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3.
Anaesthesia ; 75(9): 1180-1190, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32072617

RESUMO

Whether third-generation hydroxyethyl starch solutions provoke kidney injury or haemostatic abnormalities in patients having cardiac surgery remains unclear. We tested the hypotheses that intra-operative administration of a third-generation starch does not worsen postoperative kidney function or haemostasis in cardiac surgical patients compared with human albumin 5%. This triple-blind, non-inferiority, clinical trial randomly allocated patients aged 40-85 who underwent elective aortic valve replacement, with or without coronary artery bypass grafting, to plasma volume replacement with 6% starch 130/0.4 vs. 5% human albumin. Our primary outcome was postoperative urinary neutrophil gelatinase-associated lipocalin concentrations, a sensitive and early marker of postoperative kidney injury. Secondarily, we evaluated urinary interleukin-18; acute kidney injury using creatinine RIFLE criteria, coagulation measures, platelet count and function. Non-inferiority (delta 15%) was assessed with correction for multiple comparisons. We enrolled 141 patients (69 starch, 72 albumin) as planned. Results of the primary analysis demonstrated that postoperative urine neutrophil gelatinase-associated lipocalin (median (IQR [range])) was slightly lower with hydroxyethyl starch (5 (1-68 [0-996]) ng.ml-1 ) vs. albumin (5 (2-74 [0-1604]) ng.ml-1 ), although not non-inferior [ratio of geometric means (95%CI) 0.91 (0.57, 1.44); p = 0.15] due to higher than expected variability. Urine interleukin-18 concentrations were reduced, but interleukin-18 and kidney injury were again not non-inferior. Of 11 individual coagulation measures, platelet count and function, nine were non-inferior to albumin. Two remaining measures, thromboelastographic R value and arachidonic acid-induced platelet aggregation, were clinically similar but with wide confidence intervals. Starch administration during cardiac surgery produced similar observed effects on postoperative kidney function, coagulation, platelet count and platelet function compared with albumin, though greater than expected variability and wide confidence intervals precluded the conclusion of non-inferiority. Long-term mortality and kidney function appeared similar between starch and albumin.


Assuntos
Coagulação Sanguínea/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos , Derivados de Hidroxietil Amido/farmacologia , Cuidados Intraoperatórios/métodos , Rim/efeitos dos fármacos , Substitutos do Plasma/farmacologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Hemostáticos , Humanos , Rim/fisiologia , Masculino , Pessoa de Meia-Idade
4.
J Surg Res ; 248: 90-97, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31877435

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) and Abdominal Aortic and Junctional Tourniquet (AAJT) have received much attention in recent as methods for temporary control of junctional hemorrhage. Previous studies typically used the animal's shed blood for resuscitation. With current interest in moving REBOA to prehospital environment, this study aimed to evaluate the hemodynamic and metabolic responses to different resuscitation fluids used with these devices. METHODS: In swine (Sus scrofa), shock was induced using a controlled hemorrhage, femur fracture, and uncontrolled hemorrhage from the femoral artery. Infrarenal REBOA or AAJT was deployed for 60 min during which the arterial injury was repaired. Animals were resuscitated with 15 mL/kg of shed whole blood (SWB) or fresh frozen plasma (FFP) or 30 mL/kg of a balanced crystalloid (PlasmaLyte). RESULTS: Animals in the AAJT and REBOA groups did not show any measurable differences in hemodynamics, metabolic responses, or survival with AAJT or REBOA treatment; hence, the data are pooled and analyzed among the three resuscitative fluids. SWB, FFP, and PlasmaLyte groups did not have a difference in survival time or overall survival. The animals in the SWB and FFP groups maintained higher blood pressure after resuscitation, (P < 0.001) and required significantly less norepinephrine to maintain blood pressure than those in the PlasmaLyte group (P < 0.001). The PlasmaLyte resuscitation prolonged prothrombin time and decreased thromboelastography maximum amplitude. CONCLUSIONS: After 60 min, infrarenal REBOA or AAJT aortic occlusion SWB and FFP resuscitation provided better blood pressure support with half of the resuscitative volume of PlasmaLyte. Swine resuscitated with SWB and FFP also had a more favorable coagulation profile. These data suggest that whole blood or component therapy should be used for resuscitation in conjunction with REBOA or AAJT, and administration of these fluids should be considered if prehospital device use is pursued.


Assuntos
Técnicas Hemostáticas , Traumatismo Múltiplo/terapia , Ressuscitação , Choque Hemorrágico/terapia , Animais , Feminino , Plasma , Substitutos do Plasma , Suínos
5.
Br J Anaesth ; 123(6): 768-776, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31627889

RESUMO

BACKGROUND: Sufficient tissue oxygen tension may reduce the risk of postoperative wound infections. Supplemental administration of crystalloids increases subcutaneous oxygen tension (Psqo2). Colloids remain longer in the intravascular system and might therefore increase Psqo2 even more than crystalloids. Therefore, we tested the hypothesis that goal-directed colloid administration increases the perioperative Psqo2 more compared with crystalloid administration. METHODS: We randomly assigned 80 patients undergoing elective open abdominal surgery to receive fluid boluses of hydroxyethyl starch (HES) or lactated Ringer's (LR) solution guided by oesophageal Doppler. Intraoperative Psqo2 was measured in the upper arm. After operation, we measured the Psqo2 in the upper arm and in the surgical wound. RESULTS: Forty patients were enrolled in each group. Patients in the colloid group received HES solution 750 ml (500; 1000) and LR solution 1500 ml (1000; 2000). Patients in the crystalloid group received LR solution 2825 ml (2000; 3960). The goal-directed administration of colloids did not improve intraoperative Psqo2 in the arm compared with crystalloid administration (11.4 kPa [9.0; 16.6] vs 11.2 kPa [8.6; 15.1], respectively; P=0.58). Postoperative arm Psqo2 was 8.1 kPa (6.5; 9.6) in the colloid group and 7.3 kPa (5.7; 9.1) in the crystalloid group (P=0.11). Postoperative surgical wound Psqo2 was 10.7 kPa (8.6; 13.4) in the colloid group and 10.1 kPa (8.1; 12.7) in the crystalloid group (P=0.68). CONCLUSIONS: Goal-directed colloid administration did not increase Psqo2 compared with goal-directed crystalloid administration in patients undergoing open abdominal surgery. CLINICAL TRIAL REGISTRATION: NCT00517127.


Assuntos
Abdome/cirurgia , Hidratação/métodos , Derivados de Hidroxietil Amido/administração & dosagem , Oxigênio/metabolismo , Lactato de Ringer/administração & dosagem , Tela Subcutânea/metabolismo , Adulto , Idoso , Braço , Coloides , Soluções Cristaloides , Feminino , Objetivos , Humanos , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/administração & dosagem , Adulto Jovem
6.
Crit Care ; 23(1): 281, 2019 08 16.
Artigo em Inglês | MEDLINE | ID: mdl-31420052

RESUMO

BACKGROUND: A peripheral perfusion-targeted resuscitation during early septic shock has shown encouraging results. Capillary refill time, which has a prognostic value, was used. Adding accuracy and predictability on capillary refill time (CRT) measurement, if feasible, would benefit to peripheral perfusion-targeted resuscitation. We assessed whether a reduction of capillary refill time during passive leg raising (ΔCRT-PLR) predicted volume-induced peripheral perfusion improvement defined as a significant decrease of capillary refill time following volume expansion. METHODS: Thirty-four patients with acute circulatory failure were selected. Haemodynamic variables, metabolic variables (PCO2gap), and four capillary refill time measurements were recorded before and during a passive leg raising test and after a 500-mL volume expansion over 20 min. Receiver operating characteristic curves were built, and areas under the curves were calculated (ROCAUC). Confidence intervals (CI) were performed using a bootstrap analysis. We recorded mortality at day 90. RESULTS: The least significant change in the capillary refill time was 25% [95% CI, 18-30]. We defined CRT responders as patients showing a reduction of at least 25% of capillary refill time after volume expansion. A decrease of 27% in ΔCRT-PLR predicted peripheral perfusion improvement with a sensitivity of 87% [95% CI, 73-100] and a specificity of 100% [95% CI, 74-100]. The ROCAUC of ΔCRT-PLR was 0.94 [95% CI, 0.87-1.0]. The ROCAUC of baseline capillary refill time was 0.73 [95% CI, 0.54-0.90] and of baseline PCO2gap was 0.79 [0.61-0.93]. Capillary refill time was significantly longer in non-survivors than in survivors at day 90. CONCLUSION: ΔCRT-PLR predicted peripheral perfusion response following volume expansion. This simple low-cost and non-invasive diagnostic method could be used in peripheral perfusion-targeted resuscitation protocols. TRIAL REGISTRATION: CPP Lyon Sud-Est II ANSM: 2014-A01034-43 Clinicaltrial.gov, NCT02248025 , registered 13th of September 2014.


Assuntos
Capilares/fisiologia , Débito Cardíaco/fisiologia , Substitutos do Plasma/normas , Choque/sangue , Idoso , Área Sob a Curva , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/uso terapêutico , Estudos Prospectivos , Curva ROC , Choque/fisiopatologia , Fatores de Tempo
7.
Rev Bras Anestesiol ; 69(4): 383-389, 2019.
Artigo em Português | MEDLINE | ID: mdl-31405567

RESUMO

BACKGROUND AND OBJECTIVES: Modern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry. METHODS: Blood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation. RESULTS: In Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p>0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p<0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p<0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p>0.05). CONCLUSION: Extem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.


Assuntos
Soluções Cristaloides/administração & dosagem , Gelatina/administração & dosagem , Derivados de Hidroxietil Amido/administração & dosagem , Tromboelastografia/métodos , Adulto , Artroscopia/métodos , Coagulação Sanguínea/efeitos dos fármacos , Testes de Coagulação Sanguínea , Coloides/administração & dosagem , Feminino , Humanos , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/administração & dosagem
8.
Cochrane Database Syst Rev ; 6: CD004039, 2019 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-31251387

RESUMO

BACKGROUND: Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious effect on haemodynamic balance, and increase morbidity and mortality. Albumin is considered the standard product against which no plasma expansion or other plasma expanders, e.g. other colloids (polygeline , dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared. However, the benefits and harms of these plasma expanders are not fully clear. OBJECTIVES: To assess the benefits and harms of any plasma volume expanders such as albumin, other colloids (polygeline, dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol versus no plasma volume expander or versus another plasma volume expander for paracentesis in people with cirrhosis and large ascites. SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CNKI, VIP, Wanfang, Science Citation Index Expanded, and Conference Proceedings Citation Index until January 2019. Furthermore, we searched FDA, EMA, WHO (last search January 2019), www.clinicaltrials.gov/, and www.controlled-trials.com/ for ongoing trials. SELECTION CRITERIA: Randomised clinical trials, no matter their design or year of publication, publication status, and language, assessing the use of any type of plasma expander versus placebo, no intervention, or a different plasma expander in connection with paracentesis for ascites in people with cirrhosis. We considered quasi-randomised, retrieved with the searches for randomised clinical trials only, for reports on harms. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We calculated the risk ratio (RR) or mean difference (MD) using the fixed-effect model and the random-effects model meta-analyses, based on the intention-to-treat principle, whenever possible. If the fixed-effect and random-effects models showed different results, then we made our conclusions based on the analysis with the highest P value (the more conservative result). We assessed risks of bias of the individual trials using predefined bias risk domains. We assessed the certainty of the evidence at an outcome level, using GRADE, and constructed 'Summary of Findings' tables for seven of our review outcomes. MAIN RESULTS: We identified 27 randomised clinical trials for inclusion in this review (24 published as full-text articles and 3 as abstracts). Five of the trials, with 271 participants, assessed plasma expanders (albumin in four trials and ascitic fluid in one trial) versus no plasma expander. The remaining 22 trials, with 1321 participants, assessed one type of plasma expander, i.e. dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus another type of plasma expander, i.e. albumin in 20 of these trials and polygeline in one trial. Twenty-five trials provided data for quantitative meta-analysis. According to the Child-Pugh classification, most participants were at an intermediate to advanced stage of liver disease in the absence of hepatocellular carcinoma, recent gastrointestinal bleeding, infections, and hepatic encephalopathy. All trials were assessed as at overall high risk of bias. Ten trials seemed not to have been funded by industry; twelve trials were considered unclear about funding; and five trials were considered funded by industry or a for-profit institution.We found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality (RR 0.52, 95% CI 0.06 to 4.83; 248 participants; 4 trials; very low certainty); renal impairment (RR 0.32, 95% CI 0.02 to 5.88; 181 participants; 4 trials; very low certainty); other liver-related complications (RR 1.61, 95% CI 0.79 to 3.27; 248 participants; 4 trials; very low certainty); and non-serious adverse events (RR 1.04, 95% CI 0.32 to 3.40; 158 participants; 3 trials; very low certainty). Two of the trials stated that no serious adverse events occurred while the remaining trials did not report on this outcome. No trial reported data on health-related quality of life.We found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality (RR 1.03, 95% CI 0.82 to 1.30; 1014 participants; 14 trials; very low certainty); serious adverse events (RR 0.89, 95% CI 0.10 to 8.30; 118 participants; 2 trials; very low certainty); renal impairment (RR 1.17, 95% CI 0.71 to 1.91; 1107 participants; 17 trials; very low certainty); other liver-related complications (RR 1.10, 95% CI 0.82 to 1.48; 1083 participants; 16 trials; very low certainty); and non-serious adverse events (RR 1.37, 95% CI 0.66 to 2.85; 977 participants; 14 trials; very low certainty). We found no data on heath-related quality of life and refractory ascites. AUTHORS' CONCLUSIONS: Our systematic review and meta-analysis did not find any benefits or harms of plasma expanders versus no plasma expander or of one plasma expander such as polygeline, dextrans, hydroxyethyl starch, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus albumin on primary or secondary outcomes. The data originated from few, small, mostly short-term trials at high risks of systematic errors (bias) and high risks of random errors (play of chance). GRADE assessments concluded that the evidence was of very low certainty. Therefore, we can neither demonstrate or discard any benefit of plasma expansion versus no plasma expansion, and differences between one plasma expander versus another plasma expander.Larger trials at low risks of bias are needed to assess the role of plasma expanders in connection with paracentesis. Such trials should be conducted according to the SPIRIT guidelines and reported according to the CONSORT guidelines.


Assuntos
Ascite , Cirrose Hepática , Paracentese , Substitutos do Plasma , Ascite/etiologia , Ascite/terapia , Humanos , Cirrose Hepática/complicações , Substitutos do Plasma/uso terapêutico , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
9.
J Vet Emerg Crit Care (San Antonio) ; 29(4): 349-359, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31228334

RESUMO

OBJECTIVE: To review and discuss the use of hydroxyethyl starches (HES) in equine veterinary medicine, and to provide recommendations for its use. DATA SOURCES: Veterinary and human peer-reviewed medical literature including scientific reviews, meta-analyses, and original research articles. HUMAN DATA SYNTHESIS: Increasing evidences on adverse effects after HES use and decreasing support for beneficial effects with regards to volume expansion and colloid osmotic pressure (COP) support in critically ill subjects have led to a recent guideline to limit the use of HES in critically ill people. EQUINE VETERINARY DATA SYNTHESIS: The rationale for HES use in horses is mainly extrapolated from human medicine, and very limited studies in horses are available. There is limited evidence suggesting a superiority of volume expansion effects of HES over crystalloids. The potential for HES to increase and maintain COP is well supported, but there is no evidence that maintaining or increasing plasma COP influences outcome, tissue edema formation, or rates of complications that potentially relate to edema formation. HES induce dose-dependent changes in coagulopathic parameters, but there is no evidence that HES causes clinical coagulopathies. Insufficient data are available on other adverse effects such as acute kidney injury, or mortality in horses. The use of HES should be restricted in septic patients, but may still have some use in cases of hemorrhagic shock resuscitation, hypoalbuminemia, or perioperative fluid replacement. CONCLUSION: The evidence supporting the use of HES in horses is weak due to lack of species-specific investigations. Acknowledging species differences, the use of HES should be judicious, yet with some recognition of its benefits in particular cases. More research is necessary to improve knowledge on use of HES in horses and to establish better future recommendations.


Assuntos
Doenças dos Cavalos/terapia , Derivados de Hidroxietil Amido/uso terapêutico , Substitutos do Plasma/uso terapêutico , Animais , Cavalos , Humanos
10.
Ophthalmic Surg Lasers Imaging Retina ; 50(5): 274-280, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31100157

RESUMO

BACKGROUND AND OBJECTIVE: To assess the efficacy of perfluorodecalin (PFD) or Densiron 68 heavy silicone oil (HSO) in the management of inferior complex retinal detachment recurrence. PATIENTS AND METHODS: A retrospective, comparative consecutive case series study. Twenty-four eyes of 24 patients affected by inferior complex retinal detachment recurrence underwent pars plana vitrectomy with PFD or HSO as endotamponade. All patients recruited were affected by complicated inferior retinal detachments and had already undergone at least one vitreoretinal procedure. The primary endpoint was anatomical success with primary and secondary surgery. The secondary endpoints were functional outcome and inflammatory complications. RESULTS: Out of 24 cases of inferior retinal detachment recurrence, 12 were tamponed with PFD (PFD group) and 12 with HSO (D68 group). Retinal reattachment rate at first surgery was 50% for the D68 group and 66.6% for the PFD group. Final reattachment rate after two or more surgical operations was 91.6% for the PFD group and 83.3% for the D68 group. Best-corrected visual acuity improved in both groups from a mean of 1.00 logMAR (20/200; standard deviation [SD]: 1) to 0.60 logMAR (20/80; SD: 0.3), and from a mean of 1.81 logMAR (20/2000; SD: 1.1) to a mean of 2.00 logMAR (20/2,000; SD:1) for the PFD and D68 groups, respectively. CONCLUSION: Both the endotamponades used showed good results in solving inferior retinal detachment recurrence with a slightly better rate in the PFD group, but it was not statistically significant (P > .05). [Ophthalmic Surg Lasers Imaging Retina. 2019;50:274-280.].


Assuntos
Tamponamento Interno/métodos , Fluorcarbonetos/farmacologia , Retina/patologia , Descolamento Retiniano/cirurgia , Óleos de Silicone/farmacologia , Acuidade Visual , Vitrectomia/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma , Recidiva , Descolamento Retiniano/diagnóstico , Estudos Retrospectivos , Resultado do Tratamento
11.
Crit Care ; 23(1): 191, 2019 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-31138247

RESUMO

BACKGROUND: Optimal infusion rate of colloids in patients with suspected hypovolemia is unknown, and the primary objective of the present study was to test if plasma volume expansion by 5% albumin is greater if fluid is administered slowly rather than rapidly. METHODS: Patients with signs of hypoperfusion after major abdominal surgery were randomized to intravenous infusion of 5% albumin at a dose of 10 ml/kg (ideal body weight) either rapidly (30 min) or slowly (180 min). Plasma volume was measured using radiolabeled albumin at baseline, at 30 min, and at 180 min after the start of infusion. Primary outcome was change in plasma volume from the start of infusion to 180 min after the start of infusion. Secondary outcomes included the change in the area under the plasma volume curve and transcapillary escape rate (TER) for albumin from 180 to 240 min after the start of albumin infusion. RESULTS: A total of 33 and 31 patients were included in the analysis in the slow and rapid groups, respectively. The change in plasma volume from the start of infusion to 180 min did not differ between the slow and rapid infusion groups (7.4 ± 2.6 vs. 6.5 ± 4.1 ml/kg; absolute difference, 0.9 ml/kg [95%CI, - 0.8 to 2.6], P = 0.301). Change in the area under the plasma volume curve was smaller in the slow than in the rapid infusion group and was 866 ± 341 and 1226 ± 419 min ml/kg, respectively, P < 0.001. TER for albumin did not differ and was 5.3 ± 3.1%/h and 5.4 ± 3%/h in the slow and in the rapid infusion groups, respectively, P = 0.931. CONCLUSIONS: This study does not support our hypothesis that a slow infusion of colloid results in a greater plasma volume expansion than a rapid infusion. Instead, our result of a smaller change in the area under the plasma volume curve indicates that a slow infusion results in a less efficient plasma volume expansion, but further studies are required to confirm this finding. A rapid infusion has no effect on vascular leak as measured after completion of the infusion. TRIAL REGISTRATION: EudraCT2013-004446-42 registered December 23, 2014.


Assuntos
Albuminas/administração & dosagem , Infusões Intravenosas/estatística & dados numéricos , Idoso , Albuminas/uso terapêutico , Análise de Variância , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Infusões Intravenosas/métodos , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/administração & dosagem , Substitutos do Plasma/uso terapêutico , Volume Plasmático/efeitos dos fármacos , Volume Plasmático/fisiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Estatísticas não Paramétricas , Suécia
12.
J Vet Emerg Crit Care (San Antonio) ; 29(3): 309-313, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31066159

RESUMO

OBJECTIVE: To evaluate changes in serum creatinine and chloride concentrations in anesthetized dogs that received 6% hydroxyethyl starch (HES) 670/0.7. DESIGN: Retrospective case series, 2002-2015. SETTING: University veterinary teaching hospital. ANIMALS: Two hundred forty-four client-owned dogs undergoing general anesthesia that received an HES solution. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Medical records of dogs that received an HES solution (6%, 670/0.7) while under general anesthesia during the study period were reviewed. Information obtained from the medical record included patient signalment, reason for anesthesia or diagnosis, body weight, amount of HES solution administered, pre- and postanesthesia creatinine value, pre- and postanesthesia chloride value, and day interval between measurements. Corrected chloride values were used for all statistical analysis. Dogs received a median dose of 6.3 mL/kg hetastarch during anesthesia. Median preanesthesia creatinine and corrected chloride values were 79.5 µmol/L (0.9 mg/dL) (range 8.8-689.5 µmol/L [0.1-7.8 mg/dL]) and 111 mmol/L (111 mEq/L) (range 80-123 mmol/L [80-123 mg/dL]), respectively. Median postanesthesia creatinine was 57.4 µmol/L (0.65 mg/dL) (8.8-716 µmol/L [0.1-8.1 mg/dL]). Median postanesthesia corrected chloride was 115 mmol/L (115 mEq/L) (range 87.5-129.6 mmol/L [87.5-129.6 mEq/L]). Mann-Whitney test analysis revealed a significant decrease in creatinine (Δ Cr 17.7 µmol/L [0.2 mg/dL], P < 0.01) and a significant increase in corrected chloride (Δ Cl 4.1 mmol/L [4.1mEq/L], P < 0.01) between pre- and postanesthesia values. CONCLUSIONS: In a mixed population of hospitalized dogs undergoing general anesthesia that received a median dose of 6 mL/kg of HES, creatinine was lower and chloride was higher in the postanesthetic than in the preanesthetic period. The clinical significance of these changes and the role that HES administration played in them relative to concurrent therapies is unknown.


Assuntos
Cloretos/sangue , Creatinina/sangue , Cães/fisiologia , Derivados de Hidroxietil Amido/administração & dosagem , Substitutos do Plasma/administração & dosagem , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/veterinária , Anestesia Geral/veterinária , Animais , Cães/sangue , Feminino , Derivados de Hidroxietil Amido/efeitos adversos , Masculino , Substitutos do Plasma/efeitos adversos , Registros/veterinária , Estudos Retrospectivos
13.
J Vet Emerg Crit Care (San Antonio) ; 29(3): 279-287, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30983126

RESUMO

OBJECTIVE: To describe the frequency of renal tubular vacuolization (RTV) as a surrogate of osmotic nephrosis and assess hyperosmolar agents as predictors of RTV severity. DESIGN: Retrospective study (February 2004-October 2014). SETTING: Veterinary teaching hospital. ANIMALS: Fifty-three client-owned, critically ill dogs that had a postmortem examination. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The frequency, severity, and location of RTV were determined in small group of critically ill dogs postmortem. Logistic regression was performed to assess cumulative 6% HES (670/0.75) and mannitol dose as predictors for RTV severity with presenting serum creatinine concentration, cumulative furosemide dose, and duration of hospitalization as covariates. RTV was noted in 45 (85%) of 53 critically ill dogs and was most commonly located to the medullary rays (68%). Cumulative 6% HES (670/0.75) dose (P = 0.009) and presenting serum creatinine concentration (P = 0.027) were significant predictors of RTV severity. For every 1 mL/kg increase in 6% HES (670/0.75) dose that a dog received, there was 1.6% increased chance of having more severe RTV (OR 1.016; 95% CI 1.004-1.029). In addition, for every 88.4 µmol/L (1 mg/dL) increase in presenting serum creatinine, there was a 22.7% increased chance of having more severe RTV (OR 1.227; 95% CI 1.023-1.472). Cumulative mannitol (P = 0.548) and furosemide (P = 0.136) doses were not significant predictors of RTV severity. CONCLUSION: In a small group of critically ill dogs, there was a high frequency of RTV identified on postmortem examination. Administration of 6% HES (670/0.75) and presenting serum creatinine concentration were significant predictors of RTV severity. Larger prospective studies are needed to determine the etiology and significance of RTV in dogs.


Assuntos
Lesão Renal Aguda/veterinária , Doenças do Cão/patologia , Lesão Renal Aguda/sangue , Lesão Renal Aguda/patologia , Animais , Autopsia/veterinária , Creatinina/sangue , Cuidados Críticos , Estado Terminal , Diuréticos/administração & dosagem , Doenças do Cão/sangue , Cães , Feminino , Furosemida/administração & dosagem , Hospitais Veterinários , Derivados de Hidroxietil Amido/administração & dosagem , Masculino , Substitutos do Plasma/administração & dosagem , Estudos Prospectivos , Estudos Retrospectivos
14.
PLoS One ; 14(4): e0213057, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31034525

RESUMO

INTRODUCTION: Balanced fluid replacement solutions can possibly reduce the risks for electrolyte imbalances, for acid-base imbalances, and thus for renal failure. To assess the intraoperative change of base excess (BE) and chloride in serum after treatment with either a balanced gelatine/electrolyte solution or a non-balanced gelatine/electrolyte solution, a prospective, controlled, randomized, double-blind, dual centre phase III study was conducted in two tertiary care university hospitals in Germany. MATERIAL AND METHODS: 40 patients of both sexes, aged 18 to 90 years, who were scheduled to undergo elective abdominal surgery with assumed intraoperative volume requirement of at least 15 mL/kg body weight gelatine solution were included. Administration of study drug was performed intravenously according to patients need. The trigger for volume replacement was a central venous pressure (CVP) minus positive end-expiratory pressure (PEEP) <10 mmHg (CVP <10 mmHg). The crystalloid:colloid ratio was 1:1 intra- and postoperatively. The targets for volume replacement were a CVP between 10 and 14 mmHg minus PEEP after treatment with vasoactive agent and mean arterial pressure (MAP) > 65 mmHg. RESULTS: The primary endpoints, intraoperative changes of base excess -2.59 ± 2.25 (median: -2.65) mmol/L (balanced group) and -4.79 ± 2.38 (median: -4.70) mmol/L (non-balanced group)) or serum chloride 2.4 ± 1.9 (median: 3.0) mmol/L and 5.2 ± 3.1 (median: 5.0) mmol/L were significantly different (p = 0.0117 and p = 0.0045, respectively). In both groups (each n = 20) the investigational product administration in terms of volume and infusion rate was comparable throughout the course of the study, i.e. before, during and after surgery. DISCUSSION: Balanced gelatine solution 4% combined with a balanced electrolyte solution demonstrated significant smaller impact on blood gas analytic parameters in the primary endpoints BE and serum chloride when compared to a non-balanced gelatine solution 4% combined with NaCl 0.9%. No marked treatment differences were observed with respect to haemodynamics, coagulation and renal function. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01515397) and clinicaltrialsregister.eu, EudraCT number 2010-018524-58.


Assuntos
Abdome/cirurgia , Desequilíbrio Ácido-Base/tratamento farmacológico , Assistência Perioperatória , Desequilíbrio Hidroeletrolítico/tratamento farmacológico , Abdome/fisiopatologia , Desequilíbrio Ácido-Base/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cloretos/sangue , Eletrólitos/administração & dosagem , Feminino , Hidratação , Gelatina/administração & dosagem , Alemanha , Humanos , Concentração de Íons de Hidrogênio , Derivados de Hidroxietil Amido/administração & dosagem , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/administração & dosagem , Equilíbrio Hidroeletrolítico/efeitos dos fármacos , Desequilíbrio Hidroeletrolítico/fisiopatologia , Adulto Jovem
15.
Gen Thorac Cardiovasc Surg ; 67(4): 374-376, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30805825

RESUMO

The best priming and replenishment solution in cardiopulmonary bypass remains unknown, and the efficacy and drawbacks of artificial colloid are controversial. We retrospectively compared consecutive patients undergoing elective adult valve surgery in cases wherein cardiopulmonary bypass was primed and replenished with hydroxyethyl starch 130/0.4 (n = 12) or crystalloid solution (n = 11). The fluid overbalance during cardiopulmonary bypass was much lower in the hydroxyethyl starch 130/0.4 group (mean ± standard deviation, + 95 ± 1241 mL) than in the crystalloid solution group (+ 2921 ± 1984 mL) (P < 0.001). Renal function, intraoperative and postoperative bleeding, and blood products did not deteriorate with the use of hydroxyethyl starch 130/0.4. The postoperative intubation time was shorter in the hydroxyethyl starch 130/0.4 group (16.0 ± 2.6 h) than in the crystalloid solution group (18.7 ± 2.6 h) (P = 0.018). Although prospective randomized trials are needed to verify our findings, the impact of fluid balance differences requires serious consideration.


Assuntos
Anuloplastia da Valva Cardíaca , Ponte Cardiopulmonar/métodos , Soluções Cristaloides/uso terapêutico , Derivados de Hidroxietil Amido/uso terapêutico , Nefropatias/prevenção & controle , Hemorragia Pós-Operatória/prevenção & controle , Desequilíbrio Hidroeletrolítico/prevenção & controle , Adulto , Idoso , Feminino , Humanos , Nefropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/uso terapêutico , Hemorragia Pós-Operatória/fisiopatologia , Estudos Retrospectivos , Desequilíbrio Hidroeletrolítico/fisiopatologia
16.
BMC Surg ; 19(1): 15, 2019 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-30717728

RESUMO

BACKGROUND: To improve prognosis after esophageal surgery, intraoperative fluid optimization is important. Herein, we hypothesized that hydroxyethyl starch administration during esophagectomy reduce the total amount of fluid infused and it could have a positive effect on postoperative complication occurrence and mortality. METHODS: All consecutive adult patients who underwent elective esophageal surgery for cancer were studied. The primary outcome was the development of composite complications including death, cardio-cerebrovascular complications, respiratory complications, renal complications, gastrointestinal complications, sepsis, empyema or abscess, and multi-organ failure. The relationship between perioperative variables and composite complication was evaluated using multivariable logistic regression. RESULTS: Of 892 patients analyzed, composite complications developed in 271 (30.4%). The higher hydroxyethyl starch ratio in total fluid had a negative relationship with the total fluid infusion amount (r = - 0.256, P <  0.001). In multivariable analysis, intraoperatively administered total fluid per weight per hour (odds ratio, 1.248; 95% CI, 1.153-1.351; P <  0.001) and HES-to-crystalloid ratio (odds ratio, 2.125; 95% CI, 1.521-2.969; P <  0.001) were associated with increased risks of postoperative composite outcomes. CONCLUSIONS: Although hydroxyethyl starch administration reduces the total fluid infusion amount during esophageal surgery for cancer, intravenous hydroxyethyl starch infusion is associated with an increasing risk of postoperative composite complications.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia , Hidratação/efeitos adversos , Hidratação/métodos , Derivados de Hidroxietil Amido/efeitos adversos , Substitutos do Plasma/efeitos adversos , Idoso , Soluções Cristaloides/administração & dosagem , Soluções Cristaloides/efeitos adversos , Esofagectomia/efeitos adversos , Esofagectomia/mortalidade , Feminino , Humanos , Derivados de Hidroxietil Amido/administração & dosagem , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Morbidade , Substitutos do Plasma/administração & dosagem , Prognóstico , Estudos Retrospectivos
17.
Br J Clin Pharmacol ; 85(6): 1303-1311, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30756411

RESUMO

AIMS: A population kinetic model was developed for the body fluid shifts occurring when 20% albumin is given by intravenous infusion. The aim was to study whether its efficacy to expand the plasma volume is impaired after major surgery. METHODS: An intravenous infusion of 3 mL/kg 20% albumin over 30 minutes was given to 15 volunteers and to 15 patients on the 1st day after major open abdominal surgery. Blood samples and urine were collected during 5 hours. Mixed-effect modelling software was used to develop a fluid volume kinetic model, using blood haemoglobin and urine excretion the estimate body fluid shifts, to which individual-specific covariates were added in sequence. RESULTS: The rise in plasma albumin expanded the plasma volume in excess of the infused volume by relocating noncirculating fluid (rate constant k21 ), but it also increased losses of fluid from the kinetic system (kb ). The balance between k21 and kb maintained the rise in plasma albumin and plasma volume at a virtual steady-state for almost 2 hours. The rate constant for urinary excretion (k10 ) was slightly reduced by the preceding surgery, by a marked rise in plasma albumin, and by a high preinfusion urinary concentration of creatinine. The arterial pressure, body weight, and plasma concentrations of C-reactive protein and shedding products of the endothelial glycocalyx layer (syndecan-1, heparan sulfate, and hyaluronic acid) did not serve as statistically significant covariates. CONCLUSIONS: There were no clinically relevant differences in the kinetics of 20% albumin between postoperative patients and volunteers.


Assuntos
Albuminas/farmacocinética , Deslocamentos de Líquidos Corporais/efeitos dos fármacos , Hidratação , Modelos Biológicos , Substitutos do Plasma/farmacocinética , Abdome/cirurgia , Adulto , Albuminas/administração & dosagem , Albuminas/efeitos adversos , Feminino , Humanos , Infusões Intravenosas , Masculino , Substitutos do Plasma/administração & dosagem , Substitutos do Plasma/efeitos adversos , Cuidados Pós-Operatórios , Suécia , Resultado do Tratamento , Adulto Jovem
18.
J Vet Emerg Crit Care (San Antonio) ; 29(2): 132-142, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30767375

RESUMO

OBJECTIVE: To investigate the association between synthetic colloids and biomarkers of acute kidney injury (AKI) in dogs with hemorrhagic shock. DESIGN: Experimental interventional study. SETTING: University. ANIMALS: Twenty-four healthy ex-racing Greyhounds. INTERVENTIONS: Anesthetized Greyhounds subjected to hemorrhage for 60 min were resuscitated with 20 mL/kg of fresh whole blood (FWB), 6% hydroxyethyl starch (HES) 130/0.4, 4% succinylated gelatin (GELO), or 80 mL/kg of isotonic crystalloid (CRYST) over 20 min (n = 6 per treatment). Concentrations of biomarkers of AKI were measured at baseline, end of hemorrhage, and at 40 (T60), 100 (T120), and 160 (T180) min after fluid bolus. Biomarkers included neutrophil gelatinase-associated lipocalin in urine and serum (uNGAL; sNGAL), and urine cystatin C (uCYSC), kidney injury molecule-1 (uKIM), clusterin (uCLUST), osteopontin, gamma-glutamyl transferase, monocyte chemoattractant protein-1 (uMCP), interleukin-6, interleukin-8, protein (uPROT), hyaluronan, and F2 -isoprostanes. Renal histology was scored for tubular injury and microvesiculation. Biomarker fold-change from baseline was compared between groups using mixed effects models (Bonferroni-Holm corrected P<0.05). Frequencies of histology scores were compared by Fisher's exact test. MEASUREMENTS AND MAIN RESULTS: In dogs treated with GELO, uNGAL fold-change was markedly greater compared with all other groups at T60, T120, and T180 (all P<0.001), and uCYSC was greater at T60 compared with CRYST (P<0.001), and at T120 and T180 compared with all other groups (all P<0.001). Smaller, albeit significant, between-group differences in uKIM, uCLUST, uMCP, and urine protein concentration were observed across the FWB, GELO, and HES groups, compared with CRYST. The GELO group more frequently had marked tubular microvesiculation than the other groups (P = 0.015) although tubular injury scores were comparable. CONCLUSION: In dogs with hemorrhagic shock, GELO was associated with greater magnitude increases in urine biomarkers of AKI and more frequent marked tubular microvesiculation, compared with FWB, CRYST, and HES.


Assuntos
Lesão Renal Aguda/veterinária , Biomarcadores/urina , Doenças do Cão/tratamento farmacológico , Lipocalina-2/urina , Choque Hemorrágico/veterinária , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/urina , Animais , Cuidados Críticos , Modelos Animais de Doenças , Cães , Feminino , Gelatina/administração & dosagem , Gelatina/efeitos adversos , Derivados de Hidroxietil Amido/administração & dosagem , Derivados de Hidroxietil Amido/efeitos adversos , Masculino , Substitutos do Plasma/administração & dosagem , Substitutos do Plasma/efeitos adversos , Choque Hemorrágico/tratamento farmacológico , Succinatos/administração & dosagem , Succinatos/efeitos adversos
19.
Cir Cir ; 87(2): 164-169, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30768072

RESUMO

Objective: Establish whether the use of starch in hip arthroplasty is a risk factor for excessive surgical bleeding and requirement of red blood cell transfusion. Method: Analytical observational retrospective study in 240 patients who underwent primary total hip arthroplasty from January 2015 to January 2016. Two groups were formed: starch (94 patients) and non-starch (146 patients). Age, sex, body mass index, preoperative and postoperative hemoglobin, red cell transfusion and surgical bleeding was analyzed. Results: Starchy group had increased risk of excessive surgical bleeding (OR: 3.58; 95% CI: 2.05- 6.26) and red blood cells transfusion (OR: 3.12; 95% CI: 1.76 -5.5). In the starch group average surgical bleeding was 396 ml (SD: ± 234.94) and a decrease in hemoglobin of 4.6 g/dl (SD± 1.38). The control group had an average bleeding of 271.8 ml (SD: ± 139.22) and decrease in hemoglobin of 3.34 g/dl (SD: ± 1.4). Discussion: The starch group had higher surgical bleeding and required more often red blood cells transfusion than the non-starch group. We suggest to take in account the possible complications related to the use hydroxyethyl starch.


Assuntos
Artroplastia de Quadril , Perda Sanguínea Cirúrgica , Derivados de Hidroxietil Amido/efeitos adversos , Substitutos do Plasma/efeitos adversos , Fatores Etários , Idoso , Índice de Massa Corporal , Estudos de Casos e Controles , Intervalos de Confiança , Transfusão de Eritrócitos , Feminino , Hemoglobina A/análise , Humanos , Derivados de Hidroxietil Amido/administração & dosagem , Masculino , Razão de Chances , Substitutos do Plasma/administração & dosagem , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais
20.
PLoS One ; 14(1): e0209350, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30615630

RESUMO

BACKGROUND: Idarucizumab is a humanized Fab fragment that specifically reverses dabigatran anticoagulation. In trauma, volume expanders are used for resuscitation to compensate for blood loss and hemorrhagic shock, but it is unknown whether volume expanders influence the binding of dabigatran to its antidote. Using a porcine dilutional coagulopathy model, this study investigated whether volume replacement strategies affect binding of dabigatran to idarucizumab. METHODS: Twenty-five male pigs were treated orally with dabigatran etexilate (30 mg/kg bid) for 3 days. The following day, animals were anesthetized, infused with dabigatran (total dose 0.645 mg/kg) to achieve supratherapeutic concentrations, and randomized 1:1:1:1:1 (n = 5 per group) to control (no hemodilution) or hemodilution where ~50% of blood volume was substituted with Ringer's solution, 6% hydroxyethyl starch 130/0.4, 6% hydroxyethyl starch 200/0.5 or 4% gelatin. Idarucizumab was then administered intravenously (30 mg/kg) and serial blood samples were taken for up to 24 hours to measure diluted thrombin time (corresponding with dabigatran activity), total dabigatran (bound to antidote and free drug) and a panel of coagulation parameters. RESULTS: Mean plasma dabigatran levels were 617 ± 16 ng/mL after infusion and 600 ± 114 ng/mL after ~50% hemodilution with no significant differences between groups. Following treatment with idarucizumab, plasma concentrations of unbound dabigatran decreased markedly, with similar reductions in all groups. Dabigatran-induced prolongation of coagulation parameters was rapidly reversed in all groups. CONCLUSION: This study indicates that several volume expanders used for resuscitation in trauma do not interfere with the binding of idarucizumab to dabigatran.


Assuntos
Anticorpos Monoclonais Humanizados/sangue , Anticorpos Monoclonais Humanizados/farmacocinética , Antídotos/farmacocinética , Antitrombinas/sangue , Antitrombinas/farmacocinética , Dabigatrana/antagonistas & inibidores , Dabigatrana/farmacocinética , Hemodiluição , Animais , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/terapia , Volume Sanguíneo/fisiologia , Dabigatrana/sangue , Masculino , Modelos Animais , Substitutos do Plasma/administração & dosagem , Substitutos do Plasma/metabolismo , Sus scrofa
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