Search Results (33)

Background/Objective: Sepsis is a leading cause of death in noncoronary intensive care units (ICUs). Fluids for intravascular resuscitation include crystalloids and colloids. There is extensive clinical evidence on colloid use, but large trials comparing gelatine with crystalloid regimens in ICU and septic patients are lacking. This study aimed to determine whether early, protocol-driven volume resuscitation using a gelatine-based regimen achieves hemodynamic stability (HDS) more rapidly than a crystalloid-based regimen in septic patients. Methods: This prospective, controlled, randomised, double-blind, multinational phase IV study compared two parallel groups of septic patients receiving a gelatine-based regimen (Gelaspan^® 4% and Sterofundin^® ISO, B. Braun Melsungen AG each, at a 1:1 ratio) or a crystalloid regimen (Sterofundin^® ISO). Primary endpoint was time to first HDS within 48 h after randomisation. Secondary endpoints included fluid overload, fluid balance, and patient outcomes. Results: 167 patients were randomised. HDS was achieved after 4.7 h in the gelatine group and after 5.8 h in the crystalloid group (p = 0.3716). The gelatine group had a more favourable fluid balance at 24 h (medians: 3463.00 mL vs. 4164.00 mL; p = 0.0395) and less fluid overload (medians: 4296.05 vs. 5218.75%; p = 0.0217). No differences were observed in serious adverse events or mortality. Conclusions: The study provided clinical evidence of balanced gelatine solution for volume resuscitation in septic patients, although it was terminated prematurely. The early and protocol-based administration of gelatine was safe and effective in the enrolled patient population. Time to HDS was not different between groups but the gelatine-based regimen led to better fluid balance and less fluid overload. Full article

Background/Objectives: The use of goal-directed fluid therapy (GDFT) guided by stroke volume (SV) variation during thoracic surgery, particularly with one-lung ventilation (OLV) and protective ventilation strategies, is not well established. This study aimed to determine whether maximizing stroke volume (SV) before initiating one-lung ventilation (OLV) reduces the incidence of intraoperative hypotension requiring vasoactive agents during video-assisted thoracoscopic surgery (VATS). Methods: Sixty patients undergoing VATS were randomly assigned to an SVM group (n = 30) or a control group (n = 30). The SVM group received 6% hydroxyethyl starch before OLV to achieve and maintain an SV increase of less than 10%. The control group received no active fluid therapy before OLV positioning. Both groups received Ringer’s lactate solution intraoperatively based on baseline (control) or maximized (SVM) SV goals. The primary outcome was the use of vasoactive agents for hypotension. Results: Patients in the SVM group received significantly less Ringer’s lactate solution than controls (4.2 ± 2.4 vs. 6.1 ± 2.8 mL/kg/h, p = 0.005). While fewer patients in the SVM group required vasoactive agents (20% vs. 40%), the difference was not statistically significant (p = 0.091). IL-6 levels were significantly lower during OLV in the SVM group. Conclusions: Pre-OLV SVM was associated with reduced intraoperative crystalloid administration and attenuation of inflammatory response, with a non-significant trend toward lower vasopressor use. These findings suggest a potential benefit of SVM in thoracic surgery, though larger multicenter trials are needed to confirm clinical efficacy. Full article

Background: Shoulder arthroscopy is a common, minimally invasive surgery, but the resulting postoperative blood loss remains poorly understood. In this study, we quantified the intraoperative and postoperative blood loss, the hemoglobin (Hb) drop, and the effects of irrigation fluid retention, as well as the influence of solutions administered through infusions. Methods: A prospective observational study of 49 patients undergoing arthroscopic rotator cuff tear (RCT) repair was conducted. Their preoperative and postoperative Hb levels were measured, along with the intraoperative and postoperative blood loss. Irrigation fluid retention was analyzed, and multiple regression was used to assess the factors contributing to Hb drops. Results: The intraoperative blood loss amounted to 36.46 ± 20.34 mL, while the total blood loss reached 791.17 ± 280.96 mL, with 94.64% occurring postoperatively. The postoperative Hb drop (2.06 ± 0.74 g/dL) was significantly greater than the intraoperative Hb drop (0.11 ± 0.06 g/dL) (p < 0.001). An older age (p = 0.02) and male sex (p = 0.025) significantly predicted the postoperative Hb drop, while irrigation fluid retention and administration of crystalloids and colloids had no notable effects. Capsulotomy was associated with a small but significant increase in intraoperative blood loss (p < 0.01). Increased intraoperative blood loss correlated with greater irrigation fluid retention (r = 0.41, adjusted R2 = 0.152, p < 0.001). Conclusions: In shoulder arthroscopy, the postoperative blood loss and Hb drop are significantly greater than the intraoperative blood loss and Hb drop, as well as the fluid gain, emphasizing the need for careful monitoring, especially in high-risk patients. Future studies should investigate the potential impacts of low-molecular-weight heparin on postoperative bleeding after shoulder arthroscopy. Full article

Background: Optimizing fluid therapy is critical for maintaining hemodynamic stability in elderly patients undergoing major surgeries. Dynamic arterial elastance (Eadyn), defined as the ratio of pulse pressure variation (PPV) to stroke volume variation (SVV), has been proposed as a predictor of fluid responsiveness, especially in challenging conditions like prone-positioned spine surgery under general anesthesia. Methods: Hemodynamic parameters were measured before and after fluid loading with 500 mL of crystalloid solution. Patients were classified as responders or non-responders based on a ≥15% increase in mean arterial pressure (MAP) post-fluid administration. Predictive performance of these parameters was assessed using receiver operating characteristic (ROC) analysis. Results: Of the 37 patients, 15 were classified as responders and 22 as non-responders. Eadyn demonstrated poor predictive performance (AUC = 0.508). In contrast, SVV (AUC = 0.808), PPV (AUC = 0.738), and C (AUC = 0.741) exhibited moderate to high predictive ability. Responders exhibited significantly higher baseline SVV, PPV, and net arterial compliance compared to non-responders. Conclusions: Dynamic arterial elastance (Eadyn) showed limited predictive ability for fluid responsiveness in elderly patients undergoing spine surgery in the prone position. In contrast, stroke volume variation (SVV), pulse pressure variation (PPV), and net arterial compliance (C) demonstrated superior reliability, with SVV emerging as the most accurate predictor. Full article

Background/Objectives: Cardiopulmonary bypass can lead to hemodilution, causing a fluid shift to the interstitial space. Albumin helps counteract the intravascular fluid movement to the extravascular space and reduces the risk of complications associated with fluid imbalance. Our main objective was to evaluate the effectiveness of albumin addition in the cardiopulmonary bypass priming solution compared to standard priming, focusing on its role in reducing pleural effusion development. Methods: This was a single-center randomized controlled trial conducted at a tertiary care hospital specializing in cardiology and cardiac surgery. It involved 70 individuals scheduled for elective open-heart surgery. All cases were randomly assigned into two groups of 35 patients. The study group replaced 100 mL of standard CPB priming solution with 100 mL of 20% human albumin. We measured serum albumin levels before and after the surgery, 6 and 12 h after, and calculated colloid oncotic pressure. Thorax CT scans were performed on the first postoperative day to measure and calculate pleural effusion volume. Results: Albumin addition to cardiopulmonary bypass priming solution led to a significant reduction in pleural effusion development after CPB. An albumin level <35 g/L after the surgery showed a significant increase in pleural effusion development, and 100 mL of 20% albumin was sufficient to maintain serum albumin levels > 35 g/L. Conclusions: Our study suggests a link between postoperative hypoalbuminemia and the early development of pleural effusion after CPB, as well as the possible benefits of adding 100 mL of 20% albumin compared to standard crystalloid CPB priming to minimize postoperative pleural effusion development. Full article

Introduction: Intraoperative fluid management is one of the most important factors affecting optimal perfusion in the microcirculatory area in patients that undergo flap surgery. While insufficient fluid administration in the intraoperative period leads to flap complications and organ dysfunction, volume load can cause complications such as edema in the denervated flap tissue, the opening of the sutures, or fat necrosis. The Infrared Fluorescent Angiography Perfusion Evaluation Device (SPY) is one of the many noninvasive techniques that evaluate the well-being of microcirculation at the tissue level. This device monitors and scores the perfusion distribution in the flap area. This retrospective study aimed to investigate the effect of fluid resuscitation in head and neck free flap transfer surgery on flap quality and patient outcomes according to the change in SPY scores. Material and Method: This study included 39 ASA I–II patients who were aged 18–60 years and underwent simultaneous free flap reconstruction of the head and neck between 2015 and 2021. Patients’ blood pressure, body temperature, hemoglobin, pH, and lactate values were recorded at both baseline and end of the operation. Also, the SPY “Infrared Fluorescent Angiography Perfusion Evaluation Device” scores, the amount of intraoperative fluid and transfusion, bleeding and urine output, and the duration of mechanical ventilation, anesthesia and surgery, and the duration and amount of drainage, the length of stay in hospital and intensive care unit, and the presence of flap infection, detachment, necrosis and loss, and re-exploration rate were recorded for the patients. Results: The difference between the first and last measured SPY values was observed to be positively correlated with the length of stay in the hospital and intensive care unit and the duration of drainage. There was a positive correlation between the length of stay in the hospital and intensive care unit and the duration of drainage, the amount of drainage, as well as the duration of anesthesia and the duration of surgery (p < 0.001). A positive correlation was found between the amount of drainage and the amount of crystalloid solution administered (r = 0.36, p < 0.05). In patients with flap infection, the difference between SPYfirst and SPYlast, the duration of anesthesia, and the duration of surgery were significantly higher. The amount of crystalloid solution given and bleeding and the duration of anesthesia and surgery were found to be significantly higher in mechanically ventilated patients (p < 0.05). Conclusions: It has been concluded that SPY-guided fluid management can be beneficial in preventing morbidities, such as extended hospital and intensive care stay, by reducing flap infection, mechanical ventilation duration, and drainage, with early diagnosis of insufficient perfusion. Full article

The aim of this prospective, randomized clinical trial was to evaluate the use of the pleth variability index (PVi) to guide the rate of intraoperative fluid therapy compared to a traditional fixed-fluid-rate approach in ASA 1–2 dogs undergoing surgery. Twenty-seven dogs met the inclusion criteria and were randomly assigned to the conventional fluid management group (CFM, n = 12) or the PVi-guided group (PVi, n = 15). The CFM group received a fixed rate of 5 mL kg⁻¹ h⁻¹ of crystalloid solution, while in the PVi group the rate was continuously adjusted based on the PVi: PVi < 14% = 3 mL kg⁻¹ h⁻¹; 14% ≤ PVi ≥ 20% = 10 mL kg⁻¹ h⁻¹; and PVi > 20% = 15 mL kg⁻¹ h⁻¹. Hypotension (MAP < 65 mmHg) in the CFM was treated with a maximum of two fluid boluses (5 mL kg⁻¹ in 10 min) and in the case of no response, dobutamine (1–3 mcg kg⁻¹ min⁻¹) was administered. In the PVi group, the treatment of hypotension was similar, except when the PVi > 14%, when dobutamine was started directly. Total fluid volume was significantly lower in the PVI group (0.056 ± 0.027 mL kg⁻¹ min⁻¹) compared to the CFM group (0.132 ± 0.115 mL kg⁻¹ min⁻¹), and the incidence of hypotension was lower (p = 0.023) in the PVi group (0%) compared to the CFM group (41%). The mean arterial pressure (MAP) was significantly higher in the PVi group during surgery. Dobutamine was never administered in either group. Preliminary data suggest that the PVi may be considered as a potential target to guide fluid therapy in dogs; larger studies are needed, especially in cases of cardiovascular instability. Full article

Uncontrollable bleeding is recognized as the leading cause of preventable death among trauma patients. Early transfusion of blood products, especially plasma replacing crystalloid and colloid solutions, has been shown to increase survival of severely injured patients. However, the requirements for cold storage and thawing processes prior to transfusion present significant logistical challenges in prehospital and remote areas, resulting in a considerable delay in receiving thawed or liquid plasma, even in hospitals. In contrast, freeze- or spray-dried plasma, which can be massively produced, stockpiled, and stored at room temperature, is easily carried and can be reconstituted for transfusion in minutes, provides a promising alternative. Drawn from history, this paper provides a review of different forms of dried plasma with a focus on in vitro characterization of hemostatic properties, to assess the effects of the drying process, storage conditions in dry form and after reconstitution, their distinct safety and/or efficacy profiles currently in different phases of development, and to discuss the current expectations of these products in the context of recent preclinical and clinical trials. Future research directions are presented as well. Full article

Donation after circulatory death (DCD) hearts are predominantly maintained by normothermic blood perfusion (NBP). Nevertheless, it was shown that hypothermic crystalloid perfusion (HCP) is superior to blood perfusion to recondition left ventricular (LV) contractility. However, transcriptomic changes in the myocardium and coronary artery in DCD hearts after HCP and NBP have not been investigated yet. In a pig model, DCD hearts were harvested and maintained for 4 h by NBP (DCD-BP group, N = 8) or HCP with oxygenated histidine–tryptophane–ketoglutarate (HTK) solution (DCD-HTK, N = 8) followed by reperfusion with fresh blood for 2 h. In the DCD group (N = 8), hearts underwent reperfusion immediately after procurement. In the control group (N = 7), no circulatory death was induced. We performed transcriptomics from LV myocardial and left anterior descending (LAD) samples using microarrays (25,470 genes). We applied the Boruta algorithm for variable selection to identify relevant genes. In the DCD-BP group, compared to DCD, six genes were regulated in the myocardium and 1915 genes were regulated in the LAD. In the DCD-HTK group, 259 genes were downregulated in the myocardium and 27 in the LAD; and 52 genes were upregulated in the myocardium and 765 in the LAD, compared to the DCD group. We identified seven genes of relevance for group identification: ITPRIP, G3BP1, ARRDC3, XPO6, NOP2, SPTSSA, and IL-6. NBP resulted in the upregulation of genes involved in mitochondrial calcium accumulation and ROS production, the reduction in microvascular endothelial sprouting, and inflammation. HCP resulted in the downregulation of genes involved in NF-κB-, STAT3-, and SASP-activation and inflammation. Full article

The omentum is the predominant site of ovarian cancer metastasis, but it is difficult to remove the omentum in its entirety. There is a critical need for effective approaches that minimize the risk of colonization of preserved omental tissues by occult cancer cells. Normal saline (0.9% sodium chloride) is commonly used to wash the peritoneal cavity during ovarian cancer surgery. The omentum has a prodigious ability to absorb fluid in the peritoneal cavity, but the impact of normal saline on the omentum is poorly understood. In this review article, we discuss why normal saline is not a biocompatible solution, drawing insights from clinical investigations of normal saline in fluid resuscitation and from the cytopathologic evaluation of peritoneal washings. We integrate these insights with the unique biology of the omentum and omental metastasis, highlighting the importance of considering the absorptive ability of the omentum when administering agents into the peritoneal cavity. Furthermore, we describe insights from preclinical studies regarding the mechanisms by which normal saline might render the omentum conducive for colonization by cancer cells. Importantly, we discuss the possibility that the risk of colonization of preserved omental tissues might be minimized by using balanced crystalloid solutions for peritoneal washing. Full article

In recent decades, infusion solutions such as NaCl 0.9% and lactate Ringer’s solution have been replaced in clinical practice. Since 2017, the national guidelines for perioperative infusion therapy in children recommend balanced isotonic solutions to maintain fluid balance. The composition of balanced infusion solutions varies with respect to their electrolyte content. Hyperchloremia may be mistaken for hypovolemia and may interfere with volume therapy in pediatric patients. Sterofundin ISO^® balanced solution contains 127 mmol/L chloride and may cause hyperchloremic acidosis if administered in large volumes. Objectives: The purpose of this study was to compare the effects of Sterofundin ISO^® (SF) therapy with the balanced isochloremic solution Deltajonin^® (DJ) (106 mmol/L chloride) on the acid–base status in infants undergoing craniofacial surgery. Methods: This retrospective, non-blinded study included 100 infants undergoing craniectomy due to isolated nonsyndromic sagittal craniosynostosis. The first 50 infants received Sterofundin ISO^®. Due to changes in national guidelines, the infusion was changed to the isoionic Deltajonin^® in an additional 50 infants in 2017. Pre- and postoperative values of chloride, pH, base excess, bicarbonate, and albumin and phosphate were determined, and the strong-ion difference, strong-ion gap, anion gap, and weak acids were calculated. Results: Both groups were comparable in terms of their age, sex, underlying disease, preoperative electrolytes (except K at 3.9 ± 0.3 mmol/L (SF) vs. 4.1 ± 0.3 mmol/L (DJ) and lactate 8.7 ± 2.1 (SF) vs. 9.6 ± 2.6 mmol/L (DJ)). In the Sterofundin ISO^® group, hyperchloremic metabolic acidosis was observed in 19 patients, whereas only 2 infants in the Deltajonin^® group had hyperchloremic metabolic acidosis. The postoperative chloride level was 111 ± 2.7 mmol/L (SF) vs. 108 ± 2.4 mmol/L (DJ). The difference in anion gap was 12.5 ± 3.0 mmol/L (SF) vs. 14.6 ± 2.8 mmol/L (DJ), and the difference in SIDa (apparent strong-ion difference) was 30.9 mmol/L (SF) vs. 33.8 mmol/L (DJ). Conclusions: Hyperchloremic acidosis can be induced by the volume replacement with high-chloride-concentration crystalloids such as Sterofundin ISO^®. This can be detected using the Stewart model. Full article

Background: Although saline is commonly used during cardiopulmonary resuscitation (CPR) or post-cardiac arrest care, it has detrimental effects. This trial aimed to evaluate the efficacy of a balanced crystalloid solution (Plasma Solution-A [PS]) in out-of-hospital cardiac arrest (OHCA) patients and compare it with the efficacy of saline. Methods: A randomized, unblinded clinical trial was conducted using PS and saline for intravenous fluid administration during CPR and post-cardiac arrest care of non-traumatic OHCA patients admitted to the emergency department of a tertiary university hospital. Patients received saline (saline group) or PS (PS group) within 24 h of hospital arrival. The primary outcomes were changes in arterial pH, bicarbonate, base excess (BE), and chloride levels within 24 h. The secondary outcomes were clinical outcomes including mortality. Results: Of the 364 patients, data from 27 and 26 patients in the saline and PS groups, respectively, were analyzed. Analysis using a linear mixed model revealed a significant difference in BE change over time between the groups (treatment-by-time p = 0.044). Increase in BE and bicarbonate levels from 30 min to 2 h was significantly greater (p = 0.044 and p = 0.024, respectively) and the incidence of hyperchloremia was lower (p < 0.001) in the PS group than in the saline group. However, there was no difference in clinical outcomes. Conclusion: Use of PS for resuscitation resulted in a faster improvement in BE and bicarbonate, especially in the early phase of post-cardiac arrest care, and lower hyperchloremia incidence than the use of saline, without differences in clinical outcomes, in OHCA patients. Full article

Nanocarriers for oxygen delivery have been the focus of extensive research to ameliorate the therapeutic effects of current anti-cancer treatments and in the organ transplant field. In the latter application, the use of oxygenated cardioplegic solution (CS) during cardiac arrest is certainly beneficial, and fully oxygenated crystalloid solutions may be excellent means of myocardial protection, albeit for a limited time. Therefore, to overcome this drawback, oxygenated nanosponges (NSs) that can store and slowly release oxygen over a controlled period have been chosen as nanocarriers to enhance the functionality of cardioplegic solutions. Different components can be used to prepare nanocarrier formulations for saturated oxygen delivery, and these include native α-cyclodextrin (αCD), αcyclodextrin-based nanosponges (αCD-NSs), native cyclic nigerosyl-nigerose (CNN), and cyclic nigerosyl-nigerose-based nanosponges (CNN-NSs). Oxygen release kinetics varied depending on the nanocarrier used, demonstrating higher oxygen release after 24 h for NSs than the native αCD and CNN. CNN-NSs presented the highest oxygen concentration (8.57 mg/L) in the National Institutes of Health (NIH) CS recorded at 37 °C for 12 h. The NSs retained more oxygen at 1.30 g/L than 0.13 g/L. These nanocarriers have considerable versatility and the ability to store oxygen and prolong the amount of time that the heart remains in hypothermic CS. The physicochemical characterization presents a promising oxygen-carrier formulation that can prolong the release of oxygen at low temperatures. This can make the nanocarriers suitable for the storage of hearts during the explant and transport procedure. Full article

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The “one size fits all” approach may be “convenient” but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis. Full article

Monitoring regional blood flow distribution in the lungs appears to be useful for individually optimizing ventilation therapy. Electrical impedance tomography (EIT) can be used at the bedside for indicator-based regional lung perfusion measurement. Hypertonic saline is widely used as a contrast agent but could be problematic for clinical use due to potential side effects. In five ventilated healthy pigs, we investigated the suitability of five different injectable and clinically approved solutions as contrast agents for EIT-based lung perfusion measurement. Signal extraction success rate, signal strength, and image quality were analyzed after repeated 10 mL bolus injections during temporary apnea. The best results were obtained using NaCl 5.85% and sodium-bicarbonate 8.4% with optimal success rates (100%, each), the highest signal strengths (100 ± 25% and 64 ± 17%), and image qualities (r = 0.98 ± 0.02 and 0.95 ± 0.07). Iomeprol 400 mg/mL (non-ionic iodinated X-ray contrast medium) and Glucose 5% (non-ionic glucose solution) resulted in mostly well usable signals with above average success rates (87% and 89%), acceptable signal strength (32 ± 8% and 16 + 3%), and sufficient image qualities (r = 0.80 ± 0.19 and 0.72 ± 0.21). Isotonic balanced crystalloid solution failed due to a poor success rate (42%), low signal strength (10 ± 4%), and image quality (r = 0.43 ± 0.28). While Iomeprol might enable simultaneous EIT and X-ray measurements, glucose might help to avoid sodium and chloride overload. Further research should address optimal doses to balance reliability and potential side effects. Full article