Simultaneous infusion of crystalloid solutions during long-term parenteral nutrition.
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Catheterization↗
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Iatrogenic myocardial edema with potassium cardioplegia.
Postischemic myocardial edema depresses left ventricular function and coronary perfusion. Pharmacologic cardioplegia is being used increasingly to enhance myocardial protection during cardiac operations. In the present study we varied the colloid osmotic and osmotic pressures and the infusion pressures of four cardioplegic solutions to determine their respective roles in producing or preventing myocardial edema in a nonischemic setting. We found that myocardial edema during potassium cardioplegia (1) is independent of infusion pressures, (2) is caused by isosmotic crystalloid solutions, (3) is worsened by hyposmolar crystalloid solutions, (4) is avoided by the addition of colloid, and (5) is avoided if the solution is made hyperosmotic with the addition of mannitol.
Animals↗
Preservation of canine hearts after warm ischemia (zero to thirty minutes) and one to two days of hypothermic storage. A comparative analysis of crystalloid and colloid solutions with different osmolarity and ion composition.
The effect of extracellular crystalloid (Ringer's) and colloid (silica gel fraction [SGF]) solutions, and intracellular crystalloid (Sacks) and colloid (modified silica gel fraction [MSGF]) solutions for canine heart preservation in a 24 to 48 hour model of hypothermic storage and zero to 30 minutes of warm ischemia was compared. Canine hearts flushed with an intracellular colloid solution (MSGF) had better survival rates after transplantation than did the hearts flushed with intracellular crystalloid solutions (Sacks). Better survival results also were observed in the group of hearts flushed with extracellular colloid (SGF) solutions than extracellular crystalloid (Ringer's) solutions. The most important theoretical factor in heart preservation appears to be hyperosmolarity and elevated concentration of potassium, proteins, and glucose.
Animals↗
An explanation of impaired solute mixing in extracellular fluid after hemorrhagic hypotension.
A theory is presented suggesting that the slowed rate of solute dispersion in the extracellular fluid (ECF) space during or after hemorrhagic shock is largely due to a depressed cardiac output, and that mixing may be improved by any fluid therapy that decreases the mean recirculation time for the solute. This theory was tested by comparing solute mixing rates after treatment of shocked anesthetized dogs with either protein-free Ringer solution with Ringer solution containing 5% albumin. The rate of mixing was determined by computer analysis of the disappearance of an ECF tracer from plasma. Compared with Ringer-treated dogs, the albumin-treated group had a faster rate of tracer equilibration, larger cardiac plasma output, and smaller, approximately normal ECF volume. It was concluded that the abnormal dispersion of solute within the ECF space seen during or after hypotension can be corrected simply by restoring the cardiac output, and that albumin-containing fluid may be more effective in this regard than crystalloid solution alone.
Animals↗
Osmotic behaviour of human red blood cells: an interpretation in terms of negative intracellular fluid pressure.
1. The observation that human red blood cells do not shrink in hypertonic media as much as expected for ideal osmometers has previously been explained in terms of either a marked increase in the osmotic coefficient of the cell contents or an increase in the chloride content of the cells.2. Changes in suspension pH and haematocrit have been observed when the concentration of the unbuffered NaCl medium was doubled. The small increases in external pH, and the size of the volume decreases, are inconsistent with variations in the Cl content as a significant factor in the non-ideal osmotic responses.3. Membrane potentials of red cells in buffered media were followed using the fluorescent dye, diS-C(3)-(5). On shrinking at pH 7.4, the cells hyperpolarized ca. 5 mV as predicted if changes in the osmotic coefficient rather than in Cl content explained the osmotic behaviour.4. Regarding haemoglobin in concentrated solution as a solute with high osmotic coefficient is formally correct but is little help in understanding the properties of the solution. We have found it useful to consider separately haemoglobin and the rest of the contents of the cell. The haemoglobin then supports part of the total hydrostatic pressure on the cell leaving the crystalloid solution to experience a reduced fluid pressure. In greatly shrunken cells the contents act like a gel with the matrix of haemoglobin under compression and the fluid which fills the spaces within the matrix under tension.
Erythrocytes↗
[Investigations in the streaming blood of the alert animal and man. III. Postprandial and therapeutically induced changes of electrolyte concentration and hematocrit in man during hemodialysis (author's transl)].
Arterial haematocrit and blood electrolyte concentrations are measured continuously by conductometry in three hemodialysis patients. Haematocrit elevation during meals, particularly when rich in carbohydrates, indicate fluid losses into the gut. Simultaneous biphasic responses in electrolyte concentration indicate osmotic and diffusional shifts of water and electrolytes. Similarly, blood volume and electrolyte concentration changes can be followed during and after intravenous infusion of colloid and crystalloid solutions. The quantitative aspects of such measurements are discussed.
Adult↗
Lung water changes after thermal burns. An observational study.
Pulmonary extravascular water has been measured as lung thermal volume (LTV) in a group of nine burned patients. Transducer-detectable indicators were used to permit frequent repetition and quick results. Concurrent recordings were made of cardiac output, pulmonary capillary wedge pressure and the usual hemodynamic variables. Moderate elevation of LTV was seen in all, reaching a maximum value before peripheral edema formation was complete. Left heart filling pressures were low as plasma albumin concentration. Clinical pulmonary edema occurred in one patient treated mostly with crystalloid solution. In several, a secondary peak coincided with edema mobilization.
Adult↗
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↗
The role of thoracic aortic occlusion for massive hemoperitoneum.
Forty patients with abdominal injury and massive hemoperitoneum had left thoracotomy and thoracic aortic occlusion. All 40 patients had tense abdominal distention and 37 patients were hypotensive at the time of skin incision despite aggressive resuscitation with blood and crystalloid solution. Laparotomy was performed initially in 11 patients; seven patients had sudden cardiovascular collapse as the abdominal wall tamponade was released and four patients remained hypotensive. With thoracotomy and thoracic aortic occlusion six of the 11 patients were resuscitated and had their injuries repaired. Thoracotomy and thoracic aortic occlusion were performed before laparotomy in 29 patients: seven patients remained hypotensive and expired; blood pressure was promptly restored in 22 patients and 11 of them survived the operative procedure. Left thoracotomy and thoracic aortic occlusion, before laparotomy, is offered as an alternative approach in patients with refractory hypotension and tense, abdominal distention. This technique aids in rapid restoration of vital signs, insures continued perfusion of the brain and myocardium, provides proximal arterial control, and prevents sudden cardiac arrest as the abdominal wall tamponade is released.
Abdominal Injuries↗
Warm dry air treatment of 345 patients with burns exceeding 20 per cent of the body surface.
Two groups of patients with burns covering more than 20% of the body surface treated in a warm dry environment in two Burn Units in Sweden have been compared. The methods of treatment of the 345 patients were almost identical, using plasma and crystalloid solutions during the period of early intense therapy, use of frequent bathing and early debridement of the necrotic burned tissue and application of homo- or heterograft skin prior to the transplantation of autograft skin. The percentage mortalities in the two groups of patients (15.7% and 20.2%) were not significantly different, neither were the causes of the burn or the cause of death. Combination of the results and probit analysis did however show that treatment in a warm dry environment was associated with a lower rate of mortality in patients with very extensive burns than found in other studies not using these environmental conditions in Sweden prior to 1968 (by the same authors) in the United Kingdom and in the United States of America.
Adolescent↗
Intraosseous infusion: pressure-flow relationship and pharmacokinetics.
In order to quantitatively investigate the usefulness of intraosseous fluid and drug administration as a resuscitative modality, we studied the infusion flow rates of crystalloid solutions obtainable at varying infusion pressures into the bovine tibial medullary cavity and time to initial as well as 90% of maximal effect of intraosseously administered vasoactive drugs. Mean infusion rates +/- SEM (n = 6) at 300, 200, and 100 torr and atmosphere + 81 cm H2O were 41 +/- 2, 32 +/- 1, 27 +/-2, and 10 +/- 1 ml/min, respectively. The mean time (+/- SEM) to initial effect of intraosseous injections (n = 6) of either 0.5 mg epinephrine or 50 mg ephedrine was 17 +/- 3 seconds and mean time to 90% of maximal effect was 45 +/- 5 seconds. These results provide a quantitative basis for resuscitation by fluid and drug administration via the tibial malleolar intraosseous route and suggest that when performed in appropriate situations, the technique may have clinical utility.
Animals↗
Intraoperative hemodilution during elective vascular reconstruction.
Intraoperative hemodilution and retransfusion were used for blood replacement in 30 patients who underwent elective reconstruction of the abdominal aorta, thoracic aorta or femoropopliteal segment. During each operation, 1,000 to 2,000 milliliters of autologous blood were collected through an arterial cannula during induction of anesthesia and the initial stages of operative exposure. Each volume of shed blood was replaced with 1.5 volumes of colloid and crystalloid solutions to maintain a stable intravascular volume despite transient low hematocrit values--mean, 25.8 +/- 2.1 per cent--during the period of maximum blood loss in the surgical field. Collected blood was stored in standard citrate-phosphate-dextrose disposable units and was reinfused at the conclusion of the vascular procedure. Swan-Ganz pulmonary artery catheters were inserted in an initial study group of 15 patients. Serial blood hematocrit and coagulation studies and hemodynamic parameters were measured or calculated before and after induction of anesthesia, during hemodilution, after reinfusion of autologous blood and 24 hours after operation. Improvement in cardiac output and reduction in peripheral vascular resistance maintained adequate systemic oxygen transport during hemodilution. Transient dilution of coagulation factors was documented by abnormal prothrombin and partial thromboplastin times, but serious bleeding tendencies did not occur. Twenty-one of the 30 patients received no homologous blood. Considering the entire series of 30 patients, each required only 0.46 +/- 0.87, S.D., unit of homologous blood during operation and the postoperative period.
Adult↗
Calibration of the limulus test for blood products.
The Protein Fractionation Centre has been using the Limulus Amoebocyte Lysate test for detecting the presence of pyrogens for some five years. All tests on final plasma products have been carried out in parallel with the EP rabbit pyrogen test. Good correlation between both tests has been obtained with products such as distilled water and crystalloid solutions. However, it is more difficult to correlate results when dealing with plasma proteins. Each product appears to react differently. Some normally pass the limulus test undiluted while others, such as immune globulins and albuminoid products, have to be diluted to various concentrations before they pass. A preliminary statistical analysis has been carried out on the results of pyrogen testing on Stable Plasma Protein Solution, firstly to ascertain that a significant correlation does exist between the LAL test and the rabbit test, and secondly to try to obtain "cut off" values for the limulus test which compare well with the official EP temperature rises in the rabbit test.
Animals↗
[Anaesthesia problems in massive transfusion (author's transl)].
It is essential for adequate anaesthesia during massive transfusion to avoid further shift of the oxygen dissociation curve to the left by hyperventilating the patient, by not rewarming the cold blood and by an overenthusiastic correction of an eventually arising metabolic acidosis. The occurrence of coagulation disorders during massive transfusion has been overestimated in the past and is a poor basis for "blind" substitution. The additional use of blood microfilters and caustious attitude towards the use of crystalloid solutions e.g. Ringer lactate, are indispensable measures for counteracting impending pulmonary insufficiency. The avoidance of surfactant irritating inhalation anesthetics such as halothane or methoxyflurane seems advisable. In this context the use of adequate PEEP plays an important role. Circulatory stability is guaranteed by using ketamine or fentanyl for general anaesthesia and analgesia, and by the use of pancuronium for relaxation.
Anesthesia↗
[Risks of therapy in infectious shock].
On the basis of their experience in the intensive therapy unit, correlated with modern pharmacokinetic data, the authors discuss the adverse effects induced by polyvalent therapy in septic shock, and which may be listed in the group of iatrogenic pathointerference. To the biochemical and functional alterations of shock may be added the possible effects of antibioticotherapy, corticotherapy, plasma expanders, lipid emulsions, crystalloid solutions, alkaline correcting solutions, osmotic diuretics, oxygenotherapy, vasoactive drugs, heparin and epsilon-amino-caproic acid. The possible summation of these effects should be indicated in the rules for observance by the medical staff of intensive therapy units.
Aminocaproic Acid↗
[Resorption of crystalloid and colloidal radioisotope solutions by the peritoneal cavity under normal physiological conditions (experimental studies)].
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Absorption↗
Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock.
BACKGROUND: Whether treatment with balanced crystalloid fluid leads to better outcomes than 0.9% saline in children treated for septic shock is debated. METHODS: In this pragmatic clinical trial conducted at 47 emergency departments in five countries, patients (2 months to <18 years of age) with suspected septic shock and abnormal perfusion were randomly assigned to receive fluid resuscitation with either balanced fluid or 0.9% saline for up to 48 hours. The primary outcome was a major adverse kidney event (a composite of death, new renal-replacement therapy, or persistent kidney dysfunction) at 30 days after enrollment or hospital discharge, whichever occurred first. RESULTS: Of 9041 enrolled patients, 277 (6.1%) in the balanced-fluid group and 282 (6.2%) in the 0.9%-saline group withdrew from the trial, leaving 4235 and 4247 patients, respectively, for analysis. A primary-outcome event occurred in 137 patients (3.4%) in the balanced-fluid group and in 124 (3.0%) in the 0.9%-saline group (difference, 0.4 percentage points; 95% confidence interval [CI], -0.5 to 1.3; risk ratio, 1.10; 95% CI, 0.88 to 1.40; P = 0.85). The median number of hospital-free days during 28 days after enrollment was 23 (interquartile range, 19 to 25) in both groups. Hyperchloremia occurred in 868 patients (31.4%) in the balanced-fluid group and in 1383 (49.0%) in the 0.9%-saline group; hypernatremia in 52 (1.8%) and 89 (3.1%), respectively; and hyperlactatemia in 260 (19.8%) and 228 (16.7%). No differences in other safety outcomes or adverse events were seen. CONCLUSIONS: Among children treated for septic shock, no significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline. (Funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; PRoMPT BOLUS ClinicalTrials.gov number, NCT04102371.).
Adolescent↗
Hyper-oncotic albumin administration reduces mortality in acute Respiratory Distress Syndrome compared to crystalloid: a systematic review and meta-analysis.
BACKGROUND: To evaluate the association between albumin administration as volume replacement and mortality in adult ARDS patients, we performed this meta-analysis and trial sequential analysis (TSA). METHODS: We searched databases including PubMed, Science Direct, Scopus, Web of Science databases and Cochrane Central Register of Controlled Trials up to 12 December 2024. We screened trials that included adult ARDS patients and compared albumin with crystalloid. The 28-day mortality served as the primary endpoint, while the oxygenation change, the length of ICU stay and the length of hospital stay were designated as secondary outcomes. To clarify the differing concentrations of albumin, we formed two distinct subgroups: the hyper-oncotic albumin subgroup (≥20%) and the iso-oncotic albumin subgroup (4%∼5%). Statistical synthesis was performed with Cochrane Review Manager 5.4.1, employing random-effects models. To mitigate random errors, TSA was implemented with α = 0.05 and β = 0.20 parameters. RESULTS: The analysis incorporated 5 publications: 3 randomized controlled trials (RCTs) and 2 non-randomized studies (NRSs). Overall mortality was lower in the albumin group (33.2%, 97/292) than in the crystalloid group (44.9%, 133/296) (OR = 0.61, 95%CI 0.43-0.85, p = 0.004). RCTs (n = 204) showed no benefit (OR = 0.83, p = 0.54), but NRSs (n = 384) demonstrated reduced mortality (OR = 0.52, p = 0.002). Hyper-oncotic albumin was associated with lower mortality in NRSs (OR = 0.40, p = 0.02) but not in RCTs (OR = 0.74, p = 0.57). Iso-oncotic albumin showed no benefit (OR = 0.88, p = 0.72). Regarding the impact of albumin on oxygenation, significant improvements in oxygenation were observed only on the first (p = 0.05) and second days (p < 0.0001). The TSA indicated a continued need for high-quality RCTs. CONCLUSIONS: Our analysis suggests that hyper-oncotic albumin may reduce mortality and improve early oxygenation in ARDS patients compared to crystalloids. Larger RCTs are urgently needed to validate these findings and define their potential role in clinical management.
Humans↗