Corticosteroids in the Management of Hyponatremia, Hypovolemia, and Vasospasm in Subarachnoid Hemorrhage: A Meta-Analysis.

BACKGROUND: Cerebral vasospasm and sodium and fluid imbalances are common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and cause of significant morbidity and mortality. Studies have shown the benefit of corticosteroids in the management of these sequelae. We have reviewed the literature and analyzed the available data for corticosteroid use after SAH. METHODS: PubMed, EMBASE, and Cochrane electronic databases were searched without language restrictions, and 7 observational, controlled clinical studies of the effect of corticosteroids in the management of SAH patients were identified. Data on sodium and fluid balances, symptomatic vasospasm (SVS), and outcomes were pooled for meta-analyses using the Mantel-Haenszel random effects model. RESULTS: Corticosteroids, specifically hydrocortisone and fludrocortisone, decreased natriuretic diuresis and incidence of hypovolemia. Corticosteroid administration is associated with lower incidence of SVS in the absence of nimodipine, but does not alter the neurological outcome. CONCLUSIONS: Supplementation of corticosteroids with mineralocorticoid activity, such as hydrocortisone or fludrocortisone, helps in maintaining sodium and volume homeostasis in SAH patients. Larger trials are warranted to confirm the effects of corticosteroids on SVS and patient outcomes.

Outbreak of epidemic dropsy in Ethiopia: the clinical and therapeutic observation.

INTRODUCTION: Epidemic dropsy results from ingestion of argemone oil contaminated food staffs. The oil from Argemone Mexican seeds contains toxic alkaloids called sanguinarine and dehydrosangunarine. These cause wide spread capillary dilatation, proliferation and leakages. This leads to oedema, hypovolemia and hypotension. OBJECTIVE: To describe the socio-demographic and clinical manifestations of the patients affected with epidemic dropsy in Tikur Anbessa specialized Hospital (TASH). METHODS: A case series study was conducted in an outbreak with unusual cases which was later diagnosed to be epidemic dropsy. Clinical evaluation of suspects was done and optimal therapy given for the complications detected and information was filled in structured format by medical residents and medial chart records review was made for occurrence of new complications in the end of 9 months. RESULTS: A total of 164 patients were seen at TASH from 26 households, in 8 sub-cities of Addis Ababa. A wide range of age group was affected with 70% from 16 to 40 years of age. There was no case among less than 5 years of age. Females were affected more than threefold as compared to males. All the patients manifested with bilateral leg swelling and pitting oedema. It was tender in 50 (30.4%) of them while 43 (26.2%) had erythema. Tachycardia was the next common manifestation occurring in 135 (82.3%), followed by cough in 123 (75%), anaemia in 59 (36%), headache in 58 (35.4%), shortness of breathing in 52 (31.2%), hair loss in 44 (26.8%) and respiratory distress in 35 (21.3%). Abdominal pain, hepatomegally, nausea and vomiting were also seen. There was abnormality in the chest X-ray of 31 (27.2%). Hair loss, tingling and burning extremities, difficulty of standing, hyperpigmentation, pruritic rash and eye symptoms were observed lately during follow up. Five of the patients died while in hospital care due to acute respiratory distress syndrome (ARDS). CONCLUSIONS: The commonest clinical manifestation in our patients is bilateral leg swelling which is similar to other outbreaks of epidemic dropsy elsewhere. The mortality rate is also comparable with other series but all cases died by ARDS in our series which is unusual in other reports. As this is the first reported epidemics in Ethiopia the findings will create awareness of clinical features of epidemic dropsy among clinicians, and therefore, helps for diagnoses of similar problems in the future.

Using time-frequency analysis of the photoplethysmographic waveform to detect the withdrawal of 900 mL of blood.

BACKGROUND: We designed this study to determine if 900 mL of blood withdrawal during spontaneous breathing in healthy volunteers could be detected by examining the time-varying spectral amplitude of the photoplethysmographic (PPG) waveform in the heart rate frequency band and/or in the breathing rate frequency band before significant changes occurred in heart rate or arterial blood pressure. We also identified the best PPG probe site for early detection of blood volume loss by testing ear, finger, and forehead sites. METHODS: Eight subjects had 900 mL of blood withdrawn followed by reinfusion of 900 mL of blood. Physiological monitoring included PPG waveforms from ear, finger, and forehead probe sites, standard electrocardiogram, and standard blood pressure cuff measurements. The time-varying amplitude sequences in the heart rate frequency band and breathing rate frequency band present in the PPG waveform were extracted from high-resolution time-frequency spectra. These amplitudes were used as a parameter for blood loss detection. RESULTS: Heart rate and arterial blood pressure did not significantly change during the protocol. Using time-frequency analysis of the PPG waveform from ear, finger, and forehead probe sites, the amplitude signal extracted at the frequency corresponding to the heart rate significantly decreased when 900 mL of blood was withdrawn, relative to baseline (all P < 0.05); for the ear, the corresponding signal decreased when only 300 mL of blood was withdrawn. The mean percent decrease in the amplitude of the heart rate component at 900 mL blood loss relative to baseline was 45.2% (38.2%), 42.0% (29.2%), and 42.3% (30.5%) for ear, finger, and forehead probe sites, respectively, with the lower 95% confidence limit shown in parentheses. After 900 mL blood reinfusion, the amplitude signal at the heart rate frequency showed a recovery towards baseline. There was a clear separation of amplitude values at the heart rate frequency between baseline and 900 mL blood withdrawal. Specificity and sensitivity were both found to be 87.5% with 95% confidence intervals (47.4%, 99.7%) for ear PPG signals for a chosen threshold value that was optimized to separate the 2 clusters of amplitude values (baseline and blood loss) at the heart rate frequency. Meanwhile, no significant changes in the spectral amplitude in the frequency band corresponding to respiration were found. CONCLUSION: A time-frequency spectral method detected blood loss in spontaneously breathing subjects before the onset of significant changes in heart rate or blood pressure. Spectral amplitudes at the heart rate frequency band were found to significantly decrease during blood loss in spontaneously breathing subjects, whereas those at the breathing rate frequency band did not significantly change. This technique may serve as a valuable tool in intraoperative and trauma settings to detect and monitor hemorrhage.

[Means of reducing blood loss and volume of the used transfused media in operative treatment of burn lesions of the liver]. / Puti snizheniia velichiny krovopoteri i ob"ema ispol'zuemykh transfuzionnykh sred pri operativnom lechenii ochagovykh porazhenii pecheni.

An experience with surgical treatment of 77 patients with focal lesions of the liver is described. The patients were divided into two groups. In the main group (42 patients) the treatment-and-prophylactic method was used including acute isovolemic and hypervolemic hemodilution, preliminary preparation of autoblood, isolation and ligation of the vascular-secretory elements, the application for local hemostasis with Takhokomb of "Tissucol", gelatinous sponge with gentamycin. In the group of comparison the compression of the hepatoduodenal ligament, isolation of the vascular-secretory elements by digitoclasia method, suturing the liver stump with polysorb were used in resection of the liver. The strategy used in the main group allowed to reduce the volume of blood loss, to lessen the number of doses of the transfused donor blood, to diminish the number of postoperative complications by 30.5%. The used complex is effective, simple and is not expensive.

Albumin and artificial colloids in fluid management: where does the clinical evidence of their utility stand?

Key questions remain unresolved regarding the advantages and limitations of colloids for fluid resuscitation despite extensive investigation. Elucidation of these questions has been slowed, in part, by uncertainty as to the optimal endpoints that should be monitored in assessing patient response to administered fluid. Colloids and crystalloids do not appear to differ notably in their effects on preload recruitable stroke volume or oxygen delivery. Limited evidence nevertheless suggests that colloids might promote greater oxygen consumption than crystalloids. It remains unclear, in any case, to what extent such physiological parameters might be related to clinically relevant outcomes such as morbidity and mortality. Recent randomized controlled trial results indicate that, at least in certain forms of fluid imbalance, albumin is effective in significantly reducing morbidity and mortality. Much further investigation is needed, however, to determine the effects of colloid administration on clinically relevant outcomes in a broad range of critically ill patients. The ability of administered colloids to increase colloid osmotic pressure (COP) constitutes one mechanism by which colloids might reduce interstitial oedema and promote favourable patient outcomes. However, the applicability of this mechanism may be limited, due to the operation of compensatory mechanisms such as increased lymphatic drainage. Attempts to increase COP might also be less useful in states of increased vascular permeability such as acute respiratory distress syndrome, although this issue has by no means been settled by empirical data. Colloids are clearly more efficient than crystalloids in attaining resuscitation endpoints as judged by the need for administration of far smaller fluid volumes. Among the colloids, albumin offers several advantages compared with artificial colloids, including less restrictive dose limitations, lower risk of impaired haemostasis, absence of tissue deposition leading to severe prolonged pruritus, reduced incidence of anaphylactoid reactions, and ease of monitoring to prevent fluid overload. The cost of albumin, nevertheless, limits its usage. Crystalloids currently serve as the first-line fluids in hypovolaemic patients. Colloids can be considered in patients with severe or acute shock or hypovolaemia resulting from sudden plasma loss. Colloids may be combined with crystalloids to obviate administration of large crystalloid volumes. Further clinical trials are needed to define the optimal role for colloids in critically ill patients.