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1.
Anaesthesia ; 75(5): 634-641, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32030734

RESUMO

Intra-operative hypotension is a known predictor of adverse events and poor outcomes following major surgery. Hypotension often occurs on induction of anaesthesia, typically attributed to hypovolaemia and the haemodynamic effects of anaesthetic agents. We assessed the efficacy of fluid optimisation for reducing the incidence of hypotension on induction of anaesthesia. This prospective trial enrolled 283 patients undergoing radical cystectomy and randomly allocated them to goal-directed fluid therapy (n = 142) or standard fluid therapy (n = 141). Goal-directed fluid therapy patients received fluid optimisation based on stroke volume response to passive leg raise before induction; those with positive passive leg raise received intravenous crystalloid fluid boluses until stroke volume was optimised. Baseline mean arterial pressure was measured on the morning of surgery and on arriving in the operating theatre. This post-hoc analysis defined haemodynamic instability as either a > 30% relative drop in mean arterial pressure compared with baseline or absolute mean arterial pressure < 55 mmHg, within 15 min of induction. Forty-two (30%) goal-directed fluid therapy patients underwent fluid optimisation after finding an intravascular fluid deficit via passive leg raise testing; 106 (75%) goal-directed fluid therapy and 112 (79%) standard fluid therapy patients met criteria for haemodynamic instability. There was no significant difference in the incidence of haemodynamic instability between the goal-directed fluid therapy and standard fluid therapy groups using absolute mean arterial pressure drop below 55 mmHg (p = 0.58) or using pre-surgical testing or pre-surgical mean arterial pressure values as baseline (p = 0.21, p = 0.89, respectively); however, the difference in the incidence of haemodynamic instability was significant using the operating theatre baseline mean arterial pressure (p = 0.004). We conclude that fluid optimisation before induction of general anaesthesia did not significantly impact haemodynamic instability.


Assuntos
Anestesia/métodos , Hidratação/métodos , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Arterial , Soluções Cristaloides/administração & dosagem , Cistectomia , Eletrocardiografia , Feminino , Objetivos , Hemodinâmica , Humanos , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego , Volume Sistólico
2.
Anaesthesia ; 75(2): 254-265, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31536172

RESUMO

We conducted a Cochrane systematic review on the effectiveness of supplemental intravenous crystalloid administration in preventing postoperative nausea and vomiting. We included randomised controlled trials of patients undergoing surgery under general anaesthesia and given supplemental peri-operative intravenous crystalloid. Our primary outcomes were the risk of postoperative nausea and the risk of postoperative vomiting. We assessed the risk of bias for each included study and applied the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework for the certainty of evidence. We included 41 studies. We found that the intervention probably reduces the overall risk of postoperative nausea, the risk ratio (95%CI) being 0.62 (0.51-0.75) (I2  = 57%, p < 0.00001, 18 studies; 1766 participants; moderate-certainty evidence). It also probably reduces the risk of postoperative nausea within 6 h of surgery, with a risk ratio (95%CI) of 0.67 (0.58 to 0.78) (I2  = 9%, p < 0.00001, 20 studies; 2310 participants; moderate-certainty evidence) and by around 24 h, the risk ratio (95%CI) being 0.47 (0.32-0.69) (I2  = 38%, p = 0.0001, 17 studies; 1682 participants; moderate-certainty evidence). Supplemental intravenous crystalloid probably also reduces the overall risk of postoperative vomiting, with a risk ratio (95%CI) of 0.50 (0.40-0.63) (I2  = 31%, p < 0.00001, 20 studies; 1970 participants; moderate-certainty evidence). The beneficial effect on vomiting was seen both within 6 h and by around 24 h postoperatively.


Assuntos
Soluções Cristaloides/uso terapêutico , Assistência Perioperatória/métodos , Náusea e Vômito Pós-Operatórios/tratamento farmacológico , Administração Intravenosa , Soluções Cristaloides/administração & dosagem , Humanos
3.
Anesth Analg ; 130(1): 151-158, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31846441

RESUMO

BACKGROUND: The end-expiratory occlusion test predicts fluid responsiveness in ventilated intensive care patients; however, its utility in the operating room is questioned. We assessed end-expiratory occlusion test in laparotomic surgery for predicting volume expansion. METHODS: Forty-six patients were included in this study: stage 1 (n = 26) with an end-expiratory occlusion test of 15 seconds, followed by volume expansion, which consisted of 250 mL of colloid over 5 minutes and stage 2 (n = 20) with an end-expiratory occlusion test of 25 seconds followed by volume expansion. The last 10 patients had transdiaphragmatic pressures probed. Patients with an increase in cardiac index >15% after volume expansion were responders. Pulse pressure variation, stroke volume (SV) index, and cardiac index were analyzed. Receiver operating characteristic curves were established for changes in SV and pulse pressure induced by end-expiratory occlusion test and pulse pressure variation using the responders status for volume expansion as outcome. RESULTS: A total of 44 (38%) volume expansions were deemed responders. After end-expiratory occlusion test of 15 seconds, no hemodynamic variables were significantly increased. After end-expiratory occlusion test of 25 seconds, SV index increased in responders (37.1 ± 8.8 mL/m after end-expiratory occlusion test of 25 seconds versus 35.7 ± 8.6 before; P < .0001). End-expiratory occlusion test could not discriminate responders from nonresponders. Only pulse pressure variation had significantly different area under the curve from that expected by chance (0.7 [0.57-0.81]; P = .002 for end-expiratory occlusion test of 15 seconds; and 0.78 [0.64-0.89]; P = .0001 for end-expiratory occlusion test of 25 seconds). After laparotomy, gastric pressure decreased significantly (4 [2.75-5] vs 2 [2-4] cm H2O; P = .0417); no difference was noticed in the transdiaphragmatic gradient. CONCLUSIONS: End-expiratory occlusion test was not reliable to discriminate responders from nonresponders after volume expansion during laparotomic surgery.


Assuntos
Soluções Cristaloides/administração & dosagem , Hidratação , Hemodinâmica , Laparotomia , Monitorização Intraoperatória/métodos , Respiração Artificial , Adulto , Idoso , Soluções Cristaloides/efeitos adversos , Feminino , Hidratação/efeitos adversos , Humanos , Infusões Parenterais , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Tempo
4.
Anesthesiology ; 132(1): 95-106, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31658115

RESUMO

BACKGROUND: In congenital cardiac surgery, priming cardiopulmonary bypass (CPB) with fresh frozen plasma (FFP) is performed to prevent coagulation abnormalities. The hypothesis was that CPB priming with crystalloids would be different compared with FFP in terms of bleeding and/or need for blood product transfusion. METHODS: In this parallel-arm double-blinded study, patients weighing between 7 and 15 kg were randomly assigned to a CPB priming with 15 ml · kg PlasmaLyte or 15 ml · kg FFP in addition to a predefined amount of packed red blood cells used in all patients. The decision to transfuse was clinical and guided by point-of-care tests. The primary endpoints included postoperative bleeding tracked by chest tubes, number of patients transfused with any additional blood products, and the total number of additional blood products administered intra- and postoperatively. The postoperative period included the first 6 h after intensive care unit arrival. RESULTS: Respectively, 30 and 29 patients in the FFP and in the crystalloid group were analyzed in an intention-to-treat basis. Median postoperative blood loss was 7.1 ml · kg (5.1, 9.4) in the FFP group and 5.7 ml · kg (3.8, 8.5) in the crystalloid group (P = 0.219); difference (95% CI): 1.2 (-0.7 to 3.2). The proportion of patients additionally transfused was 26.7% (8 of 30) and 37.9% (11 of 29) in the FFP and the crystalloid groups, respectively (P = 0.355; odds ratio [95% CI], 1.7 [0.6 to 5.1]). The median number of any blood products transfused in addition to priming was 0 (0, 1) and 0 (0, 2) in the FFP and crystalloid groups, respectively (P = 0.254; difference [95% CI], 0 [0 to 0]). There were no study-related adverse events. CONCLUSIONS: The results demonstrate that in infants and children, priming CPB with crystalloids does not result in a different risk of postoperative bleeding and need for transfusion of allogeneic blood products.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Ponte Cardiopulmonar , Soluções Cristaloides/administração & dosagem , Plasma , Hemorragia Pós-Operatória , Criança , Pré-Escolar , Método Duplo-Cego , Feminino , Humanos , Lactente , Masculino
5.
Ann Pharmacother ; 54(1): 5-13, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31364382

RESUMO

Background: The optimal resuscitative fluid remains controversial. Objective: To assess the association between crystalloid fluid and outcomes in critically ill adults. Methods: Cumulative Index to Nursing and Allied Health Literature, Scopus, PubMed, and Cochrane Central Register for Controlled Trials were searched from inception through July 2019. Cohort studies and randomized trials of critically ill adults provided predominantly nonperioperative fluid resuscitation with balanced crystalloids or 0.9% sodium chloride (saline) were included. Results: Thirteen studies (n = 30 950) were included. Balanced crystalloids demonstrated lower hospital or 28-/30-day mortality (risk ratio [RR] = 0.86; 95% CI = 0.75-0.99; I2 = 82%) overall, in observational studies (RR = 0.64; 95% CI = 0.41-0.99; I2 = 63%), and approached significance in randomized trials (RR = 0.94; 95% CI = 0.88-1.02; I2 = 0%). New acute kidney injury occurred less frequently with balanced crystalloids (RR = 0.91; 95% CI = 0.85-0.98; I2 = 0%), though progression to renal replacement therapy was similar (RR = 0.91; 95% CI = 0.79-1.04; I2 = 38%). In the sepsis cohort, odds of hospital or 28-/30-day mortality were similar, but the odds of major adverse kidney events occurring in the first 30 days were less with balanced crystalloids than saline (OR = 0.78; 95% CI = 0.66-0.91; I2 = 42%). Conclusion and Relevance: Resuscitation with balanced crystalloids demonstrated lower hospital or 28-/30-day mortality compared with saline in critically ill adults but not specifically those with sepsis. Balanced crystalloids should be provided preferentially to saline in most critically ill adult patients.


Assuntos
Soluções Cristaloides/administração & dosagem , Hidratação/métodos , Soluções para Reidratação/administração & dosagem , Sepse/terapia , Cloreto de Sódio/administração & dosagem , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/terapia , Adulto , Estado Terminal , Soluções Cristaloides/efeitos adversos , Humanos , Tempo de Internação , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Soluções para Reidratação/efeitos adversos , Terapia de Substituição Renal , Sepse/mortalidade , Cloreto de Sódio/efeitos adversos
6.
J Cardiothorac Surg ; 14(1): 209, 2019 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-31783886

RESUMO

BACKGROUND: Video-assisted thoracoscopic surgery has been widely used in thoracic surgery worldwide. Our goal was to identify the risk factors for postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery lobectomy. METHODS: A retrospective analysis of adult patients undergoing video-assisted thoracoscopic surgery lobectomy between 2016 and 05 and 2017-04 was performed. We used univariate analyses and multivariate analyses to examine risk factors for postoperative pneumonia after lobectomy. RESULTS: The incidence of postoperative pneumonia was 19.7% (n = 143/727). Patients with postoperative pneumonia had a higher postoperative length of stay and total hospital care costs when compared to those without postoperative pneumonia. Multivariate analysis showed that body mass index grading ≥24.0 kg/m2 (vs. <24.0 kg/m2: odds ratio 1.904, 95% confidence interval 1.294-2.802, P = 0.001) and right lung lobe surgery (vs. left lung lobe surgery: odds ratio 1.836, 95% confidence interval 1.216-2.771, P = 0.004) were independent risk factors of postoperative pneumonia. Total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL was also identified as the risk factors (vs. 1000 to < 1500 mL: odds ratio 2.060, 95% confidence interval 1.302-3.260, P = 0.002). CONCLUSIONS: Major risk factors for postoperative pneumonia following video-assisted thoracoscopic surgery lobectomy are body mass index grading ≥24.0 kg/m2, right lung lobe surgery and total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL.


Assuntos
Soluções Cristaloides/efeitos adversos , Neoplasias Pulmonares/cirurgia , Pneumonectomia/efeitos adversos , Pneumonia/induzido quimicamente , Complicações Pós-Operatórias/induzido quimicamente , Cirurgia Torácica Vídeoassistida/efeitos adversos , Adulto , Idoso , China/epidemiologia , Soluções Cristaloides/administração & dosagem , Feminino , Humanos , Incidência , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco
7.
Crit Care ; 23(1): 366, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752973

RESUMO

BACKGROUND: Crystalloids are the most frequently prescribed drugs in intensive care medicine and emergency medicine. Thus, even small differences in outcome may have major implications, and therefore, the choice between balanced crystalloids versus normal saline continues to be debated. We examined to what extent the currently accrued information size from completed and ongoing trials on the subject allow intensivists and emergency physicians to choose the right fluid for their patients. METHODS: Systematic review and meta-analysis with random effects inverse variance model. Published randomized controlled trials enrolling adult patients to compare balanced crystalloids versus normal saline in the setting of intensive care medicine or emergency medicine were included. The main outcome was mortality at the longest follow-up, and secondary outcomes were moderate to severe acute kidney injury (AKI) and initiation of renal replacement therapy (RRT). Trial sequential analyses (TSA) were performed, and risk of bias and overall quality of evidence were assessed. Additionally, previously published meta-analyses, trial sequential analyses and ongoing large trials were analysed for included studies, required information size calculations and the assumptions underlying those calculations. RESULTS: Nine studies (n = 32,777) were included. Of those, eight had data available on mortality, seven on AKI and six on RRT. Meta-analysis showed no significant differences between balanced crystalloids versus normal saline for mortality (P = 0.33), the incidence of moderate to severe AKI (P = 0.37) or initiation of RRT (P = 0.29). Quality of evidence was low to very low. Analysis of previous meta-analyses and ongoing trials showed large differences in calculated required versus accrued information sizes and assumptions underlying those. TSA revealed the need for extremely large trials based on our realistic and clinically relevant assumptions on relative risk reduction and baseline mortality. CONCLUSIONS: Our meta-analysis could not find significant differences between balanced crystalloids and normal saline on mortality at the longest follow-up, moderate to severe AKI or new RRT. Currently accrued information size is smaller, and the required information size is larger than previously anticipated. Therefore, completed and ongoing trials on the topic may fail to provide adequate guidance for choosing the right crystalloid. Thus, physiology will continue to play an important role for individualizing this choice.


Assuntos
Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Cuidados Críticos/normas , Soluções Cristaloides/administração & dosagem , Terapia de Substituição Renal/mortalidade , Solução Salina/administração & dosagem , Lesão Renal Aguda/fisiopatologia , Cuidados Críticos/métodos , Soluções Cristaloides/efeitos adversos , Humanos , Terapia de Substituição Renal/tendências , Solução Salina/efeitos adversos
8.
Semin Nephrol ; 39(5): 473-483, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31514911

RESUMO

Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm.


Assuntos
Acidose/prevenção & controle , Lesão Renal Aguda/tratamento farmacológico , Lesão Renal Aguda/prevenção & controle , Bicarbonatos/administração & dosagem , Cloretos/administração & dosagem , Soluções Cristaloides/administração & dosagem , Acidose/induzido quimicamente , Bicarbonatos/efeitos adversos , Bicarbonatos/sangue , Cloretos/efeitos adversos , Cloretos/sangue , Humanos
9.
Cir Cir ; 87(S1): 1-7, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31501621

RESUMO

Introduction: Thromboelastometry evaluates viscoelastic changes in the coagulation process. It offers a graphic representation of the formation of the coagulum, its stability and the presence of lysis. Objective: This first case of transfusion management guided by thromboelastography in Mexico and we conducted a review of the literature. Method: A metasearch search was performed (PubMed, Scielo, Medigraphic) with the words thromboelastometry, coagulopathy, transfusion medicine and the most influential works were included. Conclusions: The rotational thromboelastometry is a diagnostic tool that graphs the functionality of the clot, for a directed and individualized management of the coagulopathy associated with bleeding.


Assuntos
Transfusão de Componentes Sanguíneos/métodos , Choque/terapia , Tromboelastografia/métodos , Tempo de Coagulação do Sangue Total/métodos , Adolescente , Afibrinogenemia/tratamento farmacológico , Afibrinogenemia/etiologia , Plaquetas/fisiologia , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/cirurgia , Soluções Cristaloides/administração & dosagem , Emergências , Transfusão de Eritrócitos/métodos , Evolução Fatal , Feminino , Fibrinogênio/uso terapêutico , Humanos , México , Plasma , Choque/etiologia , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/cirurgia
10.
Int J Hyperthermia ; 36(1): 794-800, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31450986

RESUMO

Background: Isolated limb perfusion (ILP) is a treatment option for malignancies localized to an extremity and is performed by surgical isolation of the limb which is connected to an extracorporeal circulation system. A high concentration of a chemotherapeutic agent is perfused through the limb, while systemic toxicity is avoided. Currently, the use of packed red blood cells in the priming solution is the norm during ILP. The aim of this study was to investigate the possibility to replace an erythrocyte-based prime solution with a crystalloid-based prime solution while maintaining the regional metabolic oxygen demand during ILP. Methods: In a single-center, randomized controlled, non-blinded, non-inferiority clinical trial, 21 patients scheduled for treatment with ILP were included and randomized 1:1 to either an erythrocyte-based prime solution (control) or a crystalloid-based prime solution (intervention). Results: There was a significant difference in lactate level (mmol/L) during the perfusion between the intervention group and the control group (1.6 ± 0.4 vs. 3.6 ± 0.7, p = .001). No significant differences in oxygen extraction (%) (22 ± 11 vs. 14 ± 4, p = .06), oxygen delivery (ml/min) (90 ± 49 vs. 108 ± 38, p = .39), oxygen consumption (ml/min) (14 ± 2 vs. 14 ± 5, p = .85), regional central venous saturation (%) (83 ± 10 vs. 91 ± 4, p = .07) or INVOS (%) (76 ± 14 vs. 81 ± 11, p = .42) were found between the intervention group and the control group. Conclusion: This study showed no significant improvement with the addition of packed red blood cells into the prime solution in ensuring the metabolic oxygen demand in the treated extremity during ILP, and we, therefore, recommend that a crystalloid-based prime solution should be used.


Assuntos
Soluções Cristaloides/administração & dosagem , Eritrócitos , Extremidades , Perfusão , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos Alquilantes/administração & dosagem , Feminino , Humanos , Ácido Láctico/sangue , Masculino , Melanoma/terapia , Melfalan/administração & dosagem , Pessoa de Meia-Idade , Sarcoma/terapia , Neoplasias Cutâneas/terapia , Adulto Jovem
11.
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
12.
South Med J ; 112(7): 412-418, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31282973

RESUMO

OBJECTIVES: The purpose of this retrospective study was to investigate the role of intraoperative crystalloid administration on postoperative hospital length of stay (phLOS) and on the incidence of previously reported adverse events in 100 consecutive patients who underwent esophageal resection. METHODS: The role of previously reported patient demographics, clinical characteristics, and intraoperative crystalloid administration on the duration of phLOS underwent statistical screening criteria for multivariable analysis, including the use of an instrumental variable to measure the role of unmeasured confounders on phLOS. Tests to assess the likelihood of causality also were performed. RESULTS: When the volumes of intraoperative crystalloids were expressed as dose-response relationships to outcomes, progressive decreases in phLOS, variances in phLOS, and the incidences of unplanned surgical intensive care unit admission, postoperative pneumonia, respiratory failure requiring orotracheal intubation, nonsinus cardiac dysrhythmias, and anastomotic leak were observed. Intraoperative transfusion of packed red blood cells greatly increased the duration of phLOS, which was not associated with estimated blood loss, length of surgical operation, or unplanned surgical intensive care unit admission. Instrumental variable analysis revealed no significant influence on phLOS. Causality tests supported the role of intraoperative crystalloid administration in reducing the duration and variance of phLOS. CONCLUSIONS: A dose-response relationship was clinically observed between intraoperative crystalloid administration and the duration and variance of phLOS and with commonly reported postoperative adverse events. Intraoperative transfusion of packed red blood cells greatly increased phLOS that was not associated with the severity of the surgical operation. Instrumental variables and tests for causality further supported the role of intraoperative crystalloid administration in reducing the duration and variance of phLOS.


Assuntos
Soluções Cristaloides/administração & dosagem , Esofagectomia , Hidratação/métodos , Cuidados Intraoperatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Relação Dose-Resposta a Droga , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
13.
BMJ Case Rep ; 12(5)2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31151977

RESUMO

Ciguatera is a common but underreported tropical disease caused by the consumption of coral reef fish contaminated by ciguatoxins. Gastrointestinal and neurological symptoms predominate, but may be accompanied by cardiovascular features such as hypotension and sinus bradycardia. Here, we report an unusual case of junctional bradycardia caused by ciguatera in the Caribbean; to our knowledge, the first such report from the region. An increase in global sea temperatures is predicted to lead to the spread of ciguatera beyond traditional endemic areas, and the globalisation of trade in coral reef fish has resulted in sporadic cases occurring in developed countries far away from endemic areas. This case serves as a reminder to consider environmental intoxications such as ciguatera within the differential diagnosis of bradycardias.


Assuntos
Bradicardia/etiologia , Intoxicação por Ciguatera/complicações , Animais , Bradicardia/terapia , Região do Caribe , Intoxicação por Ciguatera/terapia , Soluções Cristaloides/administração & dosagem , Diagnóstico Diferencial , Eletrocardiografia , Peixes , Humanos , Masculino , Pessoa de Meia-Idade , Potássio/administração & dosagem
14.
Enferm. clín. (Ed. impr.) ; 29(3): 195-198, mayo-jun. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-182908

RESUMO

La administración de fluidos para la reanimación del paciente grave en las unidades de cuidados intensivos es una de las intervenciones más frecuentes y hasta en un 40% de las ocasiones es el equipo de enfermería el que toma la decisión de administrar un bolo de fluido a un paciente crítico según protocolos establecidos, por lo que en el presente trabajo se realiza una revisión del estado actual de la fluidoterapia y su empleo en este tipo de pacientes. Asimismo, para optimizar los conocimientos y el tratamiento administrado a este tipo de pacientes, se describen los distintos tipos de fluidos existentes y los posibles efectos adversos que se puedan desarrollar derivados de su administración


The administration of fluids for the resuscitation of the seriously ill patient in intensive care units is one of the most frequent interventions. Up to 40% of the time it is the nursing team that makes the decision to administer a fluid bolus to a critically ill patient according to established protocols. Therefore we perform a review in this paper of the current status of fluid therapy and its use in this type of patient. In order to optimize the knowledge and the treatment administered to this type of patient, we also describe the different types of fluids currently used and possible adverse effects that may develop after their administration


Assuntos
Humanos , Enfermagem de Cuidados Críticos , Hidratação/métodos , Cuidados Críticos , Estado Terminal/enfermagem , Unidades de Terapia Intensiva , Balanço Hídrico/métodos , Soluções Cristaloides/administração & dosagem , Coloides/administração & dosagem
15.
Toxicon ; 166: 83-87, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31129161

RESUMO

INTRODUCTION: North Central Florida is the home to several venomous snakes. The most clinically significant pit vipers include the Eastern Diamondback Rattlesnake, the Water Moccasin, and less commonly the Timber Rattlesnake. Many of the dogs and cats that become envenomated by these particular snakes have moderate to severe clinical signs requiring the use of antivenom in doses that can range from 1 to 20 vials with the average case requiring two vials. Oftentimes, the pet owners' financial limitations restrict the amount of antivenom that can be administered initially to severely envenomed cases. Most of these patients will become clinically stable after the first 48 hours of treatment, but there are rare instances where some patients will follow this same initial course, and then revert back to the initial signs of envenomation associated with delayed absorption of redistributed venom from other tissue sites in addition to the bite site. This report describes three dogs that showed signs of persistent and/or recurrent envenomation requiring additional doses of antivenom. METHODS: The medical records of three dogs showing signs of persistent envenomation were reviewed by the author who was available and provided assistance during the course of the dogs' respective hospitalizations. The dog's signalment, time of year of the envenomation, clinical signs, treatment, and outcome are provided in each case. RESULTS: Each of these three dogs showed severe signs of envenomation characterized by marked mental depression, prostration, hemorrhagic lymphedema, and evidence of prolonged coagulation times. Initial treatment in each consisted of intravenous crystalloid solution and polyvalent crotalid antivenom that exceeded the usual average dose as reported in the literature. After the coagulation test normalized during the first three days, all of them reverted to abnormal prolonged clotting times with signs of clinical deterioration requiring additional doses of antivenom. Clinical stability was eventually reached and all dogs survived to be discharged. CONCLUSIONS: The clinical course of the three dogs described in this study showed that veterinary patients can experience persistent envenomation in a similar manner as described in humans. It behooves the veterinary practitioner to be aware of this complication and to be prepared to extend antivenom treatment as deemed necessary.


Assuntos
Antivenenos/uso terapêutico , Crotalus , Doenças do Cão/tratamento farmacológico , Mordeduras de Serpentes/veterinária , Animais , Antivenenos/administração & dosagem , Transtornos da Coagulação Sanguínea/induzido quimicamente , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Transtornos da Coagulação Sanguínea/veterinária , Venenos de Crotalídeos/antagonistas & inibidores , Soluções Cristaloides/administração & dosagem , Cães , Feminino , Masculino , Mordeduras de Serpentes/tratamento farmacológico
16.
Clin Exp Nephrol ; 23(8): 1039-1044, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31049746

RESUMO

BACKGROUND: A wide range of interesting mathematical models has been derived to predict the effect of intravenous fluid therapy on the serum sodium concentration (most notably the Adrogué-Madias equation), but unfortunately, these models cannot be applied to patients with disorders characterized by aberrant antidiuretic hormone (ADH) release, such as the syndrome of inappropriate ADH secretion (SIADH). The use of intravenous fluids in these patients should prompt caution, as the inability of the kidneys to properly dilute the urine can easily result in deterioration of hyponatremia. METHODS: In this report, a transparent and clinically applicable equation is derived that can be used to calculate the estimated effect of different types and volumes of crystalloid infusate on the serum sodium concentration in SIADH patients. As a "proof of concept", we discuss five SIADH patient cases from our clinic. Alternatively, our mathematical model can be used to determine the infusate volume that is required to produce a certain desired change in the serum sodium concentration in SIADH patients. CONCLUSION: The presented model facilitates rational intravenous fluid therapy in SIADH patients, and provides a valuable addition to existing prediction models.


Assuntos
Soluções Cristaloides/administração & dosagem , Hidratação , Síndrome de Secreção Inadequada de HAD/terapia , Rim/fisiopatologia , Modelos Biológicos , Sódio/sangue , Equilíbrio Hidroeletrolítico , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Soluções Cristaloides/efeitos adversos , Feminino , Hidratação/efeitos adversos , Humanos , Síndrome de Secreção Inadequada de HAD/sangue , Síndrome de Secreção Inadequada de HAD/diagnóstico , Síndrome de Secreção Inadequada de HAD/fisiopatologia , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Concentração Osmolar , Estudo de Prova de Conceito , Resultado do Tratamento
17.
Taiwan J Obstet Gynecol ; 58(3): 428-433, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31122537

RESUMO

OBJECTIVE: Spinal anesthesia induced hypotension (SAIH) is a common occurrence during spinal anesthesia for cesarean section resulting in perturbing effects on maternal and fetal outcomes. Previous studies conducted to attenuate SAIH focused on the timing of intravenous fluid infusion and demonstrated the superiority of coload strategy on traditional preload strategy but neither of them focused on the effect of the temperature of crystalloid infused on SAIH and fetal outcomes. The current study aimed to assess the effect of the temperature of the crystalloid infused with coload strategy on the incidence of SAIH and fetal outcomes. MATERIALS AND METHODS: Seventy-six parturients were enrolled into the study and data of 60 parturients were analyzed. Patients were randomly assigned to receive crystalloid coload at room temperature (Group RT, n = 30) or warmed at 37 °C (Group W, n = 30). The incidence of hypotension, cumulative hypotension episodes, heart rate, core body temperature, ephedrine dose, and fetal outcomes were recorded. RESULTS: There was no significant difference in the incidence of maternal hypotension, cumulative hypotension episodes, and ephedrine dose (p = 0,625, p = 0,871, p = 0,460 respectively). Umbilical arterial pH and fetal Apgar scores at first and fifth minutes were higher in Group W than in Group RT (p = 0.013, p = 0.006 and p = 0.045 respectively). One fetus in Group RT but none in Group W had umbilical arterial pH lower than seven. Fetal birth weight and rectal temperature measurements were comparable in both groups (p = 0.639 and p = 0.675 respectively). Demographic data, patient characteristics, and surgery data were comparable between groups. CONCLUSIONS: Isothermic crystalloid coload strategy results in higher umbilical pH values and Apgar scores in parturients scheduled for cesarean section under spinal anesthesia.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/métodos , Cesárea/métodos , Soluções Cristaloides/administração & dosagem , Hipotensão/prevenção & controle , Adulto , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Feminino , Humanos , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Temperatura , Adulto Jovem
18.
Chin J Traumatol ; 22(3): 134-137, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31078422

RESUMO

PURPOSE: The measurement of heart rate variability (HRV) is a non-invasive method to analyze the balance of the autonomic nervous system. The aim of this study was to compare the changes of HRV and base deficit (BD) during the treatment of trauma patients. METHODS: Forty-three trauma patients with a low injury severity scores (ISS < 24) and negative base excess on admission were included in this study. Based on the BD changes, patients were divided into three groups: 'end pointed' group (n = 13), patients' BDs instantly cleared after primary hydration; 'needs further resuscitation' group (n = 21), patients' BDs did not reach the end point and thus required further hydration or packed red blood cells transfusion; and 'hydration minimal change' group (n = 9), patients' BDs lower than 2.5 mmol/L at the onset of admission and thereafter had minimal change (near normal range). The changes in HRV during fluid resuscitation were detected and compared to BD changes in their arterial blood gases. All data were analysed using the SPSS software Version 15.0. Repeated measures ANOVA was used to determine the changes in HRV, heart rate, blood pressure, and BD among groups. RESULTS: A significant reverse correlation was found between the BD ratio and the HRV ratio (r = -0.562; p = 0.01). The HRV of patients with aggravated BDs after fluid resuscitation was decreased. There was an increase in HRV at the time of BD clearance. A decrease in HRV after primary crystalloid hydration bore a significant connection with the need for an ICU (p = 0.021) and transfusion of packed red blood cells (p < 0.001). CONCLUSION: Increase in HRV may be a new non-invasive index for the end point of resuscitation in trauma patients.


Assuntos
Frequência Cardíaca , Escala de Gravidade do Ferimento , Ressuscitação , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/fisiopatologia , Adolescente , Adulto , Idoso , Sistema Nervoso Autônomo/fisiopatologia , Soluções Cristaloides/administração & dosagem , Hidratação , Humanos , Pessoa de Meia-Idade , Ressuscitação/métodos , Adulto Jovem
19.
Transfusion ; 59(S2): 1429-1438, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980748

RESUMO

BACKGROUND: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. MATERIALS AND METHODS: Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy. RESULTS: Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions. CONCLUSION: Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.


Assuntos
Bancos de Sangue , Preservação de Sangue/normas , Transfusão de Sangue/normas , Redes Comunitárias , Serviços Médicos de Emergência , Hemorragia/terapia , Ressuscitação , Centros de Traumatologia , Sistema ABO de Grupos Sanguíneos , Bancos de Sangue/organização & administração , Bancos de Sangue/normas , Redes Comunitárias/organização & administração , Redes Comunitárias/normas , Soluções Cristaloides/administração & dosagem , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/normas , Feminino , Hemorragia/mortalidade , Humanos , Masculino , Texas , Centros de Traumatologia/organização & administração , Centros de Traumatologia/normas
20.
Pediatr Crit Care Med ; 20(4): 357-364, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30950987

RESUMO

OBJECTIVES: To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists. DESIGN: A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive and Critical Care Societies website, and World Federation of Pediatric Intensive and Critical Care Societies newsletter using the electronic survey distribution and collection system Research Electronic Data Capture. SETTING: PICUs around the world. SUBJECTS: Pediatric intensivists managing children after surgery for congenital heart disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One-hundred eight responses from 18 countries and six continents were received. The most common prescribed fluids for IV maintenance are isotonic solutions, mainly NaCl 0.9% (42%); followed by hypotonic fluids (33%) and balanced crystalloids solutions (14%). The majority of the respondents limit total fluid intake to 50% during the first 24 hours after cardiac surgery. The most frequently used fluid as first choice for resuscitation is NaCl 0.9% (44%), the second most frequent choice are colloids (27%). Furthermore, 64% of respondents switch to a second fluid for ongoing resuscitation, 76% of these choose a colloid. Albumin 5% is the most commonly used colloid (61%). Almost all respondents (96%) agree there is a need for research on this topic. CONCLUSIONS: Our survey demonstrates great variation in fluid management practices, not only for maintenance fluids but also for volume resuscitation. Despite the lack of evidence, colloids are frequently administered. The results highlight the need for further research and evidence-based guidelines on this topic.


Assuntos
Hidratação/métodos , Cardiopatias Congênitas/cirurgia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Soluções Isotônicas/administração & dosagem , Coloides/administração & dosagem , Soluções Cristaloides/administração & dosagem , Hidratação/economia , Humanos , Soluções Hipotônicas , Soluções Isotônicas/economia , Soluções Isotônicas/provisão & distribução
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