Massive retroperitoneal haematoma because of renal cyst rupture, report of a case / Hematoma retroperitoneal masivo por ruptura de quiste renal, reporte de caso

We report the case of an 86-year-old adult man who, as a pedestrian, is hit by a motorcycle, suffering polytrauma; in initial care, he refers to thoraco-abdominal pain and subsequently neurological deterioration. Assessed by a neurosurgeon and general surgeon, a right chest tube is placed and a laparoscopy is performed where there is little bleeding from the abdominal cavity. It shows deterioration of its general state and dies in respiratory failure. During the necropsy procedure there is subarachnoid hemorrhage and cerebral herniation, rib fractures and pneumonic consolidation, a massive retroperitoneal hematoma is observed due to rupture of simple renal cyst.

Reportamos el caso de un hombre de 86 años que, siendo peatón, es atropellado por una motocicleta, sufriendo politraumatismo. En la atención inicial refiere a dolor toracoabdominal y posteriormente deterioro neurológico. Evaluado por un neurocirujano y un cirujano general, se coloca un tubo torácico derecho y se realiza una laparoscopia y observándose poco sangrado de la cavidad abdominal. El paciente muestra deterioro de su estado general y muere por insuficiencia respiratoria. Durante el procedimiento de necropsia se determina hemorragia subaracnoidea y hernia cerebral, fracturas costales y consolidación neumónica, se observa un hematoma retroperitoneal masivo por rotura de quiste renal simple.

Value of early fluid resuscitation endpoints in evaluating blood volume in patients with acute pancreatitis / 临床肝胆病杂志

ObjectiveTo investigate the value of early fluid resuscitation endpoints in evaluating blood volume in patients with acute pancreatitis. MethodsA retrospective analysis was performed for the clinical data of 445 previously untreated patients with acute pancreatitis who were admitted to The First Affiliated Hospital of Guangxi Medical University from 2003 to 2016 and had an onset time of less than 24 hours, and according the fluid resuscitation endpoints of mean arterial pressure (MAP), hematocrit (HCT), and blood urea nitrogen (BUN), the patients were divided into standard-reaching group (MAP ＞65 mm Hg, BUN ＜7.14 mmol/L, and HCT ≥0.35 and ≤044, n=219) and non-standard-reaching group (MAP ≤65 mm Hg or BUN ≥7.14 mmol/L or HCT ＞0.44 or ＜0.35, n=226). The standard-reaching group represented normal volume, while the non-standard-reaching group represented insufficient volume. The two groups were compared in terms of symptoms, signs, etiology, severity, complication, and prognosis. The chi-square test or the Fisher’s exact test was used for comparison of categorical data between two groups, and the Mann-Whitney U test was used for comparison of continuous data between two groups. ResultsCompared with the standard-reaching group, the non-standard-reaching group had significant increases in white blood cell count, BUN, and Computed Tomography Severity Index of the pancreas (Z=-2.85, -6.725, and -2.293, all P＜0.01). As for local complications, compared with the non-standard-reaching group, the standard-reaching group had significantly lower incidence rates of peripancreatic exudation (45.2% vs 54.9%, χ2=4.15, P＜0.05) and pancreatic necrosis (10.0% vs 186%, χ2=6.59, P＜0.05). As for systemic complications, compared with the non-standard-reaching group, the standard-reaching group had significantly lower incidence rates of acute respiratory distress syndrome (ARDS) (0.5% vs 4.4%, χ2=7.26, P＜0.05) and renal dysfunction (1.4% vs 6.6%, χ2=7.95, P＜0.05). The standard-reaching group had significantly lower proportion of patients with severe pancreatitis and hospital costs than the non-standard-reaching group (both P＜0.05). ConclusionFluid resuscitation endpoints can be used to evaluate the blood volume of patients with acute pancreatitis in the early stage after admission, and the patients not reaching the standard of fluid resuscitation tend to develop the complications such as peripancreatic exudation, pancreatic necrosis, ARDS, and renal dysfunction and may have higher hospital costs.

Preoperative “R wave amplitude variation” on electrocardiogram predicts severe hypovolemia

Preoperative fasting is essential to prevent aspiration and associated complications. However, quite often patients end up fasting for 12 h or more due to changes in the operating room schedules, delays, and postponements. Preoperative fasting may lead to a fluid deficit, which may contribute to perioperative discomfort and morbidity. We report a case of 44-year-old female posted for total mastectomy with axillary clearance for carcinoma breast, with prolonged fasting where preoperative R wave amplitude variation along with associated changes in the plethysmograph was noticed on the monitor. 500 milliliters of lactated ringer solution was administered before induction of anesthesia, by the time R wave amplitude variation decreased. Variations in plethysmography became normal after 1 L of fluid administration after induction of anesthesia. Gross R wave amplitude variation is not a very common finding and may predict severe hypovolemia in preoperative area in prolonged fasting patients.

Indicações e resultados para o uso expandido da oclusão ressuscitativa por balão endovascular da aorta - REBOA / Expanding indications and results for the use of resuscitative endovascular balloon occlusion of the aorta - REBOA

RESUMO A oclusão ressuscitativa por balão endovascular da aorta (REBOA) é utilizada para controlar hemorragias não compressíveis do tronco como uma opção menos invasiva e com menos distúrbios fisiológicos quando comparado à toracotomia de emergência com clampeamento da aorta. Isso permite a melhora dos parâmetros hemodinâmicos até que a cirurgia definitiva seja realizada. É utilizada no trauma como uma medida para prevenir o colapso hemodinâmico em pacientes que estão em choque hemorrágico grave, mantendo a perfusão do cérebro e do coração enquanto diminui o sangramento distal até que o controle da hemorragia possa ser realizado. As principais complicações relatadas são insuficiência renal aguda, amputações de membros inferiores e óbitos. O objetivo desse estudo foi avaliar a expansão do uso do REBOA em situações não traumáticas de outras áreas da medicina, assim como, avaliar os resultados obtidos até o momento. Uma pesquisa online do PubMed, Medline e SciELO foi realizada com o termo "REBOA" nos últimos cinco anos, e os artigos incluídos foram os 14 que descrevem especificamente o uso do REBOA para condições não traumáticas. Os resultados sugerem que o uso do REBOA levou a um melhor controle do sangramento e aumento da pressão arterial, reduzindo a necessidade de transfusão de sangue e permitindo que os pacientes sobrevivam ao tratamento definitivo das lesões. Concluindo, o uso expandido do REBOA para emergências não traumáticas parece ser eficaz, mas estudos prospectivos e protocolos bem estabelecidos devem ser desenvolvidos para maximizar os resultados.

ABSTRACT Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) is used in trauma surgery for controlling non-compressible torso hemorrhages, as a less invasive option and with fewer physiologic disturbances compared with an invasive emergent thoracotomy for aortic cross-clamping. This can allow improvements in hemodynamic parameters until definitive surgery is performed. REBOA is also used in trauma to prevent hemodynamic collapse in patients who are in severe hemorrhagic shock, as a method to maintain perfusion of the brain and heart while decreasing distal bleeding until hemorrhage control can take place. The major complications reported are acute kidney injury, lower leg amputations, and even death. As experience with REBOA in emergency surgery grows, new indications have been described in the literature. The aim of this study was to assess the expansion of the use of REBOA in other areas of medicine, as well as evaluating the current published series. We performed an online search of PubMed, Medline and SciELO with the term "REBOA" in the last five years, and the articles included were the 14 specifically describing the use of REBOA for non-traumatic conditions. The results suggest that the use of REBOA led to improved bleeding control and increased arterial pressure, reducing blood transfusion requirements and allowing patients to survive to definitive treatment of injuries. In conclusion, the expanded use of REBOA for non-traumatic emergencies appears to be effective. However, prospective studies and well-established protocols for specific indications should be developed to maximize patient outcomes.

Clip Ovesco® como tratamiento de rescate en lesión de Dieulafoy duodenal con sangrado activo / Ovesco clip as a rescue treatment of duodenal Dieulafoy lesion with active bleeding

Las lesiones de Dieulafoy se definen como una anomalía vascular que producen un sangrado en la mucosa proveniente de una arteria submucosa anormalmente larga y tortuosa que se ubican principalmente en estómago (80%), con poca frecuencia a nivel duodenal y constituyen el 6% de los sangrados gastrointestinales no asociados a varices y del 1% al 2% de todos los sangrados gastrointestinales. Reportamos el caso de un paciente masculino de 60 años que ingresó por hematemesis, melena y signos de hipovolemia con hemoglobina de 9 g/dl, que luego de realizar su compensación hemodinámica se le realizó una endoscopía alta que evidenció una lesión de Dieulafoy con sangrado activo severo en la segunda porción duodenal realizándosele inyección con adrenalina al 1:10 000 sobre los bordes de la lesión, pero al no lograrse una hemostasia adecuada se le tuvo que realizar la colocación de un clip ovesco con hemostasia efectiva que se corroboró 24 horas después, a través de una segunda endoscopía para poder egresar al paciente sin complicaciones, ni resangrado.

Dieulafoy's lesions are vascular anomalies that produce gastrointestinal bleeding of the mucosa from an abnormally long and tortuous submucosal artery. It is found predominately in the stomach (80%) and less frequently in the duodenum. They constitute the 6% of all non-variceal bleeding and the 1 to 2% of all gastrointestinal bleeding source. We report a case of a 60-year-old man with hematemesis, melena and signs of hypovolemic shock with a hemoglobin level of 9 g/dL. After adequate fluid resuscitation, an upper endoscopy showed an actively bleeding Dieulafoy lesion in the second portion of the duodenum. After epinephrine injection over lesion borders, an adequate hemostasis was not achieved. An over-the-scope clip was placed. Follow-up endoscopy 24 hours later showed an effective hemostasis and the patient was discharged without complications or re-bleeding.

Hipercloremia y mortalidad en la unidad de cuidados intensivos / Mortality and hyperchloremia in the intensive care unit

Abstract Introduction: Administrating intravenous fluids is one of the most frequent practices in the care of critically ill patients, since most of them present shock or hypotension from any cause. The rapid and aggressive administration of these fluids may lead to adverse results, including acute renal failure and hydroelectrolytic disorders which are highly associated with fatal outcomes. Objectives: To establish the association between hyperchloremia and mortality in patients admitted to the intensive care unit (ICU) of Hospital Universitario de San José between August 2013 and January 2017, in addition to their demographic characteristics, the incidence of chloride abnormalities, and its association to renal failure. Methods: Analytic retrospective cohort study in the adult ICU at the Hospital Universitario de San José from August 1, 2013 to January 31, 2017. Results: A total of 839 patients were evaluated, 210 exposed and 629 not exposed. The relative risk of death for those who developed hyperchloremia was 3.12 (95% confidence interval [CI] 2.16^.49) (P <0.001). The multivariate analysis generated an hazard ratio of 2.31 (95% CI 1.47-3.63) adjusted for age, sex, APACHE II at admission, sepsis, neurocritical state, and development of renal failure. Conclusion: Hyperchloremia is a frequent event in patients in the ICU; it may act as an independent variable for mortality in critical patients.

Resumen Introducción: La administración de líquidos endovenosos es de los actos que con mayor frecuencia se realizan en el cuidado de los pacientes críticamente enfermos, dado que gran parte de los mismos cursan con choque o hipotensión de cualquier causa, ésta se realiza de forma agresiva y rápida, dicha administración puede conllevar a eventos desfavorables como la falla renal aguda y alteraciones hidroelectrolíticas que están altamente relacionadas con desenlaces fatales. Objetivos: Establecer la asociación entre hipercloremia y mortalidad en los pacientes hospitalizados en cuidados intensivos del hospital Universitario de San José entre agosto de 2013 y enero de 2017, así como sus características demográficas, incidencia de anormalidades del cloro y su asociación con falla renal. Métodos: Estudio analítico de cohortes retrospectiva, en la Unidad de Cuidados intensivos (UCI) adultos del Hospital Universitario de San José, en el período comprendido entre el 1 de agosto de 2013 y el 31 de enero de 2017. Resultados: Fueron evaluados 839 pacientes, 210 expuestos y 629 no expuestos. El riesgo relativo para muerte en los que desarrollaron hipercloremia fue 3.12 (IC95% 2.16-4.49) (p <0.001). En el análisis multivariado se obtuvo un HR de 2.31 (IC95% 1.473.63) ajustado por las variables de edad, sexo, APACHE II al ingreso, sepsis, estado neurocrítico y desarrollo de falla renal. Conclusiones: La hipercloremia es un evento frecuente durante la atención de los pacientes en la unidad de cuidados intensivos; puede actuar como una variable independiente de mortalidad en los pacientes críticos.

Study on clinical assessment of volume status and correlation to the respiratory variation in inferior vena cava diameter by echocardiography, a non-invasive method of measuring volume status

Introduction: Giving more fluid causes edema and less gives rise to hypoperfusion causing improper delivery of oxygen and substrate leads to cellular dysfunction and multiorgan dysfunction involving the brain, liver, kidneys, heart, lungs and causing death. Diffusion, filtration, osmosis and adequate reabsorption help in continuous exchange of water and solutes among compartment. Daily water intake from the food and water get equalized with losses in the kidneys as urine, from the gastrointestinal system as feces and evaporation of water through lung and skin. Various hormones like Angiotensin II, Aldosterone ADH, Atrial natriuretic peptide maintain sodium and water balance and hence volume status. To maintain normovolemia there is every need for meticulous evaluation for patient Volume status in each patient for adequate volume replacement. Aim of the study: Correlating the Clinical Assessment of Volume Status to the volume assessment By Echocardiography using Respiratory Variation in Inferior Vena Cava Diameter. Gnanaprakasam J, Vasantha Kumar M, Praveenkumar M, Lakshmi Priya R. Study on clinical assessment of volume status and correlation to the respiratory variation in inferior vena cava diameter by echocardiography, a non-invasive method of measuring volume status. IAIM, 2018; 5(5): 104-110. Page 105 Materials and methods: Study population consisted of 200 patient of medicine department both inpatient and outpatient of Chengalpattu Medical college. The patient was examined clinically, history suggestive of volume depletion and history suggestive of volume overload were noted, signs and symptoms of both hypovolemia and hypervolemia were noted. Echocardiography was used as a noninvasive method of measuring volume status. Results: Correlation of assessment of volume status by the clinical method and IVC method as low, normal and high was represented. Correlation – 0.797, P value < 0.001 which tell that there was a statistically significant correlation between your two variables. That means, increases or decreases in IVC do significantly relate to increase or decrease. Conclusion: The use of echocardiography as a non-invasive mode of volume assessment is helpful to empower the clinical assessment methods and hence improves diagnostic accuracy.

Short-term effects of stored homologous red blood cell transfusion on cardiorespiratory function and inflammation: an experimental study in a hypovolemia model

The pathophysiological mechanisms associated with the effects of red blood cell (RBC) transfusion on cardiopulmonary function and inflammation are unclear. We developed an experimental model of homologous 14-days stored RBC transfusion in hypovolemic swine to evaluate the short-term effects of transfusion on cardiopulmonary system and inflammation. Sixteen healthy male anesthetized swine (68±3.3 kg) were submitted to controlled hemorrhage (25% of blood volume). Two units of non-filtered RBC from each animal were stored under blood bank conditions for 14 days. After 30 min of hypovolemia, the control group (n=8) received an infusion of lactated Ringer's solution (three times the removed volume). The transfusion group (n=8) received two units of homologous 14-days stored RBC and lactated Ringer's solution in a volume that was three times the difference between blood removed and blood transfusion infused. Both groups were followed up for 6 h after resuscitation with collection of hemodynamic and respiratory data. Cytokines and RNA expression were measured in plasma and lung tissue. Stored RBC transfusion significantly increased mixed oxygen venous saturation and arterial oxygen content. Transfusion was not associated with alterations on pulmonary function. Pulmonary concentrations of cytokines were not different between groups. Gene expression for lung cytokines demonstrated a 2-fold increase in mRNA level for inducible nitric oxide synthase and a 0.5-fold decrease in mRNA content for IL-21 in the transfused group. Thus, stored homologous RBC transfusion in a hypovolemia model improved cardiovascular parameters but did not induce significant effects on microcirculation, pulmonary inflammation and respiratory function up to 6 h after transfusion.

Epidemiological profile of maternal mortality / Perfil epidemiológico de mortalidad materna / Perfil epidemiológico de mortalidade materna

ABSTRACT Objective: To know the epidemiological profile of maternal mortality in Juiz de Fora, a city in the state of Minas Gerais. Data collection was carried out from April to December 2016. Method: Summary of a confidential investigation of maternal mortality on deaths occurred from January 1st, 2005 to December 31, 2015. Results: Eighty-five deaths of women residing in Juiz de Fora were identified and analyzed. The age group was between 20 and 36 years. The women carried out prenatal care (74.1%) with less than six visits (34.0%). Cesarean section was conducted in 38.8% of the childbirths and the obstetric treatment was considered appropriate (32.9%). The first cause of maternal death was hypovolemic shock 12 (14.10%), followed by uterine hypotony 6 (7.0%). Conclusion: Cesarean section rates are high and prenatal adherence is lower than that expected, which could justify the number of deaths in the period studied.

RESUMEN Objetivo: Conocer el perfil epidemiológico de la mortalidad materna en Juiz de Fora, Minas Gerais. Datos recolectados de abril a diciembre de 2016. Método: Resumen de la investigación confidencia de muerte materna, de óbitos ocurridos entre el 1 de enero de 2005 y el 31 de diciembre de 2015. Resultados: Fueron identificadas y analizadas las 85 muertes de mujeres residentes en Juiz de Fora. Su faja etaria correspondía al segmento de 20 a 36 años. Las mujeres hicieron consultas prenatales (74,1%) de menos de seis visitas (34,0%). Se realizó cesárea en 38,8% de los partos, y el tratamiento obstétrico fue considerado correcto (32,9%). La primera causa de muerte materna fue el shock hipovolémico, 12 (14,10%), seguido de hipotonía uterina, 6 (7,0%). Conclusión: La tasa de cesáreas es alta, y la adherencia prenatal es menor a la esperada, lo cual podría justificar el número de óbitos en el período estudiado.

RESUMO Objetivo: Conhecer o perfil epidemiológico da mortalidade materna em Juiz de Fora, Minas Gerais. A coleta de dados foi realizada de abril a dezembro de 2016. Método: Resumo da investigação confidencial de morte materna, de óbitos ocorridos entre 1º de janeiro de 2005 e 31 de dezembro de 2015. Resultados: Foram identificadas e analisadas as 85 mortes de mulheres residentes em Juiz de Fora. A faixa etária foi compreendida entre 20 e 36 anos. As mulheres tiveram pré-natal (74,1%), com menos de seis visitas (34,0%). A cesariana foi realizada em 38,8% dos partos, e o tratamento obstétrico foi considerado correto (32,9%). A primeira causa de morte materna foi o choque hipovolêmico 12 (14,10%), seguido de hipotonia uterina 6 (7,0%). Conclusão: A taxa de cesariana é alta e a aderência pré-natal é menor do que a esperada, o que poderia justificar o número de óbitos no período estudado.

Progresses of ultrasonography in assessing capacity status of acute severe patients / 中国医学影像技术

Circulatory instability is one of the most common acute emergency conditions,and rapid assessment of capacity status is the key to guide treatment.At present,measuring of central venous pressure (CVP) is a commonly used method,but it is an invasive operation which may bring some recent and long-term complications.Recently,as a noninvasive examination,ultrasound has been widely used in monitoring of hemodynamics,and emergency ultrasound assessment of patient's capacity status and directing fluid therapy has become popular.The application progresses of ultrasonography in assessment of capacity status in acute severe patients were reviewed in this paper.

Progress in management of low blood volume in heart failure / 中国医师进修杂志

Diuretic treatment is the most common clinical treatment of heart failure, but it is easy to overlook another opposite treatment, rehydration treatment. Early treatment is required for patients with heart failure, whether it is high-capacity intensive diuretic therapy or low-volume fluid replacement therapy. Heart failure patients with low blood volume are not uncommon in clinical work, but it is easy to neglect. In order to prevent excessive urination, accurately determining whether there is a low blood volume in patients with heart failure, is particularly important.

Ruptura traumática de la arteria vertebral por herida penetrante en el cuello / Traumatic rupture of the vertebral artery caused by penetrating neck injury

Introducción: la exanguinación es una entidad clínica dramática que requiere rapidez de pensamiento y acción para obtener buenos resultados.Presentación del caso: se reporta el caso de un paciente de 13 años que sufrió accidente automovilístico y fue atendido en el Hospital Pediátrico Eliseo Noel Camaño , de la provincia de Matanzas, Cuba. El niño llegó con múltiples traumas en miembros superiores e inferiores, y una herida penetrante en el cuello que requirió tratamiento quirúrgico inmediato para controlar hemorragia. Se necesitó un acceso multidisciplinario de intensivistas, anestesiólogos, cirujanos pediátricos, neurocirujanos y cirujanos vasculares, porque la cuantía del sangrado y la localización de la lesión hicieron sospechar una afección traumática de la arteria vertebral. El niño sobrevivió a la lesión exanguinante, y actualmente se encuentra en proceso de recuperación.Conclusiones: la lesión penetrante del cuello puede provocar ruptura traumática de la arteria vertebral, entidad infrecuente que requiere alta sospecha diagnóstica para lograr éxito en su tratamiento. Consideramos vital la visión multidisciplinaria, en la que deben prevalecer maniobras seguras, rápidas y eficientes(AU)

Introduction: exsanguination is a dramatic clinical condition that requires quick analysis and action to achieve good results.Case report: this is a 13 years/old patient who suffered a car accident and was seen at Eliseo Noel Camano pediatric hospital in Matanzas province, Cuba. The teenager had many upper and lower limb traumas and a penetrating neck injury that required immediate surgery to control hemorrhage. It was necessary to involve intensive care experts, anesthesiologists, pediatric surgeons, neurosurgeons, and vascular surgeons because the amount of bleeding and the location of injury aroused the suspicion of traumatic damage of the vertebral artery. The teenager managed to survive from the exsanguinating injury and is currently in his recovery process.Conclusions: the penetrating neck injury may cause traumatic rupture of the vertebral artery, an uncommon condition that requires great diagnostic suspicion in order to succeed in treatment. It is vital to have a multidisciplinary vision in which safe, rapid and effective procedures should prevail(AU)

Study of renal complications of malaria

Background: Plasmodium falciparum malaria is one of the major health problems in many tropical countries including India and due to increase in the drug resistance in India the incidence of complicated malaria has increased. Objectives: To study the renal complications of malaria. Materials and methods: 50 malaria positive cases with clinical renal disease were prospectively observed clinically and by laboratory investigations till the discharge. Results: Among the 50 malaria positive cases 41 (82 %) patients had p. falciparum infection, 4 (8%) had p. vivax and 5 (10%) had mixed infections. P. falciparum and mixed infection found to be responsible for ARF in 25 (89.28%), 3 (10.70%) respectively. Volume depletion was found to be the prominent cause (75%) of ARF, hyperbilirubinemia was noted in 64.28% of patients. Urinary abnormalities were noted in 24 (48%) cases, proteinuria in 20(40%), microscopic haematuria in 20 (40%), granular casts in 7 (14%). In the present study electrolyte abnormalities were noted in 46 (92%) of the patients. The overall mortality in the present study was 5 (10%). The cause of death was multi-factorial. MODS were the commonest cause of death. Conclusion: Renal complications were seen as the commonest complication of malaria. Early diagnosis, treatment specially the fluid management reduces the overall mortality

Diagnostic value of clinical laboratory indexes in judging the hypovolemia in patients with nephrotic syndrome / 中华肾脏病杂志

Objective To evaluate the diagnostic value of clinical laboratory indexes on judgment of hypovolemia in the patients with nephrotic syndrome (NS).Methods The blood volume of each 50 cases of healthy adult men and women was assessed with indocyanine green-pulse dye densitometry (ICG-PDD).The normal range of blood volume and the cut-off value of hypovolemia were determined.The blood volume of 81 patients with NS was also measured with ICG-PDD and then these patients were divided into the hypovolemic group (21 cases) and the non-hypovolemic group (60 cases) according to the cut-off value of hypovolemia.The test data of clinical laboratory indexes of the patients in the two groups were compared,and the indexes with statistic difference were screened out.Their diagnostic values on judgment of hypovolemia were evaluated by receiver operating characteristic (ROC) curve analysis,and finally the indexes with high judgment accuracy were selected.Results ①The cut-off values of hypovolemia are ＜ 52.9 ml/kg for the male and ＜ 52.5 ml/kg for the women,which were determined with ICG-PDD.②The five clinical laboratory indexes,including orthostatic heart rate (OHR) increase ＞ 10 bit per minute,fractional excretion of sodium (FENa) ＜ 1,transtubular potassium gradient (TTKG) ＞ 60％,blood urea nitrogen/serum creatinine ratio (BUN/Scr) ＞ 20,and urine specific gravity (SG) ＞ 1.020,were used to judge the hypovolemia in NS patients in this study.ROC curve analysis showed that the diagnostic accuracy in judgment of hypovolemia by one index or two indexes combination only belonged to medium level.However,the diagnostic accuracy in judgment of hypovolemia by the following three indexes combination,i.e.OHR increase+FeNa+BUN/Scr,FeNa+ BUN/Scr+SG,OHR increase+TFKG+BUN/Scr,or ORG increase+FeNa+TTTKG,reached high level.Conclusion This study obtained the cutoff value of Chinese adults hypovolemia are ＜ 52.9 ml/kg for the male and ＜ 52.5 ml/kg for the women,which are determined with ICG-PDD,through evaluation we recommend applying the above four specific combinations of three indexes for diagnosis of hypovolemia in NS patients.

Hemotórax / Hemothorax

El hemotórax es una patología que de no ser diagnosticada y tratada a tiempo amenaza la vida del paciente, "los traumas torácicos son el 25% de los tipos de trauma en los pacientes politraumatizados" (Greenfield, 2011).Por lo tanto, es de suma importancia realizar un adecuado examen físico primario y secundario, para así poder descartar lesiones que ameriten una actitud resolutiva de emergencia; asimismo, el diagnóstico es clínico y radiológico, siempre tomando en consideración la condición global del paciente. Lo anterior, para elegir el método más práctico, rápido y fidedigno para apoyar el diagnóstico clínico; el tratamiento con sello de tórax es el manejo de elección inicial, el cual dependiendo de la evolución clínica del paciente seguirá una serie de métodos para realizar la completa evacuación del mismo y evitar, en la medida de lo posible, las complicaciones. Además, es de gran interés realizar un tratamiento rápido y eficaz para evitar que el líquido se coagule, lo cual puede producir un empiema o fibrotórax. Por esta razón, todos los proveedores de la salud, en especial los médicos encargados de emergencias y los cirujanos deben tener en mente el probable desarrollo de un hemotórax en pacientes quienes sufran síntomas inexplicables de hipovolemia, específicamente en politraumatizados, por esto se debe conocer a profundidad las características de esta patología.

Hemothorax is a disease in which if not diagnosed and treated in time, threatens the patient's life. Thoracic traumas account for 25% of trauma in politraumatized patients (Greenfield, 2011), it is paramount to perform an adequate first and secondary physical examination, so we can rule out any problems that merit an emergency operative attitude. The diagnosis is clinical and radiological, taking always into consideration the overall condition of the patient, to choose the most convenient treatment, the fastest and most reliable method to support the clinical diagnosis. The chest tube is the initial choice method, depending on the clinical evolution of the patient a number of other methods can be perform in order to complete the evacuation of the collection and avoid as much as possible the complications; it is very important to make a fast and effective treatment to prevent the liquid from clotting, which can cause empyema or fibrothorax. All health providers and more the physicians in charge of the emergency department and the surgeons, should keep in mind the likely development of a hemothorax in patients suffering unexplained symptoms of hypovolemia in trauma cases, that is why is important to know in depth the characteristics of this disease.

Non-puerperal Uterine Inversion Presented with Hypovolemic Shock

We report a non-puerperal uterine inversion with nulliparous women caused by huge pedunculated submucosal fibroid. Massive bleeding from protruding mass through vagina brought the heart to stop in 42-year-old nulliparous woman. She became cardiopulmonary resuscitation survivor in emergency room and then underwent laparotomy which ended in successful myomectomy rather than hysterectomy considering her demand for future fertility. Meticulous and adequate fluid therapy and transfusion was also administered to recover from hypovolemic status. Pathologic report confirmed benign submucosal fibroid with degeneration, necrosis and abscess formation. Thus, clinician should be aware of uterine inversion when encountered with huge protruding vaginal mass and consider uterus-preserving management as surgical option when the future fertility is concerned.

Validação de um modelo experimental de transfusão de glóbulos vermelhos estocados homólogos em suínos e avaliação de seus efeitos cardiorrespiratórios e inflamatórios na hemorragia aguda / Validation of homologous stored red blood cell transfusion in swine and evaluation of cardiorespiratory and inflammatory effects in acute hemorrhage

Objetivos: Transfusão de sangue é fundamental para a sobrevida de pacientes selecionados, porém é associada a complicações. A literatura é controversa em relação aos efeitos pulmonares, hemodinâmicos e inflamatórios da transfusão de glóbulos vermelhos (GV). Este estudo teve dois objetivos principais: 1- validar um modelo de transfusão homologa de GV estocados em suínos com hipovolemia aguda por hemorragia controlada; 2- avaliar os efeitos agudos da transfusão de GV nas trocas gasosas, mecânica respiratória, hemodinâmica e na resposta inflamatória pulmonar e sistêmica. Métodos: Este estudo foi dividido em duas etapas: 1.Coleta, processamento e estocagem por 14 dias de GV provenientes de um suino Agroceres®, avaliado antes (in vitro) e após (in vivo - marcação com cromato de sódio radioativo) à sua transfusão em suínos sadios , um autólogo e quatro homologos (n=cinco); 2. Outro grupo de suínos foi submetido à hemorragia aguda controlada (25% de sua volemia) e então dividido em dois grupos: grupo transfusão (n= oito) recebeu duas unidades de GV e solução de ringer lactato (RL) para restabelecer a volemia; grupo controle (n=oito) que recebeu somente RL. Ambos os grupos foram seguidos até 6horas após o final da ressuscitação volêmica. Dados hemodinâmicos e respiratórios foram coletados a cada hora após o inicio do estudo. Mediadores inflamatórios e expressão de RNAmensageiro(RNAm) foram medidos no plasma e no tecido pulmonar. Resultados: Houve recuperação de 97,5%±19% dos GV marcados com cromato de sódio radioativo 24 horas após a transfusão. Houve aumento significativo da saturação venosa mista, conteúdo arterial de oxigênio e dos níveis de hemoglobina e hematócrito no grupo transfundido comparado ao controle. Os parâmetros medidos para a avaliação da microcirculação e as trocas gasosas foram similares em ambos os grupos. Observou-se um aumento significativo na energia gasta na histerese pulmonar no grupo controle quando comparado ao grupo transfundido (p=0,002),...

Objectives: Blood transfusion is critical to the survival of selected patients, but may be associated with complications. Previous data related to pulmonary, hemodynamic and inflammatory effects of red blood cells (RBC) are still controversial. This study has two main objectives: 1- Validate a homologous stored red blood cell transfusion model in swine with acute hypovolemia by controlled bleeding; 2- Assess the acute effects of RBC transfusion on gas exchange, respiratory mechanics and hemodynamics, pulmonary and systemic inflammatory response. Methods: This study was divided into two phases: 1. Collection, processing and storing RBC from Agroceres® swines for 14 days and evaluation before (in vitro) and after (in vivo - labelling with radioactive sodium chromate) transfusion in one autologous and four homologous healthy swines (n = five); 2. Controlled acute hemorrhage (25% of blood volume) of sixteen pigs and then allocation in two groups: transfusion group (n = eight) received two units of RBC and Lactaded Ringer's solution (RL) to restore blood volume; control group (n = eight) that received only LR. Both groups were followed up to 6 hours after the end of resuscitation. Hemodynamic and respiratory data were collected hourly after the start of the study. Inflammatory mediators and messenger RNA(mRNA) expression were measured in plasma and lung tissue. Results: The 24-hour recovery of RBC labeled with radioactive sodium chromate was 97.5% ± 19%. We found significant increase of mixed venous oxygen saturation, oxygen arterial content, and hemoglobin and hematocrit levels in the transfused group compared to control. There were no significant differences between the two groups in microcirculation and gas exchange. There was a significant increase in the energy spent in lung hysteresis in the control group compared to the transfused group (p=0,002), as well as a tendency to decrease inspiratory energy in the transfusion group. The...

Accuracy of stroke volume variation in monitoring changes in blood volume during laparoscopic surgery / 中华麻醉学杂志

Objective To evaluate the accuracy of stroke volume variation (SVV) in monitoring the changes in blood volume during laparoscopic surgery.Methods Forty ASA physical status Ⅰ or Ⅱ patients of both sexes,aged 40-64 yr,with body mass index ranged from 20 to 25 kg/m2,scheduled for elective laparoscopic surgery under general anesthesia,were studied.After induction of general anesthesia,baseline registrations of variables were obtained.After establishing pneumoperitoneum,6％ hydroxyethyl starch (HES 130/0.4) 500 ml was infused over 30 min.Before pneumoperitoneum (T1),at 5 min after pneumoperitoneum (T2),immediately before volume expansion (T3) and at 3 min after volume expansion (T4),cardiac output (CO),cardiac index (CI),SV,stroke volume index (SVI) and SVV were monitored and recorded.The changing rate of CI (△CI) was calculated.The criterion for effective volume expansion was △CI ≥ 15％.The ROC curve for SVV in determining the volume expansion responsiveness was plotted,and the diagnostic threshold was determined.The area under the curve and 95％ confidence interval were calculated.Results SVV was significantly lower at T2 than at T1.CO,CI,SV and SVI were significantly higher,and SVV was lower at T4 than at T3.The results of ROC curve analysis showed that a 9.2％ SVV threshold discriminated between responders and non-responders with a sensitivity of 61％ and a specificity of 50％,and the area under the curve (95％ confidence interval) was 0.567 (0.378-0.757).Conclusion SVV is not a suitable index in monitoring the changes in blood volume during laparoscopic surgery.

Ultrasonography of jugular vein in assessing hypovolemia in healthy blood donor / 中国医师进修杂志

Objective To assess volume state precisely and rapidly by ultrasonography of internal jugular vein (IJV) in healthy blood donor.Methods The values of the sonographic IJV collapse index and corrected IJV longitudinal length (cIJVLL) of 46 healthy blood donors were compared before and after blood donation.The correlations between IJV collapse index and cIJV LL were analyzed.Results The value of cIJV LLs before and after blood donation were significantly difference (6.56 ± 0.32 vs.6.11 ± 0.41,P ＜ 0.01).IJV collapse index before blood donation was not differently significant after blood donation (33.12 ± 2.21 vs.39.01 ± 3.83,P＞ 0.05).There was correlation between the value of cIJV LLs before and after blood donation (r =0.81).The value of IJV collapse index before and after blood donation,as well as cIJVLL was not well correlated (r =0.24,r =0.13,respectively).Conclusion The IJV collapse index is not a useful parameter for evaluation of hypovolemia,cIJV LL is more valuable marker for the detection of blood loss in emergency.