Assessment of Fluid Responsiveness in Prone Neurosurgical Patients Undergoing Protective Ventilation: Role of Dynamic Indices, Tidal Volume Challenge, and End-Expiratory Occlusion Test.

BACKGROUND: In patients in the prone position, the reliability of pulse pressure variation and stroke volume variation (PPV and SVV) and the use of functional hemodynamic tests to predict fluid responsiveness have not previously been established. Perioperatively, in this setting, optimizing fluid management can be challenging, and fluid overload is associated with both intraoperative and postoperative complications. We designed this study to assess the sensitivity and specificity of baseline PPV and SVV, the tidal volume (VT) challenge (VTC) and the end-expiratory occlusion test (EEOT) in predicting fluid responsiveness during elective spinal surgery. METHODS: The study protocol was started during a period of intraoperative hemodynamic stability after prone positioning and before the administration of any vasopressor: (1) at baseline, the controlled ventilation was set at 6 mL/kg of predicted body weight (PBW) (T0); (2) patients underwent the first EEOT (EEOT6) by interrupting the mechanical ventilation for 30 seconds; (3) the ventilation was set again at 6 mL/kg PBW for 1 minute (T1); (4) the VTC was applied by increasing the VT up to 8 mL/kg PBW for 1 minute; (5) the ventilation was kept at 8 mL/kg PBW for 1 minute (T2); (6) a second EEOT (EEOT8) was performed; (7) the VT was reduced back to 6 mL/kg PBW for 1 minute (T3); (8) a fluid challenge of 250 mL of Ringer's solution was infused over 10 minutes. After each step, a complete set of hemodynamic measurements was recorded. RESULTS: Neither PPV and SVV values recorded at T3 nor the EEOT6 or the EEOT8 predicted fluid responsiveness. The change in PPV after VTC application predicted fluid responsiveness with an area under the curve of 0.96 (95% confidence interval, 0.87-1.00), showing a sensitivity of 95.2% and a specificity of 94.7%, using a cutoff increase of 12.2%. The change in SVV after VTC application predicted fluid responsiveness with an area under the curve 0.96 (95% confidence interval, 0.89-1.00) showing a sensitivity of 95.2% and a specificity of 94.7%, using a cutoff increase of 8.0%. A linear correlation between stroke volume index changes after fluid challenge administration and the changes in PPV and SVV after VTC application was observed (r = 0.71; P < .0001 and r = 0.68; P < .0001, respectively). CONCLUSIONS: In prone elective neurosurgical patients, the baseline values of PPV and SVV and the EEOT fail to predict fluid responsiveness, while the VTC is a very reliable functional hemodynamic test and could be helpful in guiding intraoperative fluid therapy.

Convenient detection of E. coli in Ringer's solution.

An easy and inexpensive detection method for DNA hybridization assays combining magnetic beads and enzymatically generated silver nanoparticles is introduced. The main advantage of this approach is the possibility to distinguish between positive and negative test results with the naked eye. In the case of complementary DNA sequences the sample will turn black within a few minutes, allowing readout without any hardware. In order to illustrate the applicability of the assay genomic DNA isolated from E. coli contaminated Ringer's solution was used for testing the sensitivity as well as specificity.

A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery--the FOCCUS study.

INTRODUCTION: Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. METHODS: This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. RESULTS: A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. CONCLUSIONS: Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. TRIAL REGISTRATION: Prospective Clinical Trials, ISRCTN32188676.

Corneal endothelial cell protection with a dispersive viscoelastic material and an irrigating solution during phacoemulsification: low-cost versus expensive combination.

PURPOSE: To evaluate the protective effect on corneal endothelial cells of a low-cost and an expensive combination of a dispersive viscoelastic material and an irrigating solution during phacoemulsification. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: This prospective randomized examiner- and patient-masked study comprised 90 eyes of 45 consecutive patients with age-related cataract in both eyes. For each patient, the first eye was randomly assigned to receive hydroxypropyl methylcellulose 2% (Ocucoat) and Ringer's solution (low-cost combination) or sodium chondroitin sulfate 4%-sodium hyaluronate 3% (Viscoat) and an enriched balanced salt solution (BSS Plus) (expensive combination) during phacoemulsification. The contralateral eye received the other treatment. Endothelial cell function was evaluated by measuring corneal thickness (CT) using partial coherence interferometry, morphology assessment, and endothelial cell counts. RESULTS: The acute postoperative increase in CT was +9.8 microm in the low-cost group and +10.9 microm in the expensive group; the difference between groups was not significant. After 1 month, the CT still differed significantly from baseline in the low-cost group. Three months after surgery, the CT had returned to baseline values in both groups. There was no significant between-group difference in endothelial cell counts or morphology. CONCLUSIONS: During phacoemulsification in a nonselected patient population, there was no difference in acute postoperative corneal edema and endothelial cell morphology after 3 months between a Viscoat and BSS Plus combination and an Ocucoat and Ringer's solution combination. Eyes receiving the expensive combination had marginally faster recovery of corneal swelling by 3 months. However, the cost of Viscoat and 500 mL BSS Plus is 5 times that of Ocucoat and Ringer's solution.

Examination of in vivo influences on bioluminescent microbial assessment of corrosion product toxicity.

The composition of ionically dissolved and precipitated corrosion products from both free corrosion of ASTM F75 Co-Cr-Mo and galvanostatic polarization of Co-Cr-Mo and F138 316L stainless steel was determined using differential pulse polarography and inductively coupled plasma atomic emission spectroscopy. A bacterial bioluminescence assay, Microtox, was used to assess the toxicity of the solid and dissolved corrosion products produced by galvanostatic polarization and the individual ions within them. The role of in vivo salinity, temperature, and protein content as modulators of corrosion product toxicity assessment was investigated empirically and mechanistically. Co-Cr-Mo products were found to be more toxic than those of 316L, and the most toxic ions were Cr6+, Ni2+, and Co2+. Ringer's solution potentiated the toxicity of the more toxic metal ions and reduced the toxicity of the less toxic ions. Using theoretical analysis in conjunction with experimental measurements, the ions in both alloys were found to interact in an antagonistic fashion. The presence of albumin was found to decrease metal toxicity, presumably by chelation.

Quantitative assessment of a circulating depolarizing factor in shock.

Sustained depolarization of cell membranes and cellular edema are known to accompany various forms of circulatory shock and probably contribute to hypovolemia and cellular dysfunction. It has been proposed that a circulating protein is responsible for these effects. In the present study we have confirmed the existence of a circulating depolarizing factor (CDF) in hemorrhagic shock, burn shock, sepsis, and cardiopulmonary bypass. Plasma samples from pigs or sheep in shock were quantitatively assayed for depolarizing activity using a microelectrode method on rat diaphragm in vitro. The depolarizing effect of CDF in vitro was similar in magnitude to that of shock in situ. We conclude that CDF can entirely account for membrane depolarization during shock. The depolarizing effect of CDF was dose-dependent and saturable; it could be reversed by rinsing the diaphragm with Ringer's or control plasma. CDF activity was detectable in plasma within 5 min after a severe scald and gradually increased over the next 25 min. Resuscitation of hemorrhaged pigs, but not burned sheep, eliminated plasma CDF activity.

Photoelastic assessment of the expansion of direct-placement gallium restorative alloys.

OBJECTIVE: The purpose of this study was to assess, via a photoelastic resin, the expansion of gallium restorative alloys under conditions similar to those found in the clinical situation. METHOD AND MATERIALS: Two gallium alloys, Galloy and Gallium GF II, were tested, along with a high-copper amalgam, Dispersalloy, and a low-copper alloy, New True Dentalloy. The gallium alloys were tested as (1) uncontaminated, (2) contaminated with water, Ringer's solution, or a cell culture medium, and (3) immersed in these fluids at times ranging from 5 minutes to 3 days. The gallium and amalgam alloys were condensed in a hole drilled in a block of photoelastic resin and observed for 3 months. The amount of stress was recorded on color slides taken through polarized light at regular intervals. The photographs of the color bifringen stress patterns at 1 and 3 months were ranked by two independent evaluators for least to greatest observed stress. RESULTS: Dispersalloy had the least expansion, followed by uncontaminated Galloy and Galloy contaminated with water. Next came Galloy contaminated with cell culture medium, Galloy contaminated with Ringer's solution, contaminated New True Dentalloy, and Gallium GF II. The last group was Gallium GF II contaminated with any of the three solutions. Both gallium alloys immersed in the three fluids showed a strong edge effect, and by 6 weeks many of the gallium alloys had extruded from the mold. CONCLUSION: These results corroborate the findings of some clinical studies that have shown that these gallium alloys can potentially cause catastrophic failures.

Marginal leakage of Gallium Alloy root-end fillings: an in-vitro assessment.

The sealing ability of amalgam and Gallium Alloy Gallium Filling (GF) root-end fillings was evaluated in vitro using a highly uniform collection of sheep incisor roots. Following ultrasonic canal debridement and orthograde obturation with gutta-percha and sealer, root-end cavities were prepared in 100 roots and filled with amalgam (50 teeth) or Gallium Alloy GF (50 teeth), Twenty-five teeth from each group were subjected to immediate dye leakage assessment under vacuum conditions with methylene blue dye (2%), pH 7. Linear dye penetration was measured following longitudinal splitting. The other 25 teeth from each group were incubated in Ringer's solution for 12 weeks before leakage assessment by the same method. Control teeth were included in each component of the study. Mean linear dye penetration was: amalgam--5.17 mm at baseline, 2.33 mm after 12 week's incubation; Gallium Alloy GF--2.21 mm at baseline, 1.41 mm after 12 week's incubation. The apical marginal seal of both materials improved significantly following storage in Ringer's solution (P<0.001). Gallium Alloy GF provided a better apical seal than amalgam, both at baseline and following storage (P<0.001). Subjective evaluation of the general handling characteristics of Gallium Alloy GF revealed that it was a more difficult material to manipulate than amalgam, largely because of its wetting ability and consequent adhesion to dental instruments.

A paired tracer microinjection technique designed for assessment of single-nephron glucose-calcium interactions in the anesthetized rat.

The first part of this study evaluates a new paired microinjection technique for studying single-nephron permeability (in this case to calcium) following injection of 5-10 nL of a Ringer solution into a superficial proximal tubule. The mean difference in fractional 45Ca recovery from two identical microinjections into the same nephron site was 2.2 +/- 0.2% for 89 paired microinjections. Individual nephrons therefore normally show differences in calcium permeability with time. However, moment-to-moment variations in ion transport in any one nephron are in a random direction; differences cancel one another out if enough experiments are performed. The technique thus appears well suited to studies where comparisons are made between the acute nephron responses to two test solutions. It specifically overcomes problems of nephron heterogeneity seen in some other micropuncture techniques. The second part of this study uses the new technique to investigate the effects of a raised intratubular D-glucose concentration on single-nephron calcium transport. Urinary 45Ca recoveries from late proximal microinjections were significantly higher when D- (as opposed to L-) glucose was included in the injectate (6.87 +/- 0.88 vs. 5.24 +/- 0.50%; p < .02). The ability of D-glucose to depress tubular calcium reabsorption at distal nephron sites may contribute to the observed hypercalciuria following systemic D-glucose loading. It may also be relevant to the acute renal failure accompanying renal stone disease, where a relationship between hypercalciuria, urolithiasis, and the consumption of refined carbohydrates has been proposed.