Search Results (106)

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: In septic shock, microcirculatory dysfunction contributes to organ failure and mortality. While sidestream dark-field (SDF) imaging is the reference method for assessing microvascular perfusion, its complexity limits routine use. This study evaluates near-infrared spectroscopy (NIRS) with vascular occlusion testing (VOT) as a potential bedside tool for monitoring microcirculatory changes following fluid resuscitation. Methods: Sixty-three fluid-responsive patients with sepsis were randomized to receive either 20% albumin or crystalloid. NIRS-VOT and sublingual SDF measurements were obtained at baseline and 60 min post-resuscitation. The reoxygenation slope (ReOx) derived from NIRS was calculated and compared with clinical severity scores and SDF-derived microcirculatory parameters. Results: ReOx significantly increased from baseline to 60 min in the albumin group (p = 0.025), but not in the crystalloid group. However, between-group differences at 60 min were not statistically significant. ReOx at 60 min was inversely correlated with APACHE II score (ρ = −0.325) and lactate (ρ = −0.277) and showed a weak inverse trend with norepinephrine dose. AUROC for ICU survival based on ReOx was 0.616. NIRS ReOx showed weak correlations with SDF parameters, including the number of crossings (p = 0.03) and the consensus proportion of perfused vessels (CPPV; p = 0.004). Conclusions: NIRS-VOT detected microcirculatory trends after albumin administration but showed limited agreement with SDF imaging. These findings suggest that NIRS and SDF assess different physiological domains. Further studies are warranted to define the clinical utility of NIRS as a microcirculation monitoring tool (Clinicaltrials.gov: NCT05357339). Full article

Introduction: Managing glycemic fluctuations in critically ill elderly patients with type 2 diabetes mellitus (T2DM) poses significant challenges. This case report presents a unique scenario in which increased intravenous glucose (Glc) infusion, together with insulin therapy, improved glycemic control and reduced insulin requirements during a septic episode. This finding adds to the scientific literature by suggesting that adequate Glc administration may enhance insulin sensitivity in critically ill T2DM patients. Case report: An 84-year-old female patient with T2DM, hypertension, and chronic renal failure was admitted to the intensive care unit with fever, nausea, loss of appetite, and profound weakness. Laboratory findings revealed severe hyperglycemia, electrolyte imbalances, and markedly elevated inflammatory markers, leading to the diagnosis of decompensated T2DM that was complicated by sepsis. The initial treatment consisted of continuous intravenous (IV) insulin, crystalloid infusions, and broad-spectrum antibiotics. Despite insulin therapy and the absence of nutritional intake, the patient experienced extreme fluctuations in their blood glucose levels, ranging from hyperglycemia to hypoglycemia. Due to persistent glycemic instability, IV Glc infusion was initiated alongside continuous insulin therapy. Paradoxically, increasing Glc infusion administration rate led to a reduction in the required insulin doses and stabilization of blood glucose levels below 10 mmol·L⁻¹. The patient’s C-peptide levels were initially elevated but subsequently decreased following Glc administration as well, suggesting a reduction in endogenous insulin secretion and therefore higher insulin sensitivity. The patient’s clinical condition improved, allowing for the transition to a subcutaneous insulin regime and the initiation of oral feeding. She was later transferred to a general medical ward and discharged without further complications. Conclusions: This case highlights the complex interplay between Glc and insulin in critically ill elderly patients with T2DM during sepsis. The main takeaway is that carefully managed Glc infusion, in conjunction with flexible insulin therapy, can enhance insulin sensitivity and stabilize blood glucose levels without causing further hyperglycemia. Frequent glycemia monitoring and adaptable glycemic management strategies are essential in the ICU to address rapid glycemic fluctuations in this patient population. 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

Low-frequency oscillations of blood components have been observed when the plasma is diluted by crystalloid fluid. The present study explores whether oscillations also occur during the infusion of hyper-oncotic albumin 20%. For this purpose, the hemoglobin-derived plasma dilution, plasma colloid osmotic pressure, and plasma albumin concentration were measured on 15 occasions over 5 h in 72 volunteers. All of them received 3 mL/kg of albumin 20% over 30 min in various clinical settings. Quality checks excluded 35% of the concentration–time curves, leaving 137 for analysis. Fourier transforms applied to the residuals after curve-fitting showed that the dominating frequency was 144 ± 42 min (mean ± SD), corresponding to 0.007 Hz and a wave amplitude of 1.8 ± 0.9%. The highest percentile of the amplitudes corresponded to a “peak-to-peak” variation in the plasma volume by 6%, which corresponds to a fluctuation of 180 mL, or 45% of the maximum volume expansion following the infusion of albumin 20%. Differences between settings (volunteers, surgery, postoperative, and post-burn) were small. In conclusion, oscillations with very low frequency occurred after infusion of albumin 20%. They varied the plasma volume by 3.6% and by up to 6% in the percentile with the highest amplitudes. The oscillations are large enough to affect measurements of cardiovascular function. Full article

Volume kinetics is a pharmacokinetic method for analysis of the distribution and elimination of infusion fluids. The approach has primarily been used to improve the planning of fluid therapy during surgery but is also useful for answering physiological questions. The kinetics is based on 15–35 serial measurements of the blood hemoglobin concentration during and after the fluid is administered intravenously. Crystalloid fluid, such as isotonic saline and Ringer’s lactate, distributes between three compartments that are filled in succession depending on how much fluid is administered. The equilibration of fluid between these three compartments is governed by five rate constants. The compartments are the plasma (V_c), and a fast-exchange (V_t1) and a slow-exchange interstitial compartment (V_t2). The last compartment operates like an overflow reservoir and, if filled, markedly, prolongs the half-life of the fluid. By contrast, the volume of a colloid fluid distributes in a single compartment (V_c) from where the expansion is reduced by capillary leakage and urinary excretion. This review gives 15 examples of physiological or medical questions where volume kinetics has provided answers. These include why urine flow is low during general anesthesia, the inhibitory effects of anesthetics on lymphatic pumping, the influence of dopamine and phenylephrine on urine output, fluid maldistribution in pre-eclampsia, plasma volume oscillations, and issues related to the endothelial glycocalyx layer. Full article

Background/Objectives: Acute pancreatitis (AP) is an inflammatory condition with diverse origins, often resulting in significant morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiorgan failure. Fluid resuscitation is pivotal in early management, and it is aimed at preventing hypovolemia-induced ischemia and necrosis. This review evaluates fluid therapy strategies in AP, including fluid types, resuscitation rates, and clinical outcomes. Methods: This systematic review was conducted in January 2025 using databases such as PubMed, Medline, and Google Scholar, focusing on studies published between 2010 and 2024. Search terms included “acute pancreatitis”, “fluid resuscitation”, and related keywords. Studies involving adults with AP were analyzed to compare the outcomes of crystalloid and colloid use, aggressive vs. moderate fluid resuscitation, and administration timings. The primary outcomes were mortality and severe complications, while secondary outcomes included organ failure, SIRS, and length of hospital stay. Results: Crystalloids, particularly Ringer’s lactate (RL), are superior to normal saline in reducing SIRS, organ failure, and intensive care unit stays without significantly affecting mortality rates. Colloids were associated with adverse events such as renal impairment and coagulopathy, limiting their use. Aggressive fluid resuscitation increased the risk of fluid overload, respiratory failure, and acute kidney injury, particularly in severe AP, while moderate hydration protocols achieved comparable clinical outcomes with fewer complications. Conclusions: Moderate fluid resuscitation using RL is recommended for managing AP, balancing efficacy with safety. Further research is needed to establish optimal endpoints and protocols for fluid therapy, ensuring improved patient outcomes while minimizing complications. Full article

Objective: We sought to assess variations in pulse oximetry waveform amplitude (ΔP) and peak values (ΔS) separately during passive leg raising (PLR) and challenge plus maintenance crystalloid volume resuscitation over time in mechanically ventilated (MV) patients in shock. Methods: Variables were recorded and analayzed using previously described techniques. Findings were compared between the following: at baseline, during passive leg raising (PLR), with 0.9% normal saline administration (or removal), and applying tidal volume (Vt), peak, and mean airway pressure (Paw,peak and Paw,mean, respectively) and positive end-expiratory pressure (PEEP) as covariates in multifactorial logistic regression analysis. Results: Twenty patients with sepsis or septic shock were included in the analysis. Origins of sepsis varied. Their diagnoses upon admission to the intensive care unit included sepsis in nine (45%), septic shock (defined as the need for vasopressors) in nine (45%), and one (5%) rescuscitated from pulseless electrical activity following heroin overdose, all of whom were supported by volume control MV. Eleven patients required vasoactive drugs at the outset, of which seven were on norepinephrine. Three patients required surgical drainage or removal of necrotic tissue. Median ΔP and ΔS decreased, respectively, by 42% and 37% with PLR (p = 0.036 and p = 0.061, respectively). There were no significant changes in ΔP and ΔS between PLR and net fluid volume administered. Correction for body weight did not change these relationships. Application of Vt, Paw,peak, Paw,mean, and PEEP did not significantly influence these changes. Conclusions: Hemodynamic repsonse to slow fluid volume administration can be assessed by changes in the pulse oximetry waveform amplitude over time. The effects of mechanical ventilation are negligible. Full article

Background: Postoperative pulmonary complications (PPCs) are the most common complications following lung surgery and can lead to increased postoperative mortality. In this study, we examined the incidence of PPCs, the in-hospital mortality rate, and the risk factors associated with PPCs in patients undergoing open thoracotomy lung resection (OTLR) for reasons other than primary lung cancer. Methods: Data from this multicenter, retrospective study involving 1.368 patients were extracted from the German Thorax Registry and analyzed using univariate and multivariable statistical methods. Results: In total, 278 patients showed at least one PPC. The presence of PPCs was associated with a significantly higher in-hospital mortality rate (7.2% vs. 1.5%; p = 0.000). Multivariable stepwise logistic regression analysis showed absolute age (OR 1.02) and BMI ≤ 19 (OR 2.6) as independent patient-specific risk factors. Significant preoperative risk factors included re-thoracotomy (OR 4.0) and FEV₁ < 60% (OR 2.5). Procedure-related independent risk factors for PPCs included a surgical duration surpassing 195 min (OR 2.7), the continuation of invasive ventilation post-surgery (OR 3.8), and an intraoperative infusion of crystalloids greater than 6 mL/kg/h (OR 1.8). Conclusions: Optimizing intraoperative fluid therapy and on-table extubation when possible may reduce the incidence of PPCs and associated mortality. 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

Neonatal shock presents a complex clinical challenge and is one of the leading causes of mortality. Traditionally, neonatal shock is equated to hypotension, and therapeutics are often initiated based on low blood pressure (BP) values alone. This fails to address the underlying goal of optimizing the tissue perfusion resulting in both over- and under-treatment of neonatal shock. Also, what defines a normal BP in neonates is still a contentious topic. Further, the most appropriate way of measuring BP in neonates with shock is still debated. Shock secondary to transient circulatory instability and patent ductus arteriosus, conditions that are unique to preterm neonates, have not been researched adequately. Treatment of myocardial dysfunction secondary to perinatal asphyxia, a leading cause of neonatal mortality, is still a conundrum. Quite similarly, there are only a handful of controlled trials evaluating therapeutics in some of the other commonly encountered conditions, namely, septic shock and hypoperfusion secondary to pulmonary hypertension. Even the universally practiced intervention of volume expansion with crystalloid boluses in shock is not backed by high-certainty evidence in neonates. Though the diagnostic modalities of functional echocardiography and near-infrared spectroscopy have aided greatly in the management of neonatal shock in recent years, these have not been proven to be associated with improved critical clinical outcomes such as mortality and major brain injury. To conclude, neonatologists often rely on limited evidence, mostly anecdotal, when treating neonatal shock. This review critically examines the current evidence with respect to various aspects of neonatal shock with an objective to identify the lacunae in the literature that may fuel future research, eventually paving the way to efficacious, safe and evidence-based clinical practice. Full article

Background/Objectives: Previously, we showed that blood-based polarizing cardioplegia exerted beneficial cardioprotection during hypothermic ischemia; however, these positive effects of blood-based polarizing cardioplegia were reduced during normothermic ischemia compared to blood-based hyperkalemic (depolarizing) cardioplegia. This study compares crystalloid polarizing cardioplegia to crystalloid depolarizing cardioplegia in a normothermic porcine model of cardiopulmonary bypass; Methods: Twelve pigs were randomized to receive either normothermic polarizing (n = 7) or depolarizing (n = 5) crystalloid cardioplegia. After the initiation of cardiopulmonary bypass, normothermic arrest (34 °C, 60 min) was followed by 60 min of on-pump and 90 min of off-pump reperfusion. Myocardial injury (arterial CK-MB), hemodynamic function, and the energy status of the hearts were measured; Results: The arterial release of CK-MB was comparable between groups (p = 0.78) during reperfusion. During 150 min of reperfusion, systolic left ventricular pressure (p = 0.01) and coronary flow (p = 0.009) were increased, and wedge pressure (p = 0.04) was decreased in the polarized group. Further hemodynamic parameters (cardiac output, stroke volume) and high-energy phosphate levels were similar between groups. The requirement for noradrenaline administration during reperfusion was significantly higher (p = 0.013) in the polarized group; Conclusions: Under normothermic conditions and despite a similar increase in levels of cardiac CK-MB, crystalloid polarizing cardioplegia protected systolic and diastolic cardiac function after 60 min of cardiac arrest. These results suggest beneficial effects for polarizing cardioplegia; clinical studies are required to confirm these effects. 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

Background and Objective: The modified prone position, which is an alteration of the standard prone position, reduces cardiac preload. Dynamic variables including stroke volume variation (SVV), pulse pressure variation (PPV), and pleth variability index (PVI) are reliable predictors for fluid responsiveness during surgery. To the best of our knowledge, no studies assessing dynamic variables for fluid responsiveness have been conducted in the modified prone position. This study aimed to evaluate the ability of PVI to predict fluid responsiveness in the modified prone position during cervical spine surgery. Materials and Methods: PVI, SVV, and PPV were recorded at the following times: before and after a 4 mL/kg crystalloid load in the supine position (T1, T2); after placement in the modified prone position (T3); and before and after a 4 mL/kg crystalloid administration in the modified prone position (T4, T5). Fluid responsiveness was defined as stroke volume (SV) ≥ 15%, assessed by the FloTrac/Vigileo™ (Edwards Lifesciences Corp, Irvine, CA, USA). Receiver operating characteristic (ROC) curves were analyzed to identify changes in each dynamic variable that could predict fluid responsiveness in the modified prone position. Results: Data from a total of 43 subjects were analyzed. In the supine position, 21 subjects were responders. After subjects were placed in the modified prone position, SV significantly decreased, while PVI, SVV, and PPV significantly increased (p < 0.001 for all). In the modified prone position, 13 subjects were responders, and the areas under the ROC curves for ΔPVI, ΔSVV, and ΔPPV after fluid loading were 0.524 (95% confidence interval [CI] 0.329–0.730, p = 0.476), 0.749 (95% CI 0.566–0.931, p = 0.004), and 0.790 (95% CI 0.641–0.938, p < 0.001), respectively. Conclusions: Crystalloid pre-loading could not mitigate the decrease in SV caused by the modified prone position. Changes in PVI were less reliable in predicting fluid responsiveness in the modified prone position. Full article