Fluidoterapia reflexiva: desde la fisiología a la práctica clínica / Reflexive fluid therapy: From physiology to clinical practice

Introducción. La fluidoterapia es una intervención ampliamente usada en la práctica clínica. No obstante, su aplicación no está exenta de riesgos y demanda una evaluación cuidadosa de la tolerancia del paciente y su respuesta al volumen. La práctica empírica de la reanimación con líquidos puede ser potencialmente letal. El propósito de esta revisión fue proporcionar una visión general de los principios fisiológicos y terapéuticos para la administración de líquidos intravenosos en pacientes críticamente enfermos, abordando poblaciones especiales, como los pacientes quirúrgicos, sépticos y politraumatizados. Métodos. Se hizo una revisión narrativa a partir de artículos publicados en PUBMED, ScienceDirect y LILACS, entre 2001 y 2023. Para la búsqueda se emplearon los términos MESH fluid therapy, crystalloid solutions y colloids. Resultados. Se encontraron 371 artículos, de los cuales se seleccionaron los estudios clínicos aleatorizados, las revisiones narrativas, las revisiones sistemáticas y los metaanálisis que analizaron el rol de los cristaloides y coloides. Se incluyeron manuscritos publicados en fechas por fuera del rango de búsqueda, que se consideraron relevantes para la descripción de la fisiopatología y los fundamentos del uso de líquidos endovenosos. Conclusión. La reanimación reflexiva se fundamenta en un entendimiento holístico de la fisiología y la individualización de la fluidoterapia. El uso liberal de líquidos endovenosos tiene potenciales efectos nocivos y las estrategias de reanimación deben ser guiadas por medidas dinámicas y estáticas individuales, que proporcionan un panorama seguro para el manejo de los líquidos.

Introduction. Fluid therapy is an intervention widely used in clinical practice. However, its application is not without risks and requires a careful evaluation of patient's tolerance and response to volume. The empirical practice of fluid resuscitation can be potentially lethal. The purpose of this review was to provide an overview of the physiological and therapeutic principles for the administration of intravenous fluids in critically ill patients, addressing special populations, such as surgical, septic, and trauma patients. Methods. A narrative review was carried out based on articles published in PUBMED, ScienceDirect, and LILACS between 2001 and 2023. MESH terms fluid therapy, crystalloid solutions, and colloids were employed. Results. A total of 371 articles were found, of which randomized clinical trials studies, narrative reviews, systematic reviews, and meta-analyses that analyzed the role of crystalloids and colloids were selected. Manuscripts published on dates outside the search range, which were considered relevant for the description of the pathophysiology and the rationale for the use of intravenous fluids, were included. Conclusion. Reflective resuscitation is based on a holistic understanding of physiology and individualization of fluid therapy. The liberal use of intravenous fluids has potential harmful effects and resuscitation strategies should be guided by individual dynamic and static measures, which provide a safe framework for fluid management

The research on peripheral circulation and oxygenation of different colloid osmotic pressure level in pediatric cardiac surgery under cardiopulmonary bypass / 中华胸心血管外科杂志

Objective To discuss the influence on peripheral circulation and oxygenation of different colloid osmotic pressure (COP) in pediatric cardiac surgery under cardiopulmonary bypass (CPB).Methods Sixty cases of non-cyanotic congenital heart disease patients under 10 kg were randomly selected and divided into 3 groups(n =20) according to the different COP level.COP values was adjusted by the ultrafiltration technique and colloid addition.The perioperative(T1-T6) arterial lactate level,different value between skin and rectal temperature,peripheral oxygen saturation (SpO2) and oxygenation index (OI) were observed in order to determine the different effect on peripheral circulation and oxygenation.Meanwhile,mechanical ventilation time and ICU time were recorded.Results The variation tendency of arterial lactate level was similar in each group,the value in the COP ＞ 18 mmHg (1 mmHg =0.133 kPa) group(group C) was significantly higher than COP 10-15 mmHg group (group A) and COP 16-18 mmHg group (group B) in T3 and T4,after CPB weaned,the values of Group A (1.25 ± 0.42) and Group C (1.33 ± 0.51) were higher than Group B (0.71 ± 0.29) at T6 point (P ＜ 0.05);the variation tendency of SpO2 was similar in each group too,the value of group C was significantly lower than group A and B at T5 point,the values of group A and C were significantly lower than group B at T6 point,P ＜ 0.05;the different value between skin and rectal temperature in group A was significantly higher than group B and C from T1 to T2 point(P ＜0.05),but not in T3 to T6 point;The minimal OI values of all the groups were appeared in T4 point,group B value was significantly higher than A and C in all time point,group C value was the lowest(P ＜0.05);the mechanical ventilation time in group B(2.13 ± 1.36) days and group C (2.93 ± 1.69) days were significantly lower than group A (3.83 ± 1.47) days,P ＜ 0.05.ICU time of group B (3.9 ± 1.1) days was significantly lower than group A (5.7 ± 2.5) days and C (6.0 ± 1.5) days.Conclusion During the pediatric CPB,the improper COP level will lead to bad oxygenation and poor peripheral circulation,got different prognosis ultimately.A reasonable COP level(16-18 mmHg) will do benefits to all the pediatric patients.

Effects of goal-directed fluid therapy filled with crystalliods or colliods on the recovery of tissue perfusion and postoperative recovery in patients undergoing hepatectomy / 临床麻醉学杂志

Objective To compare the difference between crystalloids and colloids under goal-directed fluid therapy (GDFT) in elective hepatectomy.Methods Seventy patients undergoing hepatectomy, 42 males and 28 females, aged 18-65 years, ASA physical status Ⅱ or Ⅲ, were included and randomly divided into three groups base on fluid treatment: conventional fluid therapy (group C, n=24), goal-directed fluid therapy filled with colloids (group G1, n=23) and goal-directed fluid therapy filled with crystalloids (group G2, n=23).Group C received conventional fluid therapy mainly based on MAP while group G1 and group G2 received goal-directed fluid therapy based on MAP, stroke volume variation (SVV) and cardiac index (CI), and the Flotrac/Vigileo system was used to obtain SVV and CI in group G1 and group G2.250 ml colloids were administered if SVV>13% in group G1 while 250 ml crystalloids were administered in group G2.If CI<2.5 L·min-1·m-2, dobutamine 2.0-10.0 μg·kg-1·min-1 was given until CI≥2.5 L·min-1·m-2.The ScvO2, Lac and Glu were tested at 5 min before anesthesia induction (T1), 5 min before hepatectomy (T2), 5 min after hepatectomy (T3) and the end of operation (T4).The duration of operation, fluid requirement, urinary output, bleeding volume, and the use of vasoactive agent were recorded.The exhaust time, ambulation time and postoperative hospital stay were recorded.Preoperative and postoperative liver and kidney function tests and postoperative complications were followed up.Results Compared with group C, the total volume was lower, flatus time, ambulation time and postoperative hospital stay were shorter, ScvO2 at T3 and T4 were higher, Lac at T2-T4 were lower, Glu at T3 and T4 were lower, ALT and AST on the third day and the fifth day after surgery were lower in group G1 (P<0.05).Compared with group G1, the amount of crystalloids was increased, the incidences of postoperative nausea and vomiting were significantly higher in group G2 (P<0.05).There was no significant difference in flatus time, ambulation time and postoperative hospital stay between group G1 and group G2.Conclusion GDFT in hepatectomy propably improves the microcirculation and tissue oxygenation, protects liver function, promotes gastrointestinal function recovery and shortens postoperative hospital stay.GDFT using colloids bolus contribute to a much lower incidence of postoperative nausea and vomiting.There is no significant difference in tissue perfusion and postoperative recovery between colloids and crystalloids.

Effect of hydroxyethyl starch on blood glucose levels / 대한마취과학회지

BACKGROUND: Hydroxyethyl starch (HES), a commonly used resuscitation fluid, has the property to induce hyperglycemia as it contains large ethyl starch, which can be metabolized to produce glucose. We evaluated the effect of 6% HES-130 on the blood glucose levels in non-diabetic patients undergoing surgery under spinal anesthesia. METHODS: Patients scheduled to undergo elective lower limb surgery were enrolled. Fifty-eight patients were divided into two groups according to the type of the main intravascular fluid used before spinal anesthesia (Group LR: lactated Ringer's solution, n = 30 vs. Group HES: 6% hydroxyethyl starch 130/0.4, n = 28). Blood glucose levels were measured at the following time points: 0 (baseline), 20 min (T1), 1 h (T2), 2 h (T3), 4 h (T4), and 6 h (T6). RESULTS: Mean blood glucose levels at T5 in the LR group and T4, T5 in the HES group, increased significantly compared to baseline. There were no significant changes in the serial differences of mean blood glucose levels from baseline between the two groups. CONCLUSIONS: Administration of 6% HES-130 increased blood glucose levels within the physiologic limits, but the degree of glucose increase was not greater than that caused by administration of lactated Ringer's solution. In conclusion, we did not find evidence that 6% HES-130 induces hyperglycemia in non-diabetic patients.

Fluid therapy for septic shock resuscitation: which fluid should be used? / Fluidoterapia para a ressuscitação no choque séptico: qual tipo de fluido deve ser utilizado?

Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may be necessary to achieve those hemodynamic goals. Nonetheless, even though fluid administration is one of the most common interventions offered to critically ill patients, the most appropriate type of fluid to be used remains controversial. According to recently published clinical trials, crystalloid solutions seem to be the most appropriate type of fluids for initial resuscitation of septic shock patients. Balanced crystalloids have theoretical advantages over the classic solutions, but there is not enough evidence to indicate it as first-line treatment. Additionally, when large amounts of fluids are necessary to restore the hemodynamic stability, albumin solutions may be a safe and effective alternative. Hydroxyethyl starches solutions must be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy and increased mortality. Our objective was to present a narrative review of the literature regarding the major types of fluids and their main drawbacks in the initial resuscitation of the septic shock patients.

A ressuscitação precoce de pacientes com choque séptico tem o potencial de reduzir sua morbidade e mortalidade. Os objetivos principais da ressuscitação no choque séptico incluem expansão volêmica, manutenção da perfusão tecidual e da oferta de oxigênio para os tecidos, guiados pela pressão venosa central, pressão arterial média, saturação venosa mista ou central de oxigênio e lactato arterial. Uma ressuscitação agressiva com fluidos, possivelmente em associação com vasopressores, inotrópicos e transfusão de concentrado de hemácias, pode ser necessária para atingir estes objetivos hemodinâmicos. Todavia, embora a administração de fluidos seja uma das intervenções mais comumente realizada em pacientes graves, o tipo de fluido mais apropriado para ser utilizado permanece controverso e incerto. De acordo com os estudos clínicos mais recentes, os cristaloides são os fluidos de escolha para serem utilizados na ressuscitação inicial de pacientes com choque séptico. As soluções cristaloides balanceadas possuem vantagens teóricas em relação as não balanceadas, porém ainda não há evidências suficientes para indicá-las como tratamento de primeira escolha. Além disso, albumina humana parece ser uma alternativa segura e efetiva quando grandes quantidades de fluidos são necessárias para o restabelecimento da estabilidade hemodinâmica. O uso de soluções de hidroxetilamido deve ser evitado em pacientes sépticos, devido ao maior risco de desenvolvimento de insuficiência renal aguda, necessidade de terapia de substituição renal e aumento de mortalidade. O objetivo deste estudo foi apresentar uma revisão narrativa da literatura sobre os principais tipos de fluidos e os problemas mais importantes na ressuscitação inicial de pacientes com choque séptico.

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions / Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões / Coloides versus cristaloides en fluidoterapia guiada por objetivos, revisión sistemática y metaanálisis. Demasiado pronto o demasiado tarde para obtener conclusiones

Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.

Foram feitos múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), muitos deles com o uso de coloides para aprimoramento da pré-carga. Após a decisão da Agência Europeia de Medicamentos, existe ainda controvérsia sobre seu uso, seus benefícios e sua possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas.

Se han realizado múltiples ensayos clínicos en fluidoterapia guiada por objetivos (FGO), muchos de ellos con el uso de coloides para la optimización de la precarga. Tras la decisión de la Agencia Europea del Medicamento, existe cierta controversia en cuanto a su utilización, beneficios y su posible contribución al fallo renal. El objetivo de esta revisión sistemática y metaanálisis es comparar el uso de coloides de última generación, derivados del maíz, con cristaloides en FGO para determinar las complicaciones y la mortalidad asociadas.

A comparative study of crystalloid solution mixed with colloidal solutions and pure crystal solution as extracorporeal circulation priming solution in adult simple heart valve replacement with cardiopulmonary bypass / 中国医师杂志

Objective To investigate physiological changes in peri extracorporeal circulation period of patients who underwent cardiac valve replacement surgeries with crystalloid solution mixed with colloidal solutions and pure crystal solution as extracorporeal circulation priming solution, and explore the clinical value and practicability of crystalloid solution as the sole extracorporeal circulation priming solution.Methods A retrospective analysis was performed in 130 patients who underwent cardiac valve replacement surgeries.Pure lactated Ringer's solution liquid and Lactated Ringer's solution mixed with Voluven as the extracorporeal circulation priming solution were used.We respectively compared hematocrit at different time points, postoperative blood routine, liver and kidney function, blood coagulation index, duration of intensive care and trachea cannula in two groups.Results There were no significant differences in ages, preoperative blood routine, kidney function, blood coagulation function, duration of operation, clamping time, bypass time, intensive care, postoperative blood routine, kidney function, blood coagulation function and hematocrit at different time points in two groups (P ＞0.05).However, the hospital day of group which used crystalloid solution as extracorporeal circulation priming solution was significant shorter compared to group which used lactated Ringer's solution mixed with Voluven (P ＜ 0.05).Alanine aminotransferase of group which used crystalloid solution as extracorporeal circulation priming solution was significant higher compared to group which used lactated Ringer's solution mixed with Voluven (P ＜0.01).Conclusions Crystalloid solution as extracorporeal circulation priming solution is safe and economy in cardiopulmonary bypass.Pure crystalloid solution as the sole extracorporeal circulation priming solution can be safely used on patients (New York Heart Association class Ⅱ-Ⅲ) who have normal liver and kidney function before the operation of adult heart valve replacement with cardiopulmonary bypass.

Recent findings on the use of hydroxyethyl starch

There has long been a controversy on the use of colloids. Many developments have now been made in the theological aspects. The new glycocalyx model and other related studies have shown that the volume expansion effect of colloids is not so superior to crystalloids in many situations. Moreover, the results from several multicenter studies on septic shock patients indicated that hydroxyethyl starch did not improve clinical outcome, but instead, increased the number of serious complications such as death and renal failure. Accordingly, this long debate has been concluded, at least about the use of hydroxyethyl starch colloid on patients with septic shock. Although there is still a lack of studies on perioperative patients, care is also needed when using colloids in their treatment.

16-2Silicon-aluminium interactions in medicinal waters. The first geochemical attempt to confirm the presence of hydroxyaluminosilicate colloids / 日本温泉気候物理医学会雑誌

  Silicon (28% wt.) and aluminium (8%) are second and third most abundant elements in Earth’s crust. In groundwaters, including the medicinal ones, both elements occur in proportionally lower concentrations than the less abundant elements of lithosphere, such as Ca, Mg, Na, K. The primary sources of Si and Al in water are represented by alumino-silicate minerals. Various minerals have been indicated as a phases which could control the solubility of silicon and/or aluminium in water. Hydroxyaluminosilicate (HAS) colloids have been also suggested as such a phase (Schneider et al., 2004). In conjuction with that the formation and structure of synthetic HAS colloids, along with their ecotoxicological role were studied (e.g. Doucet et al., 2001; Exley, 2012). Evaluation of a large set of natural water chemical analyses suggested that one of HAS colloids, the HAS_B type of a Al₂Si₂O₅(OH)₄ composition, might be formed in groundwaters (Dobrzynski, 2007).<BR>  This work presents an attempt to confirm this hypothesis by investigating the presence of HAS_B colloid in groundwater. It includes analysis of 219 fresh and mineral groundwater samples from Poland, Spain, and Malaysia. An analytical method involving ion-exchange resin was first tested on synthetic solutions and then applied for indirect identification of HAS_B in groundwaters. Additionally, the investigated water samples were subjected to micro- and ultra- filtration, and then the collected solids were analysed by XRD, EDS and SEM. The HAS colloids may have an important place in Si and Al hydro-geochemistry, especially in near-surface environments, and in eco-toxicology due to their role in limiting the concentration of bio-available and toxic aluminium species.<BR>  This study concludes that the most promising conditions for the HAS_B presence were found in silicon-rich medicinal waters from the Sudetes Mountains (Poland), especially from Swieradow Health Resort. The Si:Al molar ratio found in this work in eluates from resin prepared using waters from Swieradow showed values close to the theoretical ratio of 1:1.<BR>  This work also discusses and indicates that the most preferential settings for formation of HAS colloids occur at the short groundwater turn-over time zone in crystalline aquifer-rocks. It also discusses the mechanism for masking the presence of HAS_B colloids in water by other aluminosilicates. The presented results are still preliminary and require additional work aiming at development of analytical methods applicable for water suspensions rich in silicates.

16-2 Silicon-aluminium interactions in medicinal waters. The first geochemical attempt to confirm the presence of hydroxyaluminosilicate colloids / 日本温泉気候物理医学会雑誌

  Silicon (28% wt.) and aluminium (8%) are second and third most abundant elements in Earth’s crust. In groundwaters, including the medicinal ones, both elements occur in proportionally lower concentrations than the less abundant elements of lithosphere, such as Ca, Mg, Na, K. The primary sources of Si and Al in water are represented by alumino-silicate minerals. Various minerals have been indicated as a phases which could control the solubility of silicon and/or aluminium in water. Hydroxyaluminosilicate (HAS) colloids have been also suggested as such a phase (Schneider et al., 2004). In conjuction with that the formation and structure of synthetic HAS colloids, along with their ecotoxicological role were studied (e.g. Doucet et al., 2001; Exley, 2012). Evaluation of a large set of natural water chemical analyses suggested that one of HAS colloids, the HASB type of a Al2Si2O5(OH)4 composition, might be formed in groundwaters (Dobrzynski, 2007).   This work presents an attempt to confirm this hypothesis by investigating the presence of HASB colloid in groundwater. It includes analysis of 219 fresh and mineral groundwater samples from Poland, Spain, and Malaysia. An analytical method involving ion-exchange resin was first tested on synthetic solutions and then applied for indirect identification of HASB in groundwaters. Additionally, the investigated water samples were subjected to micro- and ultra- filtration, and then the collected solids were analysed by XRD, EDS and SEM. The HAS colloids may have an important place in Si and Al hydro-geochemistry, especially in near-surface environments, and in eco-toxicology due to their role in limiting the concentration of bio-available and toxic aluminium species.   This study concludes that the most promising conditions for the HASB presence were found in silicon-rich medicinal waters from the Sudetes Mountains (Poland), especially from Swieradow Health Resort. The Si:Al molar ratio found in this work in eluates from resin prepared using waters from Swieradow showed values close to the theoretical ratio of 1:1.   This work also discusses and indicates that the most preferential settings for formation of HAS colloids occur at the short groundwater turn-over time zone in crystalline aquifer-rocks. It also discusses the mechanism for masking the presence of HASB colloids in water by other aluminosilicates. The presented results are still preliminary and require additional work aiming at development of analytical methods applicable for water suspensions rich in silicates.

The effect of 6% Hydroxyethyl starch vs. Ringer's lactate on acute kidney injury after renal ischemia in rats

PURPOSE: To compare fluid replacement therapy with Hydroxyethyl starch 6% (HES) versus Ringer's lactate (RL) in a rodent model of non-septic renal ischemia. METHODS: Forty male Wistar rats were randomized to receive HES 2 ml.kg-1.hr-1or RL 5 ml. kg-1.hr-1 that underwent 30 minutes of renal ischemia followed by reperfusion. Twelve hours after kidney ischemia, the kidneys were evaluated for histological changes. Serum NGAL levels were obtained at different times of the experimental protocol. RESULTS: Rodents in the HES group had a median (IQR) grade of renal injury 3 (3 to 5) compared to 2 (2 to 4) in the RL group (p=0.03). NGAL levels were not associated with the severity of kidney injury. CONCLUSION: Hydroxyethyl starch administration caused more kidney injury than Ringer's lactate in a non-infectious model of renal hypoperfusion.

Plasma volume expanders: classification and characteristics of colloids

Fluid therapy remains an important therapeutic maneuver in managing surgical, medical, and the critically ill intensive care patient. However, the ideal volume replacement strategy remains under debate. The debate on whether patients should be managed with crystalloids, colloids, or both has for many years been mainly a debate about effectiveness. The dispute over crystalloids versus colloids has been enlarged to a colloid versus colloid debate because of the varying properties of different colloids. The natural colloid albumin and artificial colloids such as gelatin, dextran, and hydroxyethyl starch continue to enjoy widespread usage for clinical fluid management. Colloid is an effective plasma volume expander and is able to restore the hemodynamic profile with less total volume than crystalloid. However, colloid is associated with coagulation abnormalities, renal impairment, and allergic reactions. Albumin is considered to be one of the safe colloids. However, due to its cost, albumin cannot be recommended for hypovolemia. Gelatin and dextran can also cause coagulation abnormalities and renal impairment. Dextran is not used anymore due to its high anaphylactic potency. Each hydroxyethyl starch has different properties by concentration, mean molecular weight, molar substitution, and its C2/C6 ratio. New hydroxyethyl starches with a lower mean molecular weight and molar substitution than the old hydroxyethyl starch may be promising by improving volume management therapy with lower risks of coagulation abnormalities and renal impairment. The selection of colloid for plasma volume expansion should be based on the patients' clinical conditions and the characteristics of each colloid.

Biodistribution of 188Re-labeled stannic sulfur colloid in rabbit orthotopic liver cancer model by intratumoral injection / 中华核医学与分子影像杂志

Objective To study the biodistribution of 188Re-labeled stannic sulfur colloid in rabbit orthotopic VX2 liver cancer model by intratumoral injection and to evaluate its potential for endoradiotherapy.Methods 188Re-labeled stannic sulfur colloid was prepared with direct labeling method.The labeling efficiency and radiochemical purity were measured.Twelve rabbits xenografted by orthotopic VX2 liver cancer were used to determine the biodistribution of 188Re-labeled stannic sulfur colloid.Under CT guidance,37 MBq (0.1 ml) 188Relabeled stannic sulfur colloid was injected directly into the center of the tumor.Four rabbits were sacrificed after gamma imaging at 1,24,48 h post injection.The organ uptake was calculated as ％ID/g,the absorbed dose and T/NT ratio were calculated.One-way analysis of variance was used to analyze the data.Results The labeling efficiency of 188 Re-labeled stannic sulfur colloid was (98.23±0.25)％.The radiochemical purity was (94.23±0.54) ％ at 48 h.The radioactivity essentially accumulated in the tumor area and remained trapped up to 48 h.The radioactivity in other organs was at background level.The T/NT ratios were 88.22± 11.57,32.87±9.13 and 31.65± 10.11 at 1,24 and 48 h post injection respectively,with the corresponding tumor uptakes of (43.318±11.931) ％ID/g,(39.875±9.290) ％ID/g and (37.761±6.849) ％ID/g,which were much higher than those in normal tissues (F=77.350,97.577,417.072,all P＜0.01).Radiation dose to the tumor was (88.12 ± 12.21) Gy.Conclusions 188 Re-labeled stannic sulfur colloid may have a stable distribution at the site of orthotopic VX2 liver cancer after intratumoral injection.Thus it may have potential for the endoradiotherapy of liver cancer.

Evidencia actual sobre el uso de soluciones coloides versus cristaloides durante la reanimación del paciente con shock / Current evidence onthe use of solutions colloids versus crystalloids during the reanimation patient-with shock

La administración de fluidos intravenosos, es uno de los pilares de la reanimación del paciente en shock y su beneficio es mayor cuanto antes se inicie. Los fluidos más utilizados para tal objeto son las soluciones cristaloides (solución salina y Ringer Lactato) y los coloides (albumina, gel, dextrán y almidones). Estudios fisiológicos y clínicos han demostrado que los coloides y los cristaloides tienen diferentes efectos y perfiles de seguridad. Por otra parte, ambos tipos de fluidos administrados en exceso o a destiempo pueden tener efectos perjudiciales. Estudios clínicos recientes parecen coincidir que, en general, los coloides no ofrecen mayor beneficio clínico que los cristaloides y se asocian a mayor tasa de eventos adversos. Por tanto, el presente artículo pretende describir las ventajas y limitaciones de los tipos de soluciones que se utilizan para la reanimación de los pacientes críticos en base a literatura más reciente.

The administration of intravenous fluids, is a mainstay of patient resuscitation in shock and your benefit is greater the earlier it starts. The fluids commonly used for this purpose are crystalloid solutions (saline and Ringer Lactate) and colloids (albumin, gel, dextran and starch). Physiological and clinical studies have shown that colloids and crystalloids have different effects and safety profiles. Moreover, both ty-pes of fluids administered in excess or untimely can have detrimental effects. Recent clinical studies seem to agree that, in general, colloids offer no greater clinical benefit than crystalloids and are associated with increased rate of adverse events. Therefore, this article aims to describe the advantages and limitations of the types of solutions used for resuscitation of critically ill patients based on recent literature.

The impact of 30 ml/kg hydroxyethyl starch 130/0.4 vs hydroxyethyl starch 130/0.42 on coagulation in patients undergoing abdominal surgery.

Background & objectives: Hydroxyethyl starches (HES) 130/0.4 (Voluven®) and 130/0.42 (Venofundin®) impair coagulation less than older HES solutions with higher molecular weight and molar substitution. Thus, these may be used in high doses up to 50 ml/kg/day. The aim of this study was to investigate and compare the effects of HES 130/0.4 versus HES 130/0.42 on coagulation after the intraoperative infusion of 30 ml/kg in patients undergoing major abdominal surgery. Methods: Fifty two patients scheduled for elective major abdominal surgery were randomized to receive 30 ml/kg of HES 130/0.4 or HES 130/0.42 intraoperatively. Coagulation variables were assessed before and after infusion of the colloid solution using thrombelastography. Results: Data from 49 patients, 25 patients in the HES 130/0.4 and 24 in the HES 130/0.42 group, were analyzed. Measurements of reaction time, kinetic time, α-angle, maximum amplitude and coagulation index before and after colloid infusion did not differ between the groups. Within each group, after colloid infusion, reaction time did not change significantly, while α-angle, maximum amplitude and coagulation index values were significantly decreased (P<0.01, P<0.001 and P<0.001, respectively in HES 130/0.4 group and P<0.01, P<0.001 and P<0.01, respectively in HES 130/0.42 group). Kinetic time was significantly increased (P<0.001) in both the groups. In both groups, all thrombelastographic measurements after colloid infusion were found within normal limits. Interpretation & conclusions: HES 130/0.4 and HES 130/0.42 showed similar, not clinically significant effects on coagulation, as assessed by thrombelastography, when a dose of 30 ml/kg was administered in patients undergoing major abdominal surgery.

Long-term following-up of viability of spleen autotransplants in the Beagle canine model / Avaliação em longo prazo da viabilidade do autotransplante de baço em cães Beagle

PURPOSE: To examine the possible late complications of splenectomy or spleen autotransplantation in large laboratory animal model, in which we need non-invasive or minimal-invasive methods for long-term monitoring of the experimental animals. METHODS: Experimental groups of beagle dogs were: non-operated control, sham-operated control, splenectomy, spleen autotransplantation with 5 or 10 spleen-chips taken into the greater omentum (Furka's technique). Prior to operations, on the 1st postoperative week, monthly till the 6th as well as in the 9th and 12th month, hemorheological examinations were performed. In postoperative 12th month colloid scintigraphy and diagnostic laparoscopy were carried out. At the end of the investigation comparative morphological examinations were performed, too. RESULTS: From the 4th-5th postoperative month filtration function of spleen-autotransplants showed particular restoration compared to splenectomy group. However, the functional results did not reach the values of the control or sham-operated groups. Sham-operated control's scintigraphy nicely showed activity in the spleen. In spleen autotransplantation-groups scintigraphy indicated well the activity of spleen-chips. During diagnostic laparoscopy spleen-chips with their blood supply were found. Histologically, the structure of spleen­autotransplants was similar to normal splenic tissue. CONCLUSIONS: The autotransplants are regenerated, their functions have been partly restored, and thus spleen autotransplantation may prevent the possible complications of splenectomy. These parameters and the presented investigative protocol are suitable for long-term following-up of viability of the spleen-autotransplants.

OBJETIVO: Examinar as possíveis complicações tardias da esplenectomia ou do autotransplante de baço em modelo animal de grande porte, no qual faz-se necessário o uso de métodos não invasivos ou minimamente invasivos para monitorizar os animais de experimentação. MÉTODOS: Grupos experimentais de cães beagle foram: não-operados controle, sham-operados controle, esplenectomia, autotransplante de baço com 5 ou 10 fatias de baço colocados no grande omento (técnica de Furka). Antes das operações, na 1ª semana de pós­operatório, mensalmente até 6o.assim como no 9º. e 12º. mês, foram realizados exames hemorreológicos. No 12º. mês de pós-operatório, cintilografia colóide e laparoscopia diagnóstica foram realizadas. Ao final do experimento, exames morfológicos comparativos foram realizados também. RESULTADOS: A partir do 4º-5º mês pós-operatório, a função de filtração dos baços autotransplantados mostraram particular restauração comparados ao grupo esplenectomia. Entretanto, os resultados funcionais não alcançaram os valores dos grupos controle ou sham-operados. A cintilografia dos controles sham-operados mostraram atividade no baço. Nos grupos de autotransplante, a cintilografia indicou bem a atividade das fatias de baço. Durante a laparoscopia diagnóstica, as fatias de baço com seu suprimento sanguíneo foram encontrados. Histologicamente, a estrutura dos autotransplantes de baço foi similar ao tecido normal de baço. CONCLUSÕES: Os autotransplantes são regenerados, suas funções foram parcialmente restauradas, e então ao autotransplantate esplênico pode prevenir as possíveis complicações da esplenectomia. Estes parâmetros e o protocolo experimental são adequados para o seguimento em longo prazo da viabilidade de autotransplantes esplênicos.

Progress in perioperative liquid therapy / 国际外科学杂志

Liquid therapy is a vital method of perioperative treatment.Choosing correct kinds of transfusion and reasonable therapy strategies can significantly reduce the perioperative complications and shorten days in hospital and improve the critical patients prognosis.The historical development of perioperative liquid therapy is a forward process,which is about crystalloids vs.cilloid,dry vs.wet,and other controversial problems continuing to be summarized,explored and discussed.In this process,there are some specific perioperative treatment strategies with the physician having a deeper cognitive,such as goal-directed therapy,early goal directed therapy and fast track surgery which have significant clinical curative effect.This article summarizes the advance of perioperative liquid therapy.

Effects of colloid preconditioning on hemodynamics of patients with laparoscopic colon surgery during pneumoperitoneum period / 中国医师进修杂志

Objective To investigate the effects of colloid preconditioning on hemodynamics of patients with laparoscopic colon surgery during pneumoperitoneum period.Methods Fifty patients withlaparoscopic colon surgery were divided into control group(group A,25 cases)and colloid preconditioning group(group B,25 cases)by random digits table.The mean arterial pressure(MAP),heart rate(HR),central venous pressure(CVP),cardiac index(CI),systemic vascular resistance index(SVRI),hemoglobin(Hb)and haematocrit(Hct)were recorded before anesthesia(T0),5 min after anesthesia(T1),5 min after pneumoperitoneum(T2),10 min after pneumoperitoneum(T3),15 min after pneumoperitoneum(T4)and 5min after pneumoperitoneum completely(T5).Results MAP in group A at T1-3[(68.7±5.3),(72.5±4.8),(73.1±6.3)mm Hg(1 mm Hg=0.133 kPa)]was significantly lower than that at T0[(81.7±6.1)mm Hg](P＜0.05).MAP in group B at T3,4[(93.2±5.8),(87.6±4.2)mm Hg]was significantly higher than that at T0[(80.2±5.6)mm Hg](P＜0.05).At T1,2,MAP in group A was significantly lower than that in group B[(79.8±5.4),(83.2±5.3)mm Hg](P＜0.05).CVP in group A at T2-4[(7.8±2.4),(8.1±2.2),(8.2±2.0)cm H2O(1 cm H2O=0.098 kPa)]was significantly higher than that at T0[(6.5±2.1)cm H2O](P＜0.05).CVP in group B at T1-4[(11.7±3.4),(13.5±3.6),(15.8±3.8),(16.6±3.7)cm H2O]was significantly higher than that at T0[(6.3±2.5)cm H2O](P＜0.05).There was significant differences in CVP at T1-4 between group A[group A at T1:(5.6±2.2)cm H2O]and group B(P＜0.05).CI in group A at T2-4[(2.6±0.2),(2.1±0.1),(2.7±0.3)L/(min·m2)]was significandy lower than that at T0[(3.5±0.4)L/(min·m2)](P＜0.05).CI in group B at T2-4[(3.1±0.3),(2.9±0.3),(3.0±0.4)L/(min·m2)]was significantly lower than that at T0[(3.6±0.5)L/(min·m2)](P＜0.05).There were significant differences in C I at T2-4 between two groups.SVRI in group A at T2-4[(2853±432),(2918±510),(2718±436)dynes·s/cm5]was significantly higher than that at T0[(2318±236)dynes·s/cm5](P＜0.05).SVRI in group B at T2-4[(2756±391),(2718±402),(2694±382)dynes·s/cm5]was significantly higher than that at T0[(2356±372)dynes·s/cm5](P＜0.05).There was no significant difference in HR between two groups(P＞0.05).Hb and Hct in group B at T1-4[(123.6±11.5),(125.6±9.5),(126.1±10.2),(128.6±11.4)g/L and 0.339±0.037,0.337±0.036,0.322±0.041,0.312±0.040]were significantly lower than that at T0[(134.7±12.2)g/L and 0.371±0.039](P＜0.05).There were significant differences in Hb and Hct at T1-4between group B and group A[(131.8±10.2),(130.7±12.8),(131.6±14.3),(133.5±12.3)g/L and 0.360±0.042,0.359±0.041,0.361±0.040,0.360±0.036](P＜0.05).There was no significant different in Hb and Hct of group A(P＞0.05).Conclusion Colloid preconditioning may effectively maintain the stability of circulation,reduce blood viscosity,and improve microcirculation during the pneumoperitoneum period.

Reposição volêmica perioperatória / Perioperative volemic repositioning

Justificativa e objetivos: a reposição volêmica perioperatória tem sido alvo de inúmeros trabalhos, focando-se no debate entre o uso de criataloides ou coloides, bem como reposição restritiva ou liberal. Como ainda não existe consenso nesse assunto que interessa a todos os anestesiologistas, foi escrito este artigo objetivando esclarecer asprincipais vantagens e desvantagens de cada tipo de fluido utilizado na reposição volêmica perioperatória. Conteúdo: são apresentados sucintamente os diferentes tipos de fluidos utilizados para repor o volume, as possíveis vantagens e desvantagens de cada um, bem como seus efeitos adversos. Conclusões: a reposição volêmica deve integrar o conhecimento dos fluidos utilizados, com o volume total administrado e os procedimentos específicos, pois diferentes procedimentos têm diferentes fisiopatologias de distribuição dos fluidos.

Justification and purposes: The perioperative volemic reposition has been the focus of several studies which discuss the use of crystalloids or colloids, as well as the restrictive or unrestrictive repositioning. As there has been no consensus on this issue which is of interest to all anesthesiologists, this paper has been written with the purpose of explaining the main advantages and disadvantages of each type of fluid used in the perioperativevolemic repositioning. Content: Different types of fluids used to reposition the volume, possible advantages and disadvantages of each one as well as their adverse effects are briefly shown in this article. Conclusions: In order to better understand the volemic repositioning it is important to know about the fluids used, the total volume administered and the specific procedures, as different procedures have different pathophysiologies of fluid distribution.