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Introduction Fluid therapy in critically ill patients, especially timing and fluid choice, is controversial. Previous randomized trials produced conflicting results. This observational study evaluated the effect of colloid use on 90-day mortality and acute kidney injury (RIFLE F) within the Rational Fluid Therapy in Asia (RaFTA) registry in intensive care units. Materials and methods RaFTA is a prospective, observational study in Asian intensive care unit (ICU) patients focusing on fluid therapy and related outcomes. Logistic regression was performed to identify risk factors for increased 90-day mortality and acute kidney injury (AKI). Results Twenty-four study centers joined the RaFTA registry and collected 3,187 patient data sets from November 2011 to September 2012. A follow-up was done 90 days after ICU admission. For 90-day mortality, significant risk factors in the overall population were sepsis at admission (OR 2.185 [1.799; 2.654], p < 0.001), cumulative fluid balance (OR 1.032 [1.018; 1.047], p < 0.001), and the use of vasopressors (OR 3.409 [2.694; 4.312], p < 0.001). The use of colloids was associated with a reduced risk of 90-day mortality (OR 0.655 [0.478; 0.900], p = 0.009). The initial colloid dose was not associated with an increased risk for AKI (OR 1.094 [0.754; 1.588], p = 0.635). Conclusion RaFTA adds the important finding that colloid use was not associated with increased 90-day mortality or AKI after adjustment for baseline patient condition. Clinical significance Early resuscitation with colloids showed potential mortality benefit in the present analysis. Elucidating these findings may be an approach for future research. How to cite this article Jacob M, Sahu S, Singh YP, Mehta Y, Yang K-Y, Kuo S-W, et al. A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy. Indian J Crit Care Med 2020;24(11):1028–1036.

Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution. All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist’s free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device. Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4–7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one. In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.

Despite the frequent inclusion of fluid therapy in the treatment of many conditions in horses, there are limited studies available to provide evidenced-based, species-specific recommendations. Thus, equine fluid therapy is based on the application of physiology and extrapolation from evidence in other veterinary species and human medicine. The physiologic principles that underly the use of fluids in medicine are, at first glance, straightforward and simple to understand. However, in the past 20 years, multiple studies in human medicine have shown that creating recommendations based on theory in combination with experimental and/or small clinical studies does not consistently result in best practice. As a result, there are ongoing controversies in human medicine over fluid types, volumes, and routes of administration. For example, the use of 0.9% NaCl as the replacement fluid of choice is being questioned, and the theoretical benefits of colloids have not translated to clinical cases and negative effects are greater than predicted. In this review, the current body of equine research in fluid therapy will be reviewed, connections to the controversies in human medicine and other veterinary species will be explored and, where appropriate, recommendations for fluid therapy in the adult horse will be made based on the available evidence. This review is focused on the decisions surrounding developing a fluid plan involving crystalloids, synthetic colloids, and plasma.

Introduction: Both crystalloids and colloid preloading is recommended for spinal anaesthesia. Preloading of intravenous fluids increases circulating volume and cardiac output; thus preventing spinal anaesthesia-induced hypotension. Crystalloids have a short intravascular half-life, poor plasma expanders and large volumes are thus required. Aim: To compare the efficacy of 5 mL/kg of 6% Hetastarch (colloid) to that of 15 mL/kg of Plasmalyte (crystalloid) solution to prevent hypotension during spinal anaesthesia in patients undergoing lower abdominal surgeries. Materials and Methods: This was a randomised clinical trial from June 2016 to April 2017 on a total 80 patients, belonging to American Society of Anaesthesiologist (ASA) Grade I and II scheduled for lower abdominal surgeries under spinal anaesthesia. They were divided into two groups- Group H and Group P. Patients in group H were preloaded with 5 mL/kg solution of 6% Hetastarch, whereas those in group P were preloaded with 15 mL/kg of Plasmalyte solution. After institution of spinal anaesthesia with 3.0 mL of hyperbaric Bupivacaine using 25G Quincke’s needle, Blood Pressure (BP) and other vital parameters were monitored intraoperatively every 3 minutes for first 30 minutes and then every 5 minutes till the end of surgery. Descriptive statistics, frequency (n) and percentages (%) were calculated and the variables between the groups were compared by Students t-test, Fischers exact test and Mann Whitney U-test. Results: Both the groups showed a fall in Mean Blood Pressure (MBP) immediately after the block. Group P showed more decline in MBP and Diastolic Blood Pressure (DBP) after the block and thedifference was statistically significant at 9, 12, 15, 18 and 21minute (p-value 0.05). Conclusion: Pre-loading with 5ml/kg of 6% Hetastarch is more effective than 15ml/kg of Plasmalyte in preventing hypotension in patients undergoing lower abdominal surgeries under spinal anaesthesia.

How to cite this article: Tyagi N. Where Has All the “HES” Gone: A Case in Point vs “Crusade” to Obscurity. Indian J Crit Care Med 2020;24(11):1012–1013.

Introduction: Hypotension remains one of the most common problems associated with subarachnoid blockade. A number of strategies have been developed for its prevention, of which administration of fluids prior to subarachnoid block holds the importance. Gelatin is a colloidal plasma volume expander obtained from degraded gelatine. It is as effective as albumin solution in the treatment of spinal induced hypotension. Aim: To compare the incidence and frequency of hypotension after subarachnoid block in patients receiving colloid (polymerised gelatin) or crystalloid (0.9% normal saline) as prehydration and compare side-effects of colloid and crystalloid prehydration. Materials and Methods: A total of 60 patients scheduled for elective Transurethral Resection of Prostate (TURP) surgery were selected to participate in this prospective randomised double-blind study for a period of two years from April 2006 to April 2008. Patients were randomly allocated into two groups of 30 patients each. Group H received 500 mL of polymerised gelatine (Haemaccel) solution and group N received 1000 mL of 0.9% normal saline15 minutes prior to subarachnoid block. Intraoperative monitoring includes SBP, DBP, MAP and HR for 30 minutes. Incidence of hypotension and number of mephentermine boluses were noted.Statistical analysis of data was determined with Mann-Whitney U test and analysis of variance for repeated measures (ANOVA). Chi-square test was used to find out possible associations. Result: After spinal anaesthesia mean systolic blood pressure decreased in both the groups and was lower in group N compared to group H (97±18.9 vs 102±9.26 mmHg). There was fall in diastolic blood pressure in both the groups and was maximum at 20th minute in group N and group H (66.37±5.47 vs 64.67±10.30). There was highly significant (p

BACKGROUND Intraoperative fluids are still poorly studied in veterinary medicine. In humans the dosage is associated with significant differences in postoperative outcomes. OBJECTIVES The aim of this study is to verify the influence of three different fluid therapy rates in dogs undergoing video-assisted ovariohysterectomy. METHODS Twenty-four female dogs were distributed into three groups: G5, G10, and G20. Each group was given 5, 10, and 20 mL·kg-1·h-1 of Lactate Ringer, respectively. This study evaluated the following parameters: central venous pressure, arterial blood pressure, heart rate, respiratory rate, temperature, acid-base balance, and serum lactate levels. Additionally, this study evaluated the following urinary variables: urea, creatinine, protein to creatinine ratio, urine output, and urine specific gravity. The dogs were evaluated up to 26 h after the procedure. RESULTS All animals presented respiratory acidosis during the intraoperative period. The G5 group evidenced intraoperative oliguria (0.80 ± 0.38 mL·kg-1·h-1), differing from the G20 group (2.17 ± 0.52 mL·kg-1·h-1) (p = 0.001). Serum lactate was different between groups during extubation (p = 0.036), with higher values being recorded in the G5 group (2.19 ± 1.65 mmol/L). Animals from the G20 group presented more severe hypothermia at the end of the procedure (35.93 ± 0.61°C) (p = 0.032). Only the members of the G20 group presented mean potassium values below the reference for the species. Anion gap values were lower in the G20 group when compared to the G5 and G10 groups (p = 0.017). CONCLUSIONS The use of lactated Ringer's solution at the rate of 10 mL·kg-1·h-1 seems to be beneficial in the elective laparoscopic procedures over the 5 or 20 mL·kg-1·h-1 rates of infusion.

Background Crystalloids and different component colloids, used for volume resuscitation, are sometimes associated with various adverse effects. Clinical trial findings for such fluid types in different patients’ conditions are conflicting. Whether the mortality benefit of balanced crystalloid than saline can be inferred from sepsis to other patient group is uncertain, and adverse effect profile is not comprehensive. This study aims to compare the survival benefits and adverse effects of seven fluid types with network meta-analysis in sepsis, surgical, trauma, and traumatic brain injury patients. Methods Searched databases (PubMed, EMBASE, and Cochrane CENTRAL) and reference lists of relevant articles occurred from inception until January 2020. Studies on critically ill adults requiring fluid resuscitation were included. Intervention studies reported on balanced crystalloid, saline, iso-oncotic albumin, hyperoncotic albumin, low molecular weight hydroxyethyl starch (L-HES), high molecular weight HES, and gelatin. Network meta-analyses were conducted using random-effects model to calculate odds ratio (OR) and mean difference. Risk of Bias tool 2.0 was used to assess bias. Confidence in Network Meta-Analysis (CINeMA) web application was used to rate confidence in synthetic evidence. Results Fifty-eight trials (n = 26,351 patients) were identified. Seven fluid types were evaluated. Among patients with sepsis and surgery, balanced crystalloids and albumin achieved better survival, fewer acute kidney injury, and smaller blood transfusion volumes than saline and L-HES. In those with sepsis, balanced crystalloids significantly reduced mortality more than saline (OR 0.84; 95% CI 0.74–0.95) and L-HES (OR 0.81; 95% CI 0.69–0.95) and reduced acute kidney injury more than L-HES (OR 0.80; 95% CI 0.65–0.99). However, they required the greatest resuscitation volume among all fluid types, especially in trauma patients. In patients with traumatic brain injury, saline and L-HES achieved lower mortality than albumin and balanced crystalloids; especially saline was significantly superior to iso-oncotic albumin (OR 0.55; 95% CI 0.35–0.87). Conclusions Our network meta-analysis found that balanced crystalloids and albumin decreased mortality more than L-HES and saline in sepsis patients; however, saline or L-HES was better than iso-oncotic albumin or balanced crystalloids in traumatic brain injury patients. Trial registration PROSPERO website, registration number: CRD42018115641).

Supplemental Digital Content is available in the text., Objectives: To investigate the effect of albumin exposure in ICU after cardiac surgery on hospital mortality, complications, and costs. Design: A retrospective, single-center cohort study with economic evaluation. Setting: Cardiothoracic ICU in Australia. Patients: Adult patients admitted to the ICU after cardiac surgery. Interventions: None. Measurements and Main Results: Comparison of outcomes and costs in ICU after cardiac surgery based on 4% human albumin exposure. During the study period, 3,656 patients underwent cardiac surgery. After exclusions, 2,594 patients were suitable for analysis. One-thousand two-hundred sixty-four (48.7%) were exposed to albumin and 19 (1.4%) of those died. The adjusted hospital mortality of albumin exposure compared with no albumin was not significant (odds ratio, 1.24; 95% CI, 0.56–2.79; p = 0.6). More patients exposed to albumin returned to the operating theater for bleeding and/or tamponade (6.1% vs 2.1%; odds ratio, 2.84; 95% CI, 1.81–4.45; p < 0.01) and received packed red cell transfusions (p < 0.001). ICU and hospital lengths of stay were prolonged in those exposed to albumin (mean difference, 18 hr; 95% CI, 10.3–25.6; p < 0.001 and 87.5 hr; 95% CI, 40.5–134.6; p < 0.001). Costs (U.S. dollar) were higher in patients exposed to albumin, compared with those with no albumin exposure (mean difference in ICU costs, $2,728; 95% CI, $1,566–3,890 and mean difference in hospital costs, $5,427; 95% CI, $3,294–7,560). Conclusions: There is no increased mortality in patients who are exposed to albumin after cardiac surgery. The patients exposed to albumin had higher illness severity, suffered more complications, and incurred higher healthcare costs. A randomized controlled trial is required to determine whether albumin use is effective and safe in this setting.

Fluid and blood administration are required during surgery in children. The type, amount and tonicity of the intravenous fluids is an important aspect to be considered during anaesthesia management. The physiological differences between adults and children regarding the body water and blood volume needs to be understood. We performed a PUBMED search for English language articles using keywords including 'children', 'intravenous fluid therapy', 'crystalloids', 'colloids', 'fluid homeostasis', 'Starling equation', 'Donnan effect', 'blood loss', 'estimation of blood loss', 'blood management program'. This review discusses the physiological basis, historical background, risk of hyponatraemia, need of glucose in the intravenous fluids as well as the recent concepts in blood transfusion as related to children.

BACKGROUND: Fluid and antimicrobial therapy are the essential parts of sepsis management. The type of fluid to resuscitate with is an unsettled issue in the treatment of severe sepsis and septic shock. The objective of this study was to evaluate the cost effectiveness of albumin-based resuscitation over crystalloids.METHODS: A cost-effectiveness analysis was conducted by extracting data from a database of Sina Hospital, Islamic Republic of Iran. A decision tree was constructed by using Tree Age Pro2011. The patients were grouped based on the types of fluids used for resuscitation into crystalloid alone or crystalloid + albumin groups at the initial decision node. The patients were followed from the onset of severe sepsis and septic shock upto 28 days. The healthcare payers’ perspective was considered in constructing the model. The cost was measured in US dollars and the effectiveness was measured by life years gained.RESULTS: The addition of albumin during resuscitation of patients with severe sepsis and septic shock has an effectiveness gain of 0.09 life years and cost increment of 495.00 USD. The estimated ICER for this analysis was 5500.00 USD per life year gained. The probability that albumin is cost-effective at one GDP per capita is 49.5%.CONCLUSION: Albumin-based resuscitation is not cost-effective in Iran when a GDP per capita was considered for a life year gain. The cost-effectiveness was insensitive to the cost of standard care. We recomend the caustious use albumin as per the Surviving Sepsis Campaign guideline.

Regional centro-axial anaesthesia, primarily spinal block, is the preferred method of anaesthesia for elective caesarean section because it entails fewer risks for the mother and the foetus compared to general anaesthesia. The most common side effect associated with spinal block is hypotension due to sympatholysis, occurring in up to 75% of cases. Spinal block-induced sympatholysis leads to vasodilatation and consequently causes maternal hypotension, which may compromise uterine blood flow and foetal circulation, and thus cause foetal hypoxia, bradycardia and acidosis. The selection of the most efficient treatment strategy to achieve haemodynamic stability during spinal anaesthesia for caesarean section continues to be one of the main challenges in obstetric anaesthesiology. A number of measures for the prevention and treatment of spinal block-induced hypotension are used in clinical practice, such as preloading and coloading with crystalloid and/or colloid infusion, wrapping of lower limbs with compression stockings or bandages, administering an optimal dose of local anaesthetic and achieving an optimal spinal block level, left tilt positioning, and administering inotropes and vasopressors. Instead of administering vasopressors after a drop in blood pressure has already occurred, the latest algorithms recommend a prophylactic administration of vasopressor infusion. The preferred vasoconstrictor in this case is phenylephrine, which is associated with a lower incidence of foetal acidosis, and maternal nausea and vomiting compared to other vasoconstrictors., Regionalna centroaksijalna anestezija, prvenstveno spinalni blok, danas je metoda izbora za anesteziju pri elektivnom carskom rezu jer nosi manje rizike za majku i fetus u odnosu na opću anesteziju. Najčešća komplikacija spinalnog bloka je hipotenzija koja se javlja u jedne do tri četvrtine slučajeva uslijed simpatikolize. Simpatikoliza inducirana spinalnim blokom dovodi do vazodilatacije te na taj način uzrokuje hipotenziju u majke što može kompromitirati uterini protok krvi i fetalnu cirkulaciju uzrokujući fetalnu hipoksiju, bradikardiju i acidozu. Potraga za najefikasnijom terapijskom strategijom kako bi se postigla hemodinamska stabilnost tijekom spinalne anestezije za carski rez i dalje je jedan od glavnih izazova u opstetričkoj anesteziji. U kliničkoj praksi primjenjuje se više mjera prevencije i terapije hipotenzije uzrokovane spinalnim blokom kao što je prehidracija i kohidracija infuzijom kristaloida i/ili koloida, kompresija donjih ekstremiteta elastičnim zavojima ili čarapama, optimiziranje doze lokalnog anestetika i visine spinalnog bloka, pozicioniranje s nagibom na lijevi bok te primjena inotropa i vazopresora. Umjesto primjene vazopresora nakon što nastupi pad tlaka, noviji algoritmi preporučuju profilaktičku primjenu vazopresora u infuziji pri čemu izbor pada na fenilefrin kao najčešće korišten vazokonstriktor jer se pokazalo da najmanje utječe na pojavu fetalne acidoze te mučnine i povraćanja u majke u odnosu na druge vazokonstriktore.

Supplemental Digital Content is available in the text., OBJECTIVE: To summarize the evidence comparing various balanced crystalloid solutions. DATA SOURCES: We searched MEDLINE, EMBASE, PUBMED, and CENTRAL databases. STUDY SELECTION: We included randomized controlled trials that directly compared the IV administration of one balanced crystalloid solution with another. DATA EXTRACTION AND ANALYSIS: We examined metabolic and patient-important outcomes and conducted meta-analysis using random effects model. For comparisons or outcomes with insufficient data to allow for pooling, we describe results narratively. We assessed risk of bias for individual trials using the Cochrane risk of bias tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. DATA SYNTHESIS: We included 24 randomized controlled trials comparing Plasmalyte, Ringer’s Lactate, Ringerfundin, Hartmann’s solution, Ringer’s Bicarbonate, Sterofundin, Kabilyte, Normosol, and novel balanced solutions. Of the included studies, 16 were performed in the perioperative setting, six in the ICU, one in the emergency department, and one in healthy volunteers. Administration of Plasmalyte resulted in a lower postinfusion serum chloride concentration (mean difference, 0.83 mmol/L lower; 95% CI, 0.03–1.64 mmol/L lower, low certainty), higher postinfusion base excess (mean difference, 0.65 mmol/L higher, 95% CI, 0.25–1.05 mmol/L higher, low certainty), and lower postinfusion serum lactate levels (mean difference, 0.46 mmol/L lower; 95% CI, 0.05–0.87 mmol/L lower, low certainty) compared with administration of any other balanced crystalloid. There were no important differences in postinfusion serum pH or potassium when comparing Plasmalyte with other balanced crystalloids. Data addressing other comparisons or examining the impact of different balanced crystalloids on patient-important outcomes were sparsely reported and too heterogeneous to allow for pooling. CONCLUSIONS: Administration of Plasmalyte results in lower serum concentrations of chloride and lactate, and higher base excess than other balanced crystalloids. The certainty of evidence is low and requires further study in large randomized controlled trials to inform the choice of balanced crystalloid in patients requiring volume replacement.

The review focuses on fluid resuscitation of critically ill patients with either colloid or crystalloid solutions.In healthy patients, the volume expanding effect of colloids is greater than that of crystalloids. However, in critically ill patients, a similar amount of crystalloids and colloids is required for fluid resuscitation, suggesting a lower efficiency of colloids when capillary permeability is increased, and endothelial glycocalyx disrupted. Recent studies on synthetic colloids in surgical patients confirmed the increased risk of renal failure reported in large clinical trials performed in critically ill patients. Experimental studies suggest that albumin maintains plasma volume expansion efficiency even when the capillary permeability is impaired, and that extravasation of albumin to the interstitium is lower than that of hydroxyethyl starch.Fluid administration should be tailored to patient characteristics. Synthetic colloids should be avoided when possible, especially in patients at risk for kidney injury. In critically ill patients with suspected increased permeability, colloids may not be superior to crystalloids in expanding plasma volume. Albumin appears to be less harmful than synthetic colloids, although its beneficial effects need to be further investigated. The endothelial glycocalyx layer is the key structure finely regulating intravascular fluid distribution.

Background Over-aggressive intravenous fluid therapy with crystalloids has adverse effects in trauma patients. We assessed the role of large-volume (≥5l) administration of crystalloids within 24h of injury as an independent risk-factor for mortality, in-hospital complications, and prolonged mechanical ventilation. Methods A retrospective cohort analysis of adult trauma patients admitted to a level 1-trauma center between December 2011 and December 2012. Patient demographics, clinical and laboratory values, and total resuscitation fluid administered within the first 24h of injury were obtained. Outcomes included mortality, in-hospital complications and ventilator-days. Multivariable logistic regression and Poisson regression analyses were performed to investigate any association between the administration of ≥5L crystalloids with the aforementioned outcomes while controlling for selected clinical variables. Results A total of 970 patients were included in the analysis. 264 (27%) received ≥5L of crystalloids in the first 24h of injury. 118 (12%) had in-hospital complications and 337 (35%) required mechanical ventilation. The median age was 46 years (interquartile range (IQR) 27–65) years and 73% (n = 708) were males. The median injury severity score (ISS) was 17 (IQR 9–25). Overall mortality rate was 7% (n = 67). Multivariable logistic regression analysis showed several variables independently associated with mortality (p

Background A reanalysis of the ALBIOS trial suggested that patients with septic shock - defined by vasopressor-dependent hypotension in the presence of severe sepsis (Shock-2) - had a survival benefit when treated with albumin. The new septic shock definition (Shock-3) added the criterion of a lactate threshold of 2 mmol/L. We investigated how the populations defined according to Shock-2 and Shock-3 differed and whether the albumin benefit would be confirmed. Methods This is a retrospective analysis of the ALBIOS study, a randomized controlled study conducted between 2008 and 2012 in 100 intensive care units in Italy comparing the administration of 20% albumin and crystalloids versus crystalloids alone in patients with severe sepsis or septic shock. We analyzed data from 1741 patients from ALBIOS with serum lactate measurement available at baseline. We compared group size, physiological variables and 90-day mortality between patients defined by Shock-2 and Shock-3 and between the albumin and crystalloid treatment groups. Results We compared the Shock-2 and the Shock-3 definitions and the albumin and crystalloid treatment groups in terms of group size and physiological, laboratory and outcome variables. The Shock-3 definition reduced the population with shock by 34%. The Shock-3 group had higher lactate (p

Background Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery “bundles” because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. Methods In the “Perioperative Quality Initiative (POQI) Fluids” workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. Discussion We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.

ResumenIntroducciónSe han realizado múltiples ensayos clínicos en fluidoterapia guiada por objetivos (FGO), muchos de ellos con el uso de coloides para la optimización de la precarga. Tras la decisión de la Agencia Europea del Medicamento, existe cierta controversia en cuanto a su utilización, beneficios y su posible contribución al fallo renal. El objetivo de esta revisión sistemática y metaanálisis es comparar el uso de coloides de última generación, derivados del maíz, con cristaloides en FGO para determinar las complicaciones y la mortalidad asociadas.MétodosSe realiza una búsqueda bibliográfica en MEDLINE Pubmed, EMBASE y Cochrane Library comprobando ensayos clínicos aleatorizados en los que se comparan cristaloides con coloides dentro de FGO para cirugía mayor no cardíaca de adultos.ResultadosSe obtuvieron 130 referencias de las que se seleccionaron 38 y 29 fueron analizadas; de ellas 6 fueron incluidas para revisión sistemática y metaanálisis, incluyendo a 390 pacientes. Se apreció que el uso de coloides no se asocia con un aumento de complicaciones pero sí con una tendencia a mayor mortalidad (RR [IC 95%] 3,87 [1,121-13,38]; I2=0,0%; p=0,635).ConclusionesDebido a las limitaciones de este metaanálisis por el escaso número de ensayos clínicos aleatorizados y pacientes incluidos, los resultados deben tomarse con cautela, y se propone la realización de nuevos ensayos clínicos aleatorizados, con suficiente potencia estadística en los que se comparen coloides balanceados y no balanceados con cristaloides balanceados y no balanceados, dentro de protocolos de FGO, respetando las indicaciones actuales y las sugerencias emitidas por los grupos de expertos.AbstractIntroductionSeveral clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to kidney failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids, in GDFT, to determine complications and mortality associated associated.MethodsA bibliographic research was carried out in MEDLINE Pubmed, EMBASE and Cochrane Library, corroborating randomized clinical trials in those crystalloids are compared to colloids in GDFT for mayor non-cardiac surgery in adults.ResultsOne hundred thirty references were found, among those 38 were selected, and 29 analyzed; of these, 6 were included for systematic review and meta-analysis, including 390 patients. It was perceived that the use of colloids it not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% IC] 3.87 [1.121, 13, 38]); I2=0.0%; P=.635).ConclusionesDue to this meta-analysis’ limitations for small number of randomized clinical trials and patients included, the results should be taken cautiously, and it is proposed to carry out new randomized clinical trials, with enough statistical power, comparing balanced and non-balanced colloids to balanced and non-balanced crystalloids, following the protocols of GDFT, respecting current guidelines and suggestions made by groups of experts.

INTRODUCTION: Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.METHODS: A bibliographic research was carried out in MEDLINE PubMed, EMBASE and Cochrane Library, corroborating randomized clinical trials where crystalloids are compared to colloids in GDFT for major non-cardiac surgery in adults.RESULTS: One hundred thirty references were found and among those 38 were selected and 29 analyzed; of these, six were included for systematic review and meta-analysis, including 390 patients. It was observed that the use of colloids is not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% CI] 3.87 [1.121-13.38]; I2 = 0.0%; p = 0.635).CONCLUSIONS: Because of the limitations of this meta-analysis due to the small number of randomized clinical trials and patients included, the results should be taken cautiously, and the performance of new randomized clinical trials is proposed, with enough statistical power, comparing balanced and unbalanced colloids to balanced and unbalanced crystalloids, following the protocols of GDFT, considering current guidelines and suggestions made by groups of experts. INTRODUÇÃO: Foram feitos múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), muitos deles com o uso de coloides para aprimoramento da pré-carga. Após a decisão da Agência Europeia de Medicamentos, existe ainda controvérsia sobre seu uso, seus benefícios e sua possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas.MÉTODOS: Busca bibliográfica em Medline, Pubmed, Embase e Biblioteca Cochrane de ensaios clínicos aleatórios nos quais se comparam cristaloides com coloides dentro de FGO para cirurgia não cardíaca de grande porte em adultos.RESULTADOS: Foram obtidas 130 referências das quais se selecionaram 38 e 29 foram analisadas; dessas, seis foram incluídas para revisão sistemática e metanálise, incluindo 390 pacientes. Observou-se que o uso de coloides não está associado a um aumento de complicações, mas sim a uma tendência a maior mortalidade (RR [IC 95%] 3,87 [1,121-13,38]; I2 = 0,0%; p = 0,635).CONCLUSÕES: Devido às limitações desta metanálise em decorrência do número escasso de ensaios clínicos aleatórios e pacientes incluídos, os resultados devem ser usados com cautela e propõe-se a feitura de novos ensaios clínicos aleatórios, com potência estatística suficiente naqueles em que se comparam coloides balanceados e não balanceados com cristaloides balanceados e não balanceados, dentro de protocolos de FGO, que respeitem as indicações atuais e as sugestões emitidas pelos grupos de especialistas. INTRODUCCIÓN: Se han realizado múltiples ensayos clínicos en fluidoterapia guiada por objetivos (FGO), muchos de ellos con el uso de coloides para la optimización de la precarga. Tras la decisión de la Agencia Europea del Medicamento, existe cierta controversia en cuanto a su utilización, beneficios y su posible contribución al fallo renal. El objetivo de esta revisión sistemática y metaanálisis es comparar el uso de coloides de última generación, derivados del maíz, con cristaloides en FGO para determinar las complicaciones y la mortalidad asociadas.MÉTODOS: Se realiza una búsqueda bibliográfica en MEDLINE Pubmed, EMBASE y Cochrane Library comprobando ensayos clínicos aleatorizados en los que se comparan cristaloides con coloides dentro de FGO para cirugía mayor no cardíaca de adultos.RESULTADOS: Se obtuvieron 130 referencias de las que se seleccionaron 38 y 29 fueron analizadas; de ellas 6 fueron incluidas para revisión sistemática y metaanálisis, incluyendo a 390 pacientes. Se apreció que el uso de coloides no se asocia con un aumento de complicaciones pero sí con una tendencia a mayor mortalidad (RR [IC 95%] 3,87 [1,121-13,38]; I2 = 0,0%; p = 0,635).CONCLUSIONES: Debido a las limitaciones de este metaanálisis por el escaso número de ensayos clínicos aleatorizados y pacientes incluidos, los resultados deben tomarse con cautela, y se propone la realización de nuevos ensayos clínicos aleatorizados, con suficiente potencia estadística en los que se comparen coloides balanceados y no balanceados con cristaloides balanceados y no balanceados, dentro de protocolos de FGO, respetando las indicaciones actuales y las sugerencias emitidas por los grupos de expertos.

Introduction: Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality. Methods: A bibliographic research was carried out in MEDLINE PubMed, EMBASE and Cochrane Library, corroborating randomized clinical trials where crystalloids are compared to colloids in GDFT for major non-cardiac surgery in adults. Results: One hundred thirty references were found and among those 38 were selected and 29 analyzed; of these, six were included for systematic review and meta-analysis, including 390 patients. It was observed that the use of colloids is not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% CI] 3.87 [1.121–13.38]; I2 = 0.0%; p = 0.635). Conclusions: Because of the limitations of this meta-analysis due to the small number of randomized clinical trials and patients included, the results should be taken cautiously, and the performance of new randomized clinical trials is proposed, with enough statistical power, comparing balanced and unbalanced colloids to balanced and unbalanced crystalloids, following the protocols of GDFT, considering current guidelines and suggestions made by groups of experts. Resumo: Introdução: Foram realizados múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), sendo muitos deles com o uso de coloides para otimização da pré-carga. Após a decisão da Agencia Europea de Medicamento, existe ainda controvérsia sobre sua utilização, benefícios e possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas. Métodos: Realização de uma busca bibliográfica em MEDLINE Pubmed, EMBASE e Biblioteca Cochrane comprovando ensaios clínicos aleatórios nos quais se comparam cristaloides com coloides dentro de FGO para cirurgia não cardíaca de grande porte em adultos. Resultados: Foram obtidas 130 referências das quais se selecionaram 38 e 29 foram analizadas; destas, seis foram incluídas para revisão sistemática e metanálise, incluindo 390 pacientes. Observou-se que o uso de coloides não está associado a um aumento de complicações mas sim com uma tendência a maior mortalidade (RR [IC 95%] 3,87 [1,121-13,38]; I2 = 0,0%; p = 0,635). Conclusões: Devido às limitações desta metanálise em decorrência do número escasso de ensaios clínicos aleatórios e pacientes incluídos, os resultados devem ser usados com cautela, e propõe-se a realização de novos ensaios clínicos aleatórios, com potência estatística suficiente naqueles em que se comparam coloides balanceados e não balanceados com cristaloides balanceados e não balanceados, dentro de protocolos de FGO, respeitando as indicações atuais e as sugestões emitidas pelos grupos de especialistas. Keywords: Fluid therapy, Objective-guided fluid therapy, Colloids, Hydroxyethyl starch, Crystalloids, Systematic review, Meta-analysis, Palavras-chave: Hidratacão, Hidratacão guiada por objetivos, Coloides, Derivados de Hidroxietil Amido, Soluções Isotônicas, Revisão sistemática, Metanálise

Infusion therapy has been one of the main instruments of influence on homeostasis in critical conditions of different nature. Currently, infusion therapy is an essential component of anesthetic and intensive care. However, improper restoration of fluid balance was a major cause of mortality in intensive care units and post-operative intensive care in the 80th of XX century. The appointment of any infusion media is an intervention into the internal environment of the body, that in a greater or lesser degr ee affects the performance of water-salt metabolism, acid-base balance, osmolarity. The surgery itself causes extravasation of fluid. Crystalloid infusion in patients during abdominal surgery resulted in a decreased cardiac output in half of patients. It is believed that the creation of intravascular normovolemia during surgery protects the endothelial glycocalyx from inflammatory mediators in pathological changes, minimizes transcapillary exchange fluid by maintaining proteins endothelial glycocalyx. Restrictive regime of intravenous fluid administration significantly reduces the risk of postoperative complications. In surgical patients of high risk target controlled infusion therapy is suitable. Currently, there is no complete understanding of the pathophysiology of increased vascular permeability and microcirculation disorders in sepsis. In addition, there is a lack of adequate studies, ultimate tests of substitution fluid therapy. Voliutenz is a drug of choice for correction of disorders of circulatory homeostasis during the perioperative period, complicated by hemorrhage., Инфузионная терапия стала одним из главных методов воздействия на гомеостаз в критических условиях любого генеза. На сегодня инфузионная терапия является неотъемлемой составляющей анестезиологического пособия и лечения в условиях реанимационного отделения. Однако неадекватное восстановление водного баланса было основной причиной смертей в отделениях реанимации и интенсивной терапии в раннем послеоперационном периоде в 80-х гг. XX в. Введение любых инфузионных препаратов — это вмешательство во внутреннюю среду организма, которое в той или иной мере оказывает влияние на водно-солевой баланс, кислотно-основное состояние, осмолярность.Сама по себе операция уже является причиной потери жидкости. Введение кристаллоидных препаратов во время абдоминального хирургического вмешательства приводит к уменьшению сердечного выброса у половины пациентов. Считается, что создание внутрисосудистой нормоволемии во время операции способствует защите эндотелиального гликокаликса от воспалительных медиаторов при патологических изменениях, минимизирует транскапиллярный обмен жидкости за счет сохранения белка эндотелиального гликокаликса. Строгое соблюдение режима внутривенного введения жидкости достоверно снижает риск послеоперационных осложнений. У хирургических пациентов высокого риска необходимо под контролем проводить тщательно подобранную целевую инфузионную терапию. Сегодня остается не до конца выясненной патофизиология увеличения проницаемости сосудов и нарушений микроциркуляции при сепсисе. Кроме того, недостаточно проведено исследований по изучению инфузионной терапии. Препарат Волютенз является средством выбора для коррекции нарушений кровообращения в предоперационный период при геморрагических осложнениях., Інфузійна терапія стала одним із головних методів впливу на гомеостаз у критичних умовах будь-якого генезу. На сьогодні інфузійна терапія є невід’ємною складовою анестезіологічного забезпечення й лікування в умовах реанімаційного відділення. Проте неадекватне відновлення водного балансу було головною причиною смертей у відділеннях реанімації й інтенсивної терапії у ранньому післяопераційному періоді у 80-х рр. XX ст. Введення будь-яких інфузійних препаратів — це втручання у внутрішнє середовище організму, яке тією чи іншою мірою справляє вплив на водно-сольовий баланс, кислотно-основний стан, осмолярність.Сама по собі операція вже є причиною втрати рідини. Введення кристалоїдних препаратів під час абдомінального хірургічного втручання призводить до зменшення серцевого викиду в половини пацієнтів. Вважається, що створення внутрішньосудинної нормоволемії під час операції сприяє захисту ендотеліального глікокаліксу від запальних медіаторів при патологічних змінах, мінімізує транскапілярный обмін рідини за рахунок збереження білка ендотеліального глікокаліксу. Суворе дотримання режиму внутрішньовенного введення рідини вірогідно знижує ризик післяопераційних ускладнень. У хірургічних пацієнтів високого ризику необхідно під контролем проводити ретельно підібрану цільову інфузійну терапію. Сьогодні залишається не до кінця з’ясованою патофізіологія збільшення проникності судин і порушень мікроциркуляції при сепсисі. Крім того, недостатньо проведено досліджень з вивчення інфузійної терапії. Препарат Волютенз є засобом вибору для корекції порушень кровообігу в передопераційний період при геморагічних ускладненнях.

Made available in DSpace on 2018-11-26T15:47:46Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-03-01 Fundacao de Amparo a Pesquisa de Sao Paulo Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) BackgroundTetrastarch can cause acute kidney injury (AKI) in humans with sepsis, but less likely to result in tissue edema than lactated Ringer's solution (LRS). ObjectivesCompare effects of volume replacement (VR) with LRS and 6% tetrastarch solution (TS) on extravascular lung water (EVLW) and markers of AKI in hemorrhaged dogs. AnimalsSix healthy English Pointer dogs (19.7-35.3 kg). MethodsProspective crossover study. Animals underwent anesthesia without hemorrhage (Control). Two weeks later, dogs hemorrhaged under anesthesia on 2 occasions (8-week washout intervals) and randomly received VR with LRS or TS at 3 : 1 or 1 : 1 of shed blood, respectively. Anesthesia was maintained until 4 hour after VR for EVLW measurements derived from transpulmonary thermodilution cardiac output. Neutrophil gelatinase-associated lipocalin (NGAL) and creatinine concentrations in plasma and urine were measured until 72 hour after VR. ResultsThe EVLW index (mL/kg) was lower at 1 hour after TS (10.0 1.9) in comparison with controls (11.9 +/- 3.4, P = 0.04), and at 4 hour after TS (9.7 +/- 1.9) in comparison with LRS (11.8 +/- 2.7, P = 0.03). Arterial oxygen partial pressure-to-inspired oxygen fraction ratio did not differ among treatments from 0.5 to 4 hour after VR. Urine NGAL/creatinine ratio did not differ among treatments and remained below threshold for AKI (120,000 pg/mg). Conclusions and Clinical ImportanceAlthough TS causes less EVLW accumulation than LRS, neither fluid produced evidence of lung edema (impaired oxygenation). Both fluids appear not to cause AKI when used for VR after hemorrhage in healthy nonseptic dogs. Univ Estadual Paulista, Fac Med, Botucatu, SP, Brazil Univ Estadual Paulista, Fac Med Vet & Zootecnia, BR-18618970 Botucatu, SP, Brazil Univ Estadual Paulista, Fac Med, Botucatu, SP, Brazil Univ Estadual Paulista, Fac Med Vet & Zootecnia, BR-18618970 Botucatu, SP, Brazil Fundacao de Amparo a Pesquisa de Sao Paulo: 2014/25115-8 Fundacao de Amparo a Pesquisa de Sao Paulo: 2015/04810-2 Fundacao de Amparo a Pesquisa de Sao Paulo: 2017/19711-5 CNPq: 306342/2015-4

Fluid management has been a vital part of routine clinical care for more than 180 years. The increasing number of available fluids has generated controversy about the optimal choice of resuscitation fluid. In this review, we provide a critical overview of the different fluids available, their composition, the relevant physiology as well as the published evidence on clinical outcomes to guide their use. Commonly used infusion fluids include semisynthetic colloids and crystalloids; the latter comprises both normal saline (NaCl 0.9%) and the more chloride-restricted 'balanced' crystalloids. Despite their significantly greater intravascular persistence, semisynthetic colloids have an importantly adverse safety profile and are associated with greater incidence of renal failure and increased mortality; their use should be restricted. To date, evidence for clinical benefits associated with albumin solutions is generally lacking; its merits in specific clinical situations are the subject of further investigation. Infusion of normal saline, with its supraphysiological chloride content, is associated with higher serum chloride concentrations and metabolic acidosis, as well as renal vasoconstriction in animal and human models. Infusion of 'balanced' crystalloids is not linked to such changes. Although data on clinical outcomes associated with crystalloid infusion are heterogeneous, advantages of balanced salt solutions might include a lower need of blood products, and lower incidence of renal replacement therapy, hyperkalaemia and postoperative infections. Taken together, a critical appraisal of the data suggests that balanced salt solutions deserve consideration as infusates of first choice.

Background Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery “bundles” because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. Methods In the “Perioperative Quality Initiative (POQI) Fluids” workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. Discussion We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.

Background Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA. Methods We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume. Results Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices. Conclusions Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians. Electronic supplementary material The online version of this article (doi:10.1186/s13741-016-0035-2) contains supplementary material, which is available to authorized users.

Sepsis is a systemic inflammatory response to severe infection causing significant morbidity and mortality that costs the health care system $20.3 billion annually within the United States. It is well established that fluid resuscitation is a central component of sepsis management; however, to date there is no consensus as to the ideal composition of fluid used for resuscitation. In this review, we discuss the progression of clinical research comparing various fluids, as well as the historical background behind fluid selection for volume resuscitation. We conclude that the use of balanced fluids, such as Ringer's Lactate, seems very promising but further research is needed to confirm their role.

Study objective: To compare the effect of normal saline (NS), lactated Ringer's, and Plasmalyte on the acid-base status of dehydrated patients in the emergency department (ED). Method: We conducted a prospective, double-blind, randomized trial of consecutive adult patients who presented to the emergency department with moderate-severe dehydration. Patients were randomly allocated to blindly receive normal saline (NS), lactated Ringer's or Plasmalyte at 20 ml/kg/h for 2 hours. Outcome measures of the study were pH and changes in electrolytes, including serum potassium, sodium, chloride and bicarbonate levels at 0, 60, and 120 minutes in venous blood gas samples. Results: Ninety patients participated in the study and were randomized to NS (30 patients), lactated Ringer's (30 patients) and Plasmalyte (30 patients) groups. Mean age was 48±20 years and 50% (n=45) of the patients were female. All pH values were in the physiological range (7.35-7.45) throughout the study period. In the NS group there was a significant tendency to lower pH values, with pH values of 7.40, 7.37, and 7.36 at 0, 1, and 2 hours respectively. Average bicarbonate levels fell in the NS group (23.1, 22.2, and 21.5 mM/L) and increased in the Plasmalyte group (23.4, 23.9, and 24.4 mM/L) at 0, 1, and 2 hours, respectively. There were no significant changes in potassium, sodium, or chloride levels. Conclusions: NS, lactated Ringer's, and Plasmalyte have no significant effect on acid-base status and all can be used safely to treat dehydrated patients in the emergency department. However, NS can effect acidosis which might be significant in patients who have underlying metabolic disturbances; thus, its use should be weighed before fluid administration in the ED.

OBJECTIVE: In patients with shock, late-onset acute respiratory distress syndrome (ARDS) carries poor prognosis. Hypooncotic fluids may improve kidney function preservation, whereas hyperoncotic fluids may in theory decrease the risk of late-onset ARDS. Our objective was to determine whether predominant or exclusive use of crystalloids and/or hypooncotic colloids for shock resuscitation influenced the risk of late-onset ARDS. PARTICIPANT AND SETTINGS: International prospective cohort of consecutive adults who were free of ARDS on admission and who received fluid resuscitation for shock in 115 intensive care units (ICUs) during a 4-week period. MEASUREMENTS AND RESULTS: Severity scores, hemodynamic status, indication for fluids, risk factors for ARDS, plasma expander use, transfusions, and late-onset ARDS were recorded prospectively. Logistic regression models were tested to determine whether predominant or exclusive use of hypooncotic fluids was associated with higher incidence of late-onset ARDS. Of 905 patients, 81 [8.9% ; 95% confidence interval (CI) 7.2-11.0] developed ARDS, with no difference between patients given only hypooncotic fluids (10.4% ; 95% CI 7.6-13.7) and the other patients (7.7% ; 95% CI 5.5-10.5 ; p = 0.16). Late-onset ARDS was significantly associated with sepsis [odds ratio (OR) 1.90 ; 95% CI 1.06-3.40], worse chest X-ray score at fluid initiation (1.55 ; 95% CI 1.27-1.91), positive fluid balance (1.06 per l ; 95% CI 1.02-1.09), and greater transfusion volume (1.14 per l ; 95% CI 1.01-1.29). The proportion of hypooncotic fluids in the plasma expander regimen was not associated with late-onset ARDS (1.01 per % ; 95% CI 0.99-1.01). CONCLUSIONS: Based on this observational study, there is no evidence that in patients with shock the use of hypooncotic fluids increases the risk of late-onset ARDS. This finding needs to be confirmed.

The type of fluid used during resuscitation may have an important impact on tissue edema. We evaluated the impact of two different regimens of fluid resuscitation on hemodynamics and on lung and intestinal edema during splanchnic hypoperfusion in rabbits. The study included 16 female New Zealand rabbits (2.9 to 3.3 kg body weight, aged 8 to 12 months) with splanchnic ischemia induced by ligation of the superior mesenteric artery. The animals were randomized into two experimental groups: group I (N = 9) received 12 mL x kg-1 x h-1 lactated Ringer solution and 20 mL/kg 6% hydroxyethyl starch solution; group II (N = 7) received 36 mL x kg-1 x h-1 lactated Ringer solution and 20 mL/kg 0.9% saline. A segment from the ileum was isolated to be perfused. A tonometric catheter was placed in a second gut segment. Superior mesenteric artery (Q SMA) and aortic (Qaorta) flows were measured using ultrasonic flow probes. After 4 h of fluid resuscitation, tissue specimens were immediately removed for estimations of gut and lung edema. There were no differences in global and regional perfusion variables, lung wet-to-dry weight ratios and oxygenation indices between groups. Gut wet-to-dry weight ratio was significantly lower in the crystalloid/colloid-treated group (4.9 +/- 1.5) than in the crystalloid-treated group (7.3 +/- 2.4) (P0.05). In this model of intestinal ischemia, fluid resuscitation with crystalloids caused more gut edema than a combination of crystalloids and colloids.

"Balanced" solutions are commonly defined as intravenous fluids having an electrolyte composition close to that of plasma. As such, they should minimally affect acid-base equilibrium, as compared to the commonly reported 0.9% NaCl-related hyperchloremic metabolic acidosis. Recently, the term "balanced" solution has been also employed to indicate intravenous fluids with low chloride content, being the concentration of this electrolyte the most altered and supra-physiologic in 0.9% NaCl as compared to plasma, and based upon a suggested detrimental effect on renal function associated with hyperchloremia. Despite efforts for its identification, the ideal balanced solution, with minimal effects on acid-base status, low chloride content, and adequate tonicity, is not yet available. After the accumulation of pre-clinical and clinical physiologic data, in the last three years, several clinical trials, mostly observational and retrospective, have addressed the question of whether the use of balanced solutions has beneficial effects as compared to the standard of care, sometimes even suggesting an improvement in survival. Nonetheless, the first large randomized controlled trial comparing the effects of a balanced vs. unbalanced solution on renal function in critically-ill patients (SPLIT trial, the 0.9% Saline vs Plasma-Lyte 148 for Intensive Cate Unit Fluid Therapy), just recently published, showed identical equipoise between the two treatments. In the present review, we offer a comprehensive and updated summary on this issue, firstly, by providing a full physiological background of balanced solutions, secondly, by summarizing their potential pathophysiologic effects, and lastly, by presenting the clinical evidence available to support, at the moment, their use.

Objective: To compare the colloids 5% albumin, 4% gelatin, and 6% HES 130/0.4 with one another and with normal saline regarding their plasma expanding effects at increased permeability and to compare the results with those from a previous study at normal permeability. Design and setting: Prospective controlled randomized laboratory study in a university research laboratory. Subjects: 48 adult male Sprague-Dawley rats. Interventions: Permeability was increased by an injection of 0.5 ml dextran 70 using the fact that dextran causes anaphylactic reaction in the rat. Plasma volume was determined (I-125 albumin tracer technique) after anesthesia, 1 h after dextran injection (before infusion for 10-15 min of 20 ml/kg bw of each of the colloids or 80 ml/kg saline), and 3 h later. Blood pressure, hematocrit, blood gases, and electrolytes were measured. CVP was measured in four rats. Measurements and results: Plasma volume was 41.1 +/- 1.9 ml/kg at baseline (n = 9), and 29.1 +/- 4.1 ml/kg (n = 35) 1 h after the dextran injection. Three hours after infusion of the plasma expander plasma volume had increased by 17.1 +/- 3.4 ml/kg in the albumin group, 7.9 +/- 3.6 ml/kg in the gelatin group, 7.4 +/- 4.4 ml/kg in the HES group, and 12.2 +/- 3.1 ml/kg in the saline group. It was unchanged in a control group given no solution (n = 7 for all groups). Conclusion: Albumin was a more effective plasma volume expander than gelatin or HES or saline (saline in 4 times larger volume). Gelatin and HES were equally effective. All solutions showed a smaller plasma expanding effect than observed in a previous study with normal permeability.

Objective To examine weight loss (WL) and excess weight loss (EWL) among newborns of caesarean delivery, comparing colloids plus crystalloids versus crystalloids only. Also, to examine different doses of intrapartum intravenous fluids on WL and EWL. Design Comparative safety retrospective cohort study. Setting University Teaching Hospital, Moncton, Canada. Patients Mothers exposed to intravenous fluids with caesarean delivery between 2008 and 2016. Interventions Exposure to colloids plus crystalloids was compared with crystalloids only, and dose-response analyses were performed for colloids, crystalloids and total intravenous fluids doses. Linear and logistic regression models were used, adjusting for potential confounders. Main outcome measures Infants’ WL was measured at days 1, 2 and 3 post partum, and EWL defined as loss of >7% of birth weight. Results From 801 mother-infant pairs, 176 were exposed to colloids plus crystalloids and 625 were exposed to crystalloids only (overall mean birth weight=3416 g, EWL=2%, 41.4% and 55.5% on days 1, 2 and 3, respectively). No significant difference in newborns’ WL was observed on any of the days assessed. Adjusted OR (95% CI) of EWL was 1.0 (0.3 to 3.3) at 24 hours, 1.0 (0.7 to 1.5) at 48 hours and 1.4 (0.9 to 2.2) at 72 hours. No dose-response relationship was detected with type-specific and total intravenous fluids exposures. Conclusions The risk of EWL was similar with colloids plus crystalloids and crystalloids only, suggesting that both therapeutic options can be considered during caesarean delivery. The absence of dose-response relationships adds confirmatory evidence to the intravenous fluids safety profiles.

Background The effectiveness of fluid preloading is in doubt, so co-loading has been attempted to reduce the incidence of spinal anaesthesia induced hypotension in caesarean patients. Aim To compare crystalloid preloading, colloid preloading and colloid co-loading for prevention of maternal hypotension in caesarean delivery. Settings and design Study conducted in tertiary level hospital on 90 ASA I/II term parturients posted for elective caesarean section. Patients were randomly allocated to three Groups. Materials and methods Group A (n=30) was given 10 ml/kg of 6% hydroxyethyl starch (HES) 20 minutes prior to spinal anaesthesia, Group B (n=30) was given 10 ml/kg of 6% HES by rapid infusion in 10 minutes immediately after spinal anaesthesia and Group C (n=30) was given 10 ml/kg of Ringer's Lactate 20 minutes prior to spinal anaesthesia. Intraoperatively, Heart rate, systolic, diastolic and mean arterial pressure were recorded every five minutes. Episodes of hypotension were recorded and treated with bolus of 5 mg of ephedrine and total amount of ephedrine was noted. Adverse effects, if any were recorded. Statistical analysis ANNOVA for Quantitative Analysis and chi-Square test and Z-test for Qualitative Analysis. Results Baseline parameters were similar in all the three Groups. Heart rate decreased from the baseline in all the three Groups, however, mean heart rate was highest in Group C. Heart rate was statistically similar in Groups A and B. MAP decreased in all three Groups from baseline, however, highest fall was recorded in Group C whereas, MAP was statistically similar in Groups A and B. Incidence of hypotension was 66.66% in Group C as compared to 36.66% in Groups A and 40% in Group B respectively. Group C patients received 5.33±4.54 mg of ephedrine as compared to 2.00±2.82 mg in Group A and 2.33±3.14 mg in Group B. Thus, the incidence of hypotension and ephedrine consumption was significantly higher in Group C as compared to Groups A and B whereas, this difference was statistically not significant among Groups A and B. Conclusion Colloid preloading and co-loading are equally effective and both are superior to crystalloid preloading for prevention of maternal hypotension in caesarean section patients.

Human beings are constituted mainly of water. In particular, children's total body water might reach 75-80% of their body weight, compared to 60-70% in adults. It is therefore not surprising, that children, especially hospitalized new-borns and infants, are markedly prone to water and electrolyte imbalances. Parenteral fluid therapy is a cornerstone of medical treatment and is thus of exceptional relevance in this patient population. It is crucial to appreciate the fact that intravenous fluids are drugs with very different characteristics, different indications, contraindications and relevant side effects. In the present review, we will summarize the physiology and pathophysiology of water and electrolyte balance, underlining the importance and high prevalence of non-osmotic antidiuretic hormone release in hospitalized and critically ill children. Furthermore, we will discuss the characteristics and potential side effects of available crystalloids for the paediatric population, making a clear distinction between fluids that are hypotonic or isotonic as compared to normal plasma. Finally, we will review the current clinical practice regarding the use of different parenteral fluids in children, outlining both the current consensus on fluids employed for resuscitation and replacement and the ongoing debate concerning parenteral maintenance fluids.

We summarize the emerging new literature regarding the pathophysiological principles underlying the beneficial and deleterious effects of fluid administration during resuscitation, as well as current recommendations and recent clinical evidence regarding specific colloids and crystalloids. This systematic review allows us to conclude that there is no clear benefit associated with the use of colloids compared to crystalloids and no evidence to support the unique benefit of albumin as a resuscitation fluid. Hydroxyethyl starch use has been associated with increased acute kidney injury (AKI) and use of renal replacement therapy. Other synthetic colloids (dextran and gelatins) though not well studied do not appear superior to crystalloids. Normal saline (NS) use is associated with hyperchloremic metabolic acidosis and increased risk of AKI. This risk is decreased when balanced salt solutions are used. Balanced crystalloid solutions have shown no harmful effects, and there is evidence for benefit over NS. Finally, fluid resuscitation should be applied in a goal-directed manner and targeted to physiologic needs of individual patients. The evidence supports use of fluids in volume-responsive patients whose end-organ perfusion parameters have not been met.

A mensuracao de parâmetros sericos durante procedimentos dependentes de anestesia geral sao passiveis de variacoes devido a diferencas do protocolo utilizado, armazenamento esplenico e tambem da fluidoterapia instituida. O objetivo deste trabalho foi avaliar o hematocrito buscando evidenciar as alteracoes flutuantes promovidas por fluidoterapia controlada e anestesia geral em caes submetidos a ovariohisterectomia laparoscopica. Seis cadelas sem raca definida foram submetidas a um protocolo anestesico com acepromazina (0,03 mg kg-1) e tramadol (5,0 mg kg-1) como medicacao pre-anestesica, inducao com propofol (3,0 mg kg-1) e mantidas com isoflurano e ventilacao mecânica durante 120 minutos. Apos a inducao, receberam a infusao de 10,0 ml kg hr-1 de solucao Ringer com lactato. Foram realizadas afericoes de hematocrito do inicio (ou antes?) ate 72 horas apos a anestesia, sendo avaliadas estatisticamente para verificar se houve alteracoes relevantes durante os tempos. A fluidoterapia e o uso de acepromazina e propofol no protocolo anestesico para esta tecnica cirurgica promoveram uma reducao de hematocrito significativa ate quatro horas apos a anestesia geral.

Background: Excessive crystalloid administration is common and associated with negative outcomes in critically ill trauma patients. Continuous furosemide infusion (CFI) to remove excessive fluid has not been previously described in this population. We hypothesized that a goal-directed CFI is more effective for fluid removal than intermittent bolus injection (IBI) diuresis without excess incidence of hypokalemia or renal failure. Materials and Methods: CFI cases were prospectively enrolled between November 2011 and August 2012, and matched to historic IBI controls by age, gender, Injury Severity Score (ISS), and net fluid balance (NFB) at diuresis initiation. Paired and unpaired analyses were performed to compare groups. The primary endpoints were net fluid balance, potassium and creatinine levels. Secondary endpoints included intensive care unit (ICU) and hospital length of stay (LOS), ventilator-free days (VFD), and mortality. Results: 55 patients were included, with 19 cases and 36 matched controls. Mean age was 54 years, mean ISS was 32.7, and mean initial NFB was +7.7 L. After one day of diuresis with CFI vs. IBI, net 24 h fluid balance was negative (−0.55 L vs. +0.43 L, P = 0.026) only for the CFI group, and there was no difference in potassium and creatinine levels. Cumulative furosemide dose (59.4mg vs. 25.4mg, P < 0.001) and urine output (4.2 L vs. 2.8 L, P < 0.001) were also significantly increased with CFI vs. IBI. There were no statistically significant differences in ICU LOS, hospital LOS, VFD, or mortality. Conclusions: Compared to IBI, goal-directed diuresis by CFI is more successful in achieving net negative fluid balance in patients with fluid overload with no detrimental side effects on renal function or patient outcome.

Intravascular fluid therapy is a common critical care intervention. However, the optimal type of resuscitation fluid, crystalloid or colloid, remains controversial. Despite the many theoretical benefits of human albumin administration in critically ill patients, there has been little evidence to support its widespread clinical use. Previous systematic reviews have led to conflicting results regarding the safety and efficacy of albumin. The recently reported Saline versus Albumin Evaluation study has provided conclusive evidence that 4% albumin is as safe as saline for resuscitation, although no overall benefit of albumin use was seen. Subgroup analysis of the albumin-treated group revealed a trend towards decreased mortality in patients with septic shock, and a trend towards increased mortality in trauma patients, especially those with traumatic brain injury. The results of these subgroups, as well as the use of higher albumin concentrations and other synthetic colloids (dextrans, starches), require rigorous evaluation in clinical trials. Finally, the Saline versus Albumin Evaluation trial represents a methodological milestone in critical care medicine, due to its size, its efficient trial design, and its logistical coordination. Future studies are still required, however, to establish a therapeutic niche for albumin and other colloids.

В исследование включено 70 женщин, у которых изучали влияния физиологической беременности на водные секторы организма и их изменения под влиянием кристаллоидных растворов, применяемых при инфузионной терапии неосложненного перипартального периода. Установлено, что на фоне инфузии сбалансированного солевого раствора (Стерофундин) происходит ускоренная нормализация водных пространств в послеродовом периоде по сравнению с несбалансированным 0,9 % раствором Натрия хлорида.

The recent Cochrane report on albumin administration is analysed and criticised on the grounds of clinical methodology, content and interpretation. Although it is naïve and illogical to treat hypoalbuminaemia with albumin infusions, a more balanced view on the use of albumin for resuscitation in acute hypovolaemia is necessary. Once the acute phase of critical illness is past, interstitial volume is often expanded causing oedema, with a low plasma volume. We argue for the use of salt-poor albumin solutions in this situation and conclude that, on current evidence, the assertion that albumin should be avoided in all situations is irrational and untenable.

PURPOSE: To determine whether there was a correlation between the type of administered infusion solutions intraoperatively with the quantity of administered infusion solutions, differences in values of cardiac output (CO) and cardiac index (CI) and need to use vasopressors and inotropes, between control and research groups. METHODS: This randomized prospective study included 55 patients with colorectal cancer. Subjects in the control group received only crystalloid solutions intraoperatively and postoperatively. The patients in the research group received a combination of colloid in dosage of 10mg/kg and crystalloid solutions. Patients in both groups were given goal directed fluid therapy. RESULTS: The control group received a significantly larger amount of crystalloid solution per kg of body weight during the entire surgical operation, in comparison with the volume of crystalloids in the research group (mean±SD 50.78±28.13 vs. 31.63±25.60 respectively, p=0.01). During the first hour of the surgery, the control group received a larger quantity of fluid in comparison with the research group (mean±SD 31.14±9.78 vs. 22.17±9.92 respectively, p=0.001). From the beginning of anesthesia until 6th postoperative hr the values of CI were significantly higher in the research group in comparison with the control group. CONCLUSIONS:Goal directed fluid therapy with colloids, followed by crystalloids during surgery, decreased the total intraoperative fluid volumes, and provided higher values of CI intraoperatively which were also maintained postoperatively.