Changes in colloid oncotic pressure during cardiac surgery with different prime fluid strategies.

OBJECTIVE: In cardiac surgery, colloid oncotic pressure (COP) is affected by haemodilution that results from composition and volume of prime fluid of cardiopulmonary bypass (CPB). However, the extent to which different priming strategies alter COP is largely unknown. Therefore, we investigated the effect of different priming strategies on COP in on-pump cardiac surgery. METHODS: Patients (n = 60) were divided into 3 groups (n = 20 each), based on the center in which they were operated and the specific prime fluid strategy used in that center during the inclusion period. CPB prime fluids were either gelofusine-, albumin-, or crystalloid based, the latter two with or without retrograde autologous priming. RESULTS: In all groups, COP was lowest after weaning from CPB and one hour after CPB. Between groups, COP was lowest with gelofusine prime fluid (16.4, 16.8 mmHg, respectively) compared with crystalloids (MD: -1.9; 95% CI:-3.6, -0.2; p = .02 and MD: -2.4, 95% CI: -4.2, -0.7; p = .002) and albumin (MD: -1.8, 95% CI: -3.5, -0.50; p = .041 and MD: -2.4, 95% CI: -4.1, -0.7; p = .002). In all groups, the decrease in COP one hour after bypass compared to baseline correlated positively with fluid balance at the end of surgery (p < .001). CONCLUSIONS: COP significantly decrease during CPB surgery with the largest decrease in COP at the end of surgery, while at the same time fluid balance increases. We suggest that prime fluid strategy should be carefully selected when maintenance of COP during cardiac surgery is desirable.

Effects of crystalloid and colloid priming strategies for cardiopulmonary bypass on colloid oncotic pressure and haemostasis: a meta-analysis.

OBJECTIVES: Colloid oncotic pressure (COP) is an important factor in cardiac surgery, owing to its role in haemodilution. The effect of cardiopulmonary bypass prime fluids on the COP is unknown. In this study, the effect of crystalloid and colloid prime fluids, with or without retrograde autologous priming (RAP), on the COP during elective cardiac surgery was evaluated. METHODS: Randomized controlled trials and prospective clinical trials comparing crystalloid and colloid priming fluids or with RAP were selected. The primary outcome was the COP; secondary outcomes were fluid balance, fluid requirements, weight gain, blood loss, platelet count and transfusion requirements. RESULTS: From 1582 records, 29 eligible studies were identified. COPs were comparable between gelofusine and hydroxyethyl starch (HES) during bypass [mean difference (MD): 0.69; 95% confidence interval (CI): -2.05, 3.43; P = 0.621], after bypass (MD: -0.11; 95% CI: -2.54, 2.32; P = 0.930) and postoperative (MD: -0.61; 95% CI: -1.60, 0.38; P = 0.228). Fluid balance was lower with HES than with crystalloids. RAP reduced transfusion requirements compared with crystalloids. Blood loss was comparable between groups. CONCLUSIONS: COPs did not differ between crystalloids and colloids. As a result of increased transcapillary fluid movement, fluid balance was lower with HES than with crystalloids. Haematocrit and transfusion requirements were comparable between groups. However, the latter was lower when RAP was applied to crystalloid priming compared with crystalloids alone. Finally, no differences in blood loss were observed between the groups.

Advances in airway management and mechanical ventilation in inhalation injury.

PURPOSE OF REVIEW: Airway management, mechanical ventilation, and treatment of systemic poisoning in burn patients with inhalation injury remains challenging. This review summarizes new concepts as well as open questions. RECENT FINDINGS: Several life-threatening complications, such as airway patency impairment and respiratory insufficiency, can arise in burn patients and require adequate and timely airway management. However, unnecessary endotracheal intubation should be avoided. Direct visual inspection via nasolaryngoscopy can guide appropriate airway management decisions. In cases of lower airway injury, bronchoscopy is recommended to remove casts and estimate the extent of the injury in intubated patients. Several mechanical ventilation strategies have been studied. An interesting modality might be high-frequency percussive ventilation. However, to date, there is no sound evidence that patients with inhalation injury should be ventilated with modes other than those applied to non-burn patients. In all burn patients exposed to enclosed fire, carbon monoxide as well as cyanide poisoning should be suspected. Carbon monoxide poisoning should be treated with an inspiratory oxygen fraction of 100%, whereas cyanide poisoning should be treated with hydroxocobalamin. SUMMARY: Burn patients need specialized care that requires specific knowledge about airway management, mechanical ventilation, and carbon monoxide and cyanide poisoning.

The European Board of Anaesthesiology recommendations for safe medication practice: First update.

These European Board of Anaesthesiology (EBA) recommendations for safe medication practice replace the first edition of the EBA recommendations published in 2011. They were updated because evidence from critical incident reporting systems continues to show that medication errors remain a major safety issue in anaesthesia, intensive care, emergency medicine and pain medicine, and there is an ongoing need for relevant up-to-date clinical guidance for practising anaesthesiologists. The recommendations are based on evidence wherever possible, with a focus on patient safety, and are primarily aimed at anaesthesiologists practising in Europe, although many will be applicable elsewhere. They emphasise the importance of correct labelling practice and the value of incident reporting so that lessons can be learned, risks reduced and a safety culture developed.

Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement.

INTRODUCTION: Hydroxyethyl starch (HES) is a commonly used colloid in critically ill patients. However, its safety has been questioned in recent studies and meta-analyses. METHODS: We re-evaluated prospective randomised controlled trials (RCT) from four meta-analyses published in 2013 that compared the effect of HES with crystalloids in critically ill patients, focusing on the adherence to 'presumably correct indication'. Regarding the definition of 'presumably correct indication', studies were checked for the following six criteria (maximum six points): short time interval from shock to randomisation (<6 h), restricted use for initial volume resuscitation, use of any consistent algorithm for haemodynamic stabilisation, reproducible indicators of hypovolaemia, maximum dose of HES, and exclusion of patients with pre-existing renal failure or renal replacement therapy. RESULTS: Duration of fluid administration ranged from 90 min up to a maximum of 90 days. Four studies considered follow-up until 90-day mortality, three studies 28-/30-day mortality, whereas four studies reported only early mortality. Included studies showed a large heterogeneity of the indication score ranging between 1 and 4 points with a median (25%; 75% quartile) of 4 (2; 4). CONCLUSIONS: The most important question, whether or not HES may be harmful when it is limited to immediate haemodynamic stabilisation, cannot be answered yet in the absence of any study sufficiently addressing this question. In order to overcome the limitations of most of the previous studies, we now suggest an algorithm emphasising the strict indication of HES. Additionally, we give a list of suggestions that should be adequately considered in any prospective RCT in the field of acute volume resuscitation in critically ill patients.

Beat-to-beat hemodynamic monitoring during electroconvulsive therapy.

OBJECTIVES: Rapid parasympathetic and sympathetic hemodynamic effects during electroconvulsive therapy (ECT) may pose vulnerable patients to significant risk for cardiovascular complications. Here, we evaluated the clinical feasibility of noninvasive beat-to-beat arterial blood pressure (BP) measurements in patients undergoing ECT. METHODS: Beat-to-beat hemodynamic effects were measured with a noninvasive BP monitor in 24 individual patients undergoing ECT during general anesthesia. Heart rate, systolic (SBP), and diastolic BP (DBP) as well as cardiac output (CO) were measured continuously. A significant increase in pulse rate and/or BP was treated with intermittent administration of esmolol and ketanserin. Data are presented as mean ± SD. RESULTS: The ECT stimulus induced a transient drop in BP and pulse rate, followed by a sharp rise in both parameters. The parasympathetic phase lasted 17 ± 9 seconds and was characterized by a drop in heart rate from 89 ± 15 to 42 ± 24 beats per minute, in SBP from 143 ± 22 to 91 ± 31 mm Hg, in DBP from 82 ± 13 to 54 ± 22 mm Hg, and in CO from 5.7 ± 2.3 to 1.4 ± 1.0 L/min, respectively. During the subsequent sympathetic phase, the heart rate increased to 125 ± 26 beats per minute, the SBP to 192 ± 33 mm Hg, the DBP to 113 ± 21 mm Hg, and the CO to 7.4 ± 4.3 L/min. The time interval between the lowest and highest SBP was 60 ± 48 seconds. CONCLUSIONS: Noninvasive beat-to-beat BP measurements are feasible during ECT and may be used to guide rapid therapeutic interventions during ECT-induced hemodynamic effects.