytoplasm changes, and sloughing of the endothelial cell layer. BSS+ and BSS produced statistically significant (P less than .001) improvement over the other two irrigation fluids in the arteries. BSS+ and BSS were statistically superior (P less than .001) in the venous vessels. The compositions of BSS and BSS+ tend to maintain a physiologic environment in the presence of ischemia. These fluids maintained a morphologic appearance closer to that of perfusion-fixed controls. The data suggest a protective effect of such physiologic preparations on the endothelium. The preservation of intact endothelium may play a role in decreased platelet activation, continued production of prostacyclin, and maintenance of an intact barrier between the intracellular and extracellular spaces. This could enhance the survival of transplanted or transferred tissue, by helping to maintain nearly normal endothelium during surgery.

Acetates↗
PubMed1990

[Hemodynamic, coagulation and glycoregulation changes induced by brain death].

Brain death results in various changes in circulation haemostasis, acid-base balance and glycoregulation. This study was carried out between February 1988 and December 1988 in 91 patients with brain death. Age range was between 6 and 58 years. The cause of brain death was brain trauma (71%) and vascular malformations (26%). In all patients a cardio-vascular collapse occurred at the moment of brain death, requiring an intravascular loading (466.3 +/- 240.3 ml.h-1) with crystalloids and albumin. Dopamine was used in 70% of cases at the dose of 3 micrograms.kg.min-1 to improve kidney and splanchnic perfusion. No alterations of acid-base balance were observed in these patients who admitted for organ donation in a short delay (17.1 +/- 6 h). Haemostasis was modified in all patients but the alterations occurred before the brain death and were related to brain injury. Further investigations are required for a better understanding of glycoregulation changes as they could influence pancreatic transplant survival. Hormonal changes have also to be more extensively studied for possible physiopathologic causes of the variations. A better understanding of these alterations will be of benefit for management of patients in brain death and potential organ donors.

Adolescent↗
PubMed2001

Does a hyperoncotic cardiopulmonary bypass prime affect extravascular lung water and cardiopulmonary function in patients undergoing coronary artery bypass surgery?

OBJECTIVE: Different types of colloidal priming for cardiopulmonary bypass (CPB) have been used to reduce fluid load and to avoid the fall of plasma colloid osmotic pressure (COP) that leads to edema formation and consequently can cause organ dysfunction. The discussion about the optimal priming composition, however, is still controversial. We investigated the effect of a hyperoncotic CPB-prime with hydroxyethyl starch (HES) 10% (200;0.5) on extravascular lung water (EVLW) and post-pump cardiac and pulmonary functions. METHODS: In 20 randomized patients undergoing elective coronary artery bypass graft surgery (CABG), a colloid prime (COP: 48 mmHg, HES-group, n = 10) and a crystalloid prime (Ringer's lactate, crystalloid group, n = 10) of equal volume were compared with respect to the effects on cardiopulmonary function. Cardiac index (CI), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance index (SVRI), pulmonary artery pressure (PAP), pulmonary vascular resistance index (PVRI), alveolo-arterial oxygen difference (AaDO(2)), pulmonary shunt fraction (Q(s)/Q(T)), EVLW (double-indicator dilution technique with ice-cold indocyanine green), COP, fluid balance and body weight were evaluated peri-operatively. RESULTS: Pre-operative demographic and clinical data, CPB-time, cross-clamp time and the number of anastomoses were comparable for both groups. During CPB, COP was reduced by 20% in the HES-group (18.9 +/- 3.7 vs. 23.7 +/- 2.2 mmHg, P < 0.05) while it was reduced by more than 50% of the pre-CPB value (9.8 +/- 2.0 vs. 21.4 +/- 2.1 mmHg, P < 0.05) in the crystalloid group (P < 0.05 HES- vs. crystalloid group). Post-CPB EVLW was unchanged in the HES-group but it was elevated by 22% in the crystalloid group (P < 0.05 HES- vs. crystalloid group), CI was higher in the HES-group (3.4 +/- 0.3 vs. 2.7 +/- 0.5l/min, P < 0.05). Fluid balance was less in the HES-group (813 +/- 619 vs. 2143 +/- 538, P < 0.05). Post-operative weight gain could be prevented in the HES-group but not in the crystalloid group (1.5 +/- 1.2 vs. -0.3 +/- 1.5, P < 0.05). No significant differences were seen for MAP, PAP, PCWP, SVRI, PVRI, AaDO(2) and (Q(s)/Q(T)) between the two groups at any time. CONCLUSIONS: Hyperoncotic CPB-prime using HES 10% improves CI and prevents EVLW accumulation in the early post-pump period, while pulmonary function is unchanged. This effect can be of benefit especially in patients with congestive heart failure.

Blood Loss, Surgical↗