Per-operative fluid therapy, vasopressor and transfusion rate in DIEP-flap breast reconstruction. A series of cases / Fluidoterapia, uso de vasopresores y tasa transfusional peroperatoria en la reconstrucción mamaria con colgajo DIEP. Una serie de casos

OBJECTIVE: Anesthetic management in DIEP-flap breast reconstruction surgery may influence the appearance of postoperative complications. Fluid therapy, vasopressor use, and blood management are controversial. The aim was to audit hemodynamic management and to assess its impact on perioperative outcomes. MATERIAL AND METHODS: Sixty-seven cases of DIEP-flap breast reconstruction were reviewed. Data collected: anthropometric data; ASA score; comorbidities; timing of reconstruction (immediate/delayed), type of reconstruction (unilateral/bilateral); length of surgery; per-operative complications; per-operative fluid therapy, use of vasopressors, transfusion rate; re-intervention requirements; surgical success rate; hospital stay, and readmission rate. RESULTS: Median crystalloid infusion rate was 3.18 (2.63-3.76) ml/kg/h in the first 24 hours. Intraoperatively, colloids were administered in 35 (52%) patients at a median infusion rate of 1.40 (1.08-1.86) ml/Kg/h; 21 (60%) of them presented some postoperative complication. Hypotensive events were registered in 13 (19%) patients; 9 (69%) suffered some postoperative complication. The only vasopressor used was Ephedrine in 14 (21%) patients, at a median dose of 0 (0-6) mg. Red blood cell (RBC) transfusion was required in 18 (27%) patients. All of the patients who were transfused, 11 (61%) presented some postoperative complication. Hospital stay was 7 (7-9) days. Surgery was successful in 46 (69%) patients and readmission was necessary in 11 (16%) patients. CONCLUSIONS: Colloids administration, intraoperative hypotensive events, RBC transfusion, and delayed surgery are variables that could increase the risk of postoperative complications in our series.

OBJETIVO: El manejo anestésico en la cirugía de reconstrucción mamaria con colgajo DIEP podría influir en la aparición de complicaciones posoperatorias. La fluidoterapia, el uso de vasopresores y la tasa transfusional son motivo de controversia. Nuestro objetivo fue auditar el manejo hemodinámico y valorar su impacto en los resultados perioperatorios. MATERIAL Y MÉTODOS: Analizamos 67 pacientes programadas para reconstrucción mamaria con colgajo DIEP. Datos registrados: antropométricos; ASA; comorbilidades; momento de la reconstrucción (inmediata/diferida); tipo de reconstrucción (unilateral/bilateral); duración quirúrgica; complicaciones perioperatorias; fluidoterapia, vasopresores y tasa transfusional peroperatorios; tasa de reintervención, reingresos y éxito de la cirugía; estancia hospitalaria. RESULTADOS: La velocidad promedio de infusión de cristaloides fue de 3,18 (2,63-3,76) ml/kg/h en las primeras 24 h. Intraoperatoriamente se administraron coloides en 35 (52%) pacientes a una velocidad promedio de infusión de 1,40 (1,08-1,86) ml/kg/h, presentando complicaciones posoperatorias en 21 (60%) casos. Trece (19%) pacientes presentaron eventos hipotensivos intraoperatorios, registrándose complicaciones en 9 (69%). El único vasopresor utilizado fue la efedrina en 14 (21%) pacientes, a una dosis mediana de 0 (0-6) mg. Requirieron transfusión sanguínea 18 (27%) pacientes. Del total de pacientes transfundidos, 11 (61%) habían presentado alguna complicación posoperatoria. La cirugía fue un éxito en 46 (69%) casos. La estancia hospitalaria fue de 7 (7-9) días y el reingreso fue necesario en 11 (16%) casos. CONCLUSIONES: La administración de coloides, los eventos hipotensivos intraoperatorios, la transfusión de hemoderivados y la cirugía con reconstrucción tardía son variables que podrían incrementar el riesgo de complicaciones posoperatorias.

Des-resucitación en la sobrecarga de fluidos asociada a la lesión renal aguda / Des-resuscitation in the overload of fluids associated with acute kidney injury

Los resultados generales del tratamiento de la lesión renal aguda en los últimos años han mejorado casi de manera constante, aunque sin una comprensión completa de su fisiopatología. La respuesta a este interrogante radicaría en la comprensión del rol proactivo en lo que hace a la administración / remoción de los fluidos, abarcando todo el proceso de reanimación de los pacientes críticos, es decir no limitándose a la administración sino también al momento oportuno de la remoción de los mismos, buscando como principal objetivo mejorar la perfusión tisular. Se discute entre otros el papel clave que ejerce la integridad vascular en la sobrecarga de fluidos, haciendo hincapié en el papel del glicocálix endotelial. Las maniobras de des-resucitación activa con diuréticos o con terapias de soporte renal, podrían ser instrumentos cada vez más reconocidos en la aplicación de la sobrecarga de fluidos, en particular en aquellos pacientes con lesión renal aguda.

In the last few years the general results in the treatment of acute kidney injury has improved constantly, without a complete comprehension of its pathophysiology. With this paradigm in mind, in these last few years we have seen an evolving comprehension of the possible answers that may be based on recognizing the more proactive role of fluid management in the resuscitation of critical patients, not limited only to the delivery of fluids, but also to their active removal, having as the principal objective the improvement of tissue perfusion. The key role of vascular integrity in fluid overload is discussed, emphasizing the role of the endothelial glycocalyx. Active des-resuscitation maneuvers with diuretics or with renal support therapies could be increasingly recognized instruments in the management of fluid overload, particularly in those patients with acute kidney injury.

Urea incorporated into ordered mesoporous silica for potential cosmetic application

Urea's thermal instability and burning on sensitive skin can cause problems for cosmetic formulations. To overcome these drawbacks, urea was incorporated into ordered mesoporous silica (SBA-15). SBA-15 was synthesized using tetraethyl orthosilicate and Pluronic® P123 in an acid medium. Urea (20 wt.%) was incorporated into calcined SBA-15 by the incipient wetness impregnation method. Several techniques were used to characterize the samples. Skin hydration and transepidermal water loss were measured using Corneometer® CM 825 PC and Tewameter® 300 TM. Results showed that the structural properties of SBA-15Urea were similar to pure SBA-15, indicating that SBA-15 remained structured even after urea incorporation. Nitrogen physisorption data showed the volume and surface area of the pores in SBA-15Urea were much lower than those in SBA-15, demonstrating that urea was deposited inside the mesopores. In vivo moisturization studies revealed that SBA-15Urea was not able to reduce transepidermal water loss compared to the other products and control, while forming a non-occlusive surface film on the skin. We conclude that incorporation of urea in the pores of the inorganic SBA-15 matrix is a promising approach to enhancing its stability and providing a prolonged moisturizing effect.

A sobrecarga intravenosa de fluidos e sódio pode contribuir para a menor infusão de nutrição enteral em pacientes críticos / Intravenous overload of fluids and sodium may contribute to the lower infusion of enteral nutrition in critically ill patients

RESUMO Objetivo: Avaliar os efeitos da administração intravenosa de fluidos e sódio no primeiro dia de internação com a infusão de nutrição enteral em pacientes de terapia intensiva. Métodos: Estudo de coorte prospectivo realizado com pacientes críticos, não cirúrgicos, em ventilação mecânica internados pelo menos há 5 dias com nutrição enteral. Investigaram-se a quantidade de fluidos e sódio administrados por via venosa no primeiro dia e o volume de nutrição enteral infundido nos primeiros 5 dias. Comparou-se o volume de fluidos intravenosos do primeiro dia > 35mL/kg ou ≤ 35mL/kg de peso corporal e de sódio (acima ou abaixo do percentil 25), com o total de nutrição enteral infundida. Resultados: Estudaram-se 86 pacientes com média (± desvio padrão) de 65 ± 17 anos, sendo 54,7% do sexo feminino. Foram administrados, no primeiro dia, 3.393,7 ± 1.417,0mL de fluidos (48,2 ± 23,0mL/kg) e 12,2 ± 5,1g de sódio. Cinquenta e oito (67,4%) pacientes receberam mais de 35mL/kg de fluidos. Em 5 dias, foram ofertados 67 ± 19,8% (2.993,8 ± 1.324,4mL) da nutrição enteral. Os pacientes que receberam > 35mL/kg de fluidos intravenosos também receberam menos nutrição enteral em 5 dias (2.781,4 ± 1.337,9 versus 3.433,6 ± 1.202,2mL; p = 0,03) versus quem recebeu ≤ 35mL/kg. Pacientes com infusão de sódio intravenoso acima do percentil 25 (≥ 8,73g) no primeiro dia receberam menos volume de nutrição enteral em 5 dias (2.827,2 ± 1.398,0 versus 3.509,3 ± 911,9mL; p = 0,02). Conclusão: Os resultados deste estudo apoiam o pressuposto de que a administração de fluidos intravenosos no primeiro dia de internação > 35mL/kg e de sódio ≥ 8,73g pode contribuir para a menor infusão de nutrição enteral em pacientes críticos.

ABSTRACT Objective: To evaluate the effects of intravenous infusion of fluids and sodium on the first day of admission on infusion of enteral nutrition in the first 5 days in intensive care patients. Methods: A prospective cohort study was conducted with critical nonsurgical patients admitted for at least 5 days who were on mechanical ventilation and receiving enteral nutrition. The amount of intravenous fluids and sodium infused on the first day and the volume of enteral nutrition infused in the first 5 days were investigated. The volume of intravenous fluids > 35mL/kg or ≤ 35mL/kg of body weight and sodium (above or below the 25th percentile) infused on the first day was compared with infused enteral nutrition. Results: A total of 86 patients were studied, with a mean (± standard deviation) of 65 ± 17 years, of which 54.7% were female. On the first day, 3,393.7 ± 1,417.0mL of fluid (48.2 ± 23.0mL/kg) and 12.2 ± 5.1g of sodium were administered. Fifty-eight (67.4%) patients received more than 35mL/kg of fluids. In 5 days, 67 ± 19.8% (2,993.8 ± 1,324.4mL) of the prescribed enteral nutrition was received. Patients who received > 35mL/kg of intravenous fluids also received less enteral nutrition in 5 days (2,781.4 ± 1,337.9 versus 3,433.6 ± 1,202.2mL; p = 0.03) versus those who received ≤ 35mL/kg. Patients with intravenous sodium infusion above the 25th percentile (≥ 8.73g) on the first day received less enteral nutrition volume in 5 days (2,827.2 ± 1,398.0 versus 3,509.3 ± 911.9mL; p = 0.02). Conclusion: The results of this study support the assumption that the administration of intravenous fluids > 35mL/kg and sodium ≥ 8.73g on the first day of hospitalization may contribute to the lower infusion of enteral nutrition in critically ill patients.

Hiponatremia adquirida en el hospital: ¿influye el tipo de fluidoterapia en los niños ingresados a cuidados intensivos? / Hospital-acquired hyponatremia: Does the type of fluid therapy affect children admitted to intensive care?

Resumen: Introducción: Este estudio tuvo por objetivo valorar las diferencias entre el tipo de fluidoterapia ini cial utilizada (sueros isotónicos o hipotónicos) en el desarrollo de hiponatremia, valores de cloro y to lerancia de las vías venosas. Pacientes y Método: Estudio retrospectivo de cohortes en una Unidad de Cuidados Intensivos Pediátricos (UCIP) de un hospital terciario. Se incluyeron niños menores de 15 años ingresados durante el primer semestre de los años 2010 y 2013, que recibieron fluidoterapia in travenosa, excluyéndose los sometidos a cirugía cardiaca, trasplantados renales y aquellos con ingreso inferior a 24 h. Se recogieron datos epidemiológicos, de comorbilidad y relacionados con el ingreso, tipo de suero recibido, valores de sodio y cloro en las primeras 72 h y la incidencia de extravasaciones de vías periféricas. Resultados: Se incluyeron 111 niños: 68 (61,3%) recibieron líquidos hipotónicos y 43 (38,7%) isotónicos. No hubo diferencias respecto a la patología y gravedad, ni tampoco en el volumen de líquidos recibido. Entre los pacientes que recibieron sueros hipotónicos, 28 (41,2%) pre sentaron hiponatremia, siendo esta moderada (Na <130 mEq/kg) en 11 de ellos, en comparación con 8 niños (18,6%) entre los que recibieron sueros isotónicos, registrando hiponatremia moderada solo en un caso (p=0,027). No se registró ningún caso de hipernatremia, ni hubo diferencias en los valores de cloro plasmático. Tampoco se objetivó mayor frecuencia de pérdida del acceso venoso utilizando la fluidoterapia isotónica (4,7% vs. 7,4%, p=0,704). Conclusión: El uso de líquidos iniciales isotóni cos en niños hospitalizados en UCIP se asocia con menor incidencia y gravedad de hiponatremia, sin cambio en la cloremia y es bien tolerado por las vías venosas periféricas.

Abstract: Introduction: The objective of this study was to evaluate the association between the type of initial fluid therapy used (isotonic or hypotonic solutions) and the development of hyponatremia, the plas ma chlorine values and the tolerance of venous access. Patients and Method: Retrospective cohort study in a Pediatric Intensive Care Unit (PICU) of a high complexity hospital. There were included children younger than 15 years old hospitalized during the first semester of 2010 and 2013 who recei ved intravenous maintenance fluid therapy, excluding patients undergoing cardiac surgery, kidney transplant and admissions that lasted less than 24 hours. Epidemiological, comorbidity and admis sion-related data were collected, including type of solution received, sodium and chlorine values in the first 72 hours of hospitalization and the incidence of extravasation of peripheral intravenous lines. Results: 111 children were included; 68 children (61.3%) were treated with hypotonic solutions and 43 (38.7%) with isotonic solutions. There were no differences in pathology and severity, and also in the volume of fluid received. Among the patients who received hypotonic solutions, 28 (41.2%) de veloped hyponatremia, wich was moderate (Na <130 mEq/Kg) in 11 cases, compared with 8 children (18.6%) who received isotonic solutions, with only one case of moderate hyponatremia (p = 0.027). No cases of hypernatremia were recorded, and there were no differences in plasma chlorine values. There was also no increased frequency of venous access loss in patients treated with isotonic solutions (4.7% versus 7.4%, p = 0.704). Conclusion: Treatment with initial isotonic solutions in children hos pitalized in PICU is associated with a lower incidence and severity of hyponatremia, without changes in the plasma chlorine values and it is well tolerated by peripheral intravenous lines.

Stability and in vivo efficiency of natural cosmetic emulsion systems with the addition of vegetable oils

The aim of the paper is to test stability and biophysical properties of hydrophilic and lipophilic emulsions with selected vegetable seed oils: Limnanthes alba, Prunus amygdalus dulcis, Cannabis sativa, Rosa rubiginosa and Hellianthus annuus. Biophysical properties of emulsions are investigated in vivo using non-invasive instrumental methods (corneometry, tewametry and pH) in a group of 12 healthy women volunteers. Their stability profiles (colour, phase separation and centrifugation) under various temperatures (9, 25, 37 and 57 °C) and storage time (24 hours, 2, 7, 14, 21 and 28 days) were monitored. The moisturising activities of the emulsions supplemented with various oils were comparable. The lipophilic emulsions showed a better ability to improve the condition of the skin barrier due to formation of a surface lipid film. The tested formulations regulated the pH of the skin towards neutral values. Lipophilic emulsions showed earlier phase separation and changes in colour. The greatest resistance to thermal stress during storage was observed for the emulsion bases. Emulsions containing oils, except for those with rosehip and hempseed oils, were stable up to the temperature of 37 °C. The studied emulsion systems are excellent vehicles of vegetable oils and exhibit relatively good stability, benefiting the natural properties of skin.

Sobrecarga hídrica em crianças submetidas à ventilação mecânica / Fluid overload in children undergoing mechanical ventilation

RESUMO Os pacientes admitidos em uma unidade de terapia intensiva estão sujeitos à sobrecarga fluídica acumulada e recebem volume endovenoso pela ressuscitação agressiva, preconizada nas recomendações de tratamento do choque séptico, além de outras fontes de líquidos relacionadas às medicações e ao suporte nutricional. A estratégia liberal de oferta hídrica tem sido associada a maiores morbidade e mortalidade. Apesar de haver poucos estudos prospectivos pediátricos, novas estratégias estão sendo propostas. Esta revisão não sistemática discute a fisiopatologia da sobrecarga fluídica, suas consequências e as estratégias terapêuticas disponíveis. Durante a síndrome da resposta inflamatória sistêmica, o glicocálice endotelial é danificado, favorecendo o extravasamento fluídico, traduzido em edema intersticial. O extravasamento para o terceiro espaço se traduz em maior tempo de ventilação mecânica, maior necessidade de terapia de substituição renal e mais tempo de internação na unidade de terapia intensiva e no hospital, entre outros. A monitorização hemodinâmica adequada, bem como a infusão cautelosa de fluídos, pode minimizar estes danos. Uma vez instalada a sobrecarga fluídica acumulada, o tratamento com o uso crônico de diuréticos de alça pode levar a uma resistência ao uso destas medicações. A utilização precoce de vasopressores (norepinefrina) para melhora do débito cardíaco e perfusão renal, a associação de diuréticos e uso da aminofilina para indução de diurese, e a utilização de protocolos de sedação e mobilização precoce são algumas estratégias que podem reduzir morbimortalidade na unidade de terapia intensiva.

ABSTRACT Patients admitted to an intensive care unit are prone to cumulated fluid overload and receive intravenous volumes through the aggressive resuscitation recommended for septic shock treatment, as well as other fluid sources related to medications and nutritional support. The liberal liquid supply strategy has been associated with higher morbidity and mortality. Although there are few prospective pediatric studies, new strategies are being proposed. This non-systematic review discusses the pathophysiology of fluid overload, its consequences, and the available therapeutic strategies. During systemic inflammatory response syndrome, the endothelial glycocalyx is damaged, favoring fluid extravasation and resulting in interstitial edema. Extravasation to the third space results in longer mechanical ventilation, a greater need for renal replacement therapy, and longer intensive care unit and hospital stays, among other changes. Proper hemodynamic monitoring, as well as cautious infusion of fluids, can minimize these damages. Once cumulative fluid overload is established, treatment with long-term use of loop diuretics may lead to resistance to these medications. Strategies that can reduce intensive care unit morbidity and mortality include the early use of vasopressors (norepinephrine) to improve cardiac output and renal perfusion, the use of a combination of diuretics and aminophylline to induce diuresis, and the use of sedation and early mobilization protocols.

Balance de líquidos y lesión renal aguda en el choque séptico / Fluid balance and acute kidney injury in septic shock

Resumen: Introducción: En el paciente con choque séptico, la administración excesiva de líquidos puede incrementar la morbilidad y mortalidad. El objetivo de este estudio fue evaluar la asociación entre el balance de líquidos, la lesión renal aguda y la mortalidad en pacientes con choque séptico. Métodos: Se realizó un estudio de casos y controles en una unidad de terapia intensiva pediátrica. Se comparó el balance de líquidos en las primeras 72 h y la presencia de lesión renal aguda en pacientes con diagnóstico de choque séptico que fallecieron contra pacientes que sobrevivieron a la misma patología. Se realizó un análisis univariado y multivariado. Resultados: Se incluyeron 45 casos y 45 controles en el análisis. La mortalidad se asoció con riesgo pediátrico de mortalidad (PRISM) ≥ 26 puntos (RM 7.5, IC 95% 2.8-18.7; p = 0.000), disfunción orgánica logística pediátrica (PELOD) ≥ 24 puntos (RM 11.0, IC 95% 4.1-29.4; p = 0.000), creatinina ≥ 0.65 mg/dl (RM 5.6, IC 95% 2.2-13.9; p = 0.000), lactato ≥ 2.5 mmol/l (RM 2.5, IC 95% 1.1-5.9; p = 0.033), SvO2 < 60% (RM 4.6, IC 95% 4.5-4.5; p = 0.001), balance positivo > 9% en 72 h (RM 4.3, IC 95% 1.6-11.7; p = 0.003), lesión renal aguda (RM 5.7, IC 95% 2.2-15.1; p = 0.000). En el modelo multivariado, PRISM ≥ 26 y PELOD ≥ 24 puntos permanecieron significativas. Conclusiones: En los pacientes que fallecieron por choque séptico, el modelo multivariado mostró una asociación con PRISM ≥26 y PELOD ≥24 y una tendencia hacia la asociación con SvO2 <60% y balance de líquidos positivo >9%.

Abstract: Background: In patients with septic shock, excessive fluid administration can lead to increased morbidity and mortality. The aim of this study was to evaluate the association between fluid balance, acute kidney injury and mortality in patients with septic shock. Methods: A study of cases and controls was conducted in a Pediatric Intensive Care Unit. The fluid balance in the first 72 h and the presence of acute kidney injury was compared in patients diagnosed with septic shock who died against patients who survived the same condition. Univariate and multivariate analyses were performed. Results: Forty-five cases and forty-five controls were included in the analysis. Mortality was associated with Pediatric Risk of Mortality (PRISM III) ≥ 26 points (OR 7.5, 95% CI 2.8-18.7; p = 0.000), Pediatric Logistic Organ Dysfunction (PELOD) ≥ 24 points (OR 11.0, 95% CI 4.1-29.4; p = 0.000), creatinine ≥ 0.65 mg/dl (OR 5.6, 95% CI 2.2-13.9; p = 0.000), lactate ≥ 2.5 mmol/l (OR 2.5, 95% CI 1.1-5.9; p = 0.033), SvO2 < 60% (OR 4.6, 95% CI 4.5-4.5; p = 0.001), positive balance > 9% in 72 h (OR 4.3, 95% CI 1.6-11.7; p = 0.003), acute kidney injury (OR 5.7, 95% CI: 2.2-15.1; p = 0.000). In the multivariate model, the values of PRISM ≥26 and PELOD ≥24 points were significant. Conclusions: In patients who died due to septic shock, the multivariate model showed an association with PRISM ≥26 and PELOD ≥24 and a trend toward association with SvO2 <60% and positive balance of liquids > 9%.

Sobrecarga hídrica y falla renal en niños con sepsis grave y shock séptico: un estudio de cohortes / Fluid overload and kidney failure in children with severe sepsis and septic shock: A cohort study

Introducción. En niños con sepsis, la sobrecarga hidrica como resultado de una terapia de resucitación agresiva o por la administración excesiva de fluidos puede afectar la función renal y aumentar la mortalidad. Objetivo. Determinar la asociación entre la sobrecarga hidrica y la tasa de falla renal en un grupo de niños con sepsis grave y shock séptico. Población y métodos. Estudio de cohortes prospectivo realizado en la Unidad de Cuidados Intensivos del Hospital Universitario de Pediatría "Dr. Agustín Zubillaga" (Barquisimeto, Estado Lara, Venezuela), entre marzo de 2013 y mayo de 2016, en niños con sepsis grave o shock séptico. Resultados. Un total de 149 niños fueron incluidos en el análisis. La sepsis predominó en el 59,7% de los casos; el promedio de edad fue 6,4 ± 3,3 años; el peso promedio fue 17,8 ± 3,6 kg; en el 30,2%, hubo sobrecarga hidrica y la mortalidad general fue 25,5%. Hubo falla renal en el 16,1% de los casos. Mediante un modelo de regresión logística binaria, se identificaron como predictores independientes de falla renal sobrecarga hidrica (OR 1,5; IC 95%: 1,2-4,9; p= 0,028) y shock mayor de dos días (OR 1,7; IC 95%: 1,3-6,3; p= 0,039). Además, se observó un incremento significativo del riesgo de mortalidad en los niños con falla renal y sobrecarga hidrica, según el método de Kaplan-Meier (p= 0,019). Conclusión. La sobrecarga hidrica y una duración del shock mayor de dos dias incrementan el riesgo de falla renal en niños criticamente enfermos con sepsis grave y shock séptico.

Introduction. In children with sepsis, fluid overload as a result of an aggressive fluid replacement or excessive fluid administration may result in kidney impairment and increased mortality.Objective. To determine the association between fluid overload and the rate of kidney failure in a group of children with severe sepsis and septicshock. Population and methods. This was a prospective cohort study conducted in the intensive care unit of Hospital Universitario de Pediatría Dr. Agustín Zubillaga (Barquisimeto, Lara State, Venezuela), between March 2013 and May 2016, in children with severe sepsis or septic shock.Results. One hundred and forty-nine patients were included in the analysis. Sepsis predominated in 59.7% of cases; patients' average age was 6.4 ± 3.3 years old, their average weight was 17.8 ± 3.6 kg, 30.2% had fluid overload, and overall mortality was 25.5%. Kidney failure occurred in 16.1% of cases. A binary logistic regression model was used to identify fluid overload (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.2-4.9, p = 0.028) and shock for more than 2 days (OR: 1.7; 95% CI: 1.3-6.3, p = 0.039) as independent predictors of kidney failure. In addition, a significant increase in the risk of mortality among children with kidney failure and fluid overload was observed as per the Kaplan-Meier method (p= 0.019). Conclusion. Fluid overload and shock for more than 2 days increase the risk for kidney failure in critically ill children with severe sepsis and septic shock.

Cristaloides balanceados para ressuscitação do choque séptico / Balanced crystalloids for septic shock resuscitation

RESUMO A administração de fluidos em tempo adequado é crucial para a manutenção da perfusão tissular nos pacientes com choque séptico. Entretanto, a questão da escolha do fluido a ser utilizado para ressuscitação no choque séptico ainda é um assunto em debate. É crescente o corpo de evidência que sugere que o tipo, a quantidade e o momento da administração de fluidos durante a evolução da sepse podem afetar os desfechos do paciente. Os cristaloides têm sido recomendados como fluidos a serem administrados em primeira linha na ressuscitação do choque. No entanto, à luz da natureza inconclusiva da literatura disponível, não se podem fazer recomendações definitivas quanto à solução cristaloide mais apropriada. A ressuscitação de pacientes críticos sépticos e não sépticos com cristaloides não balanceados, principalmente a solução salina a 0,9%, tem sido associada a uma maior incidência de desordens do equilíbrio ácido-base e a distúrbios eletrolíticos, além de poder se associar à maior incidência de lesão renal aguda, à maior necessidade de terapia de substituição renal e à mortalidade. Foi proposto o uso de soluções cristaloides balanceadas como uma alternativa às soluções de cristaloides não balanceados, para mitigar seus efeitos deletérios. Entretanto, a segurança e a eficácia dos cristaloides balanceados para ressuscitação do choque séptico necessitam ser mais bem exploradas em estudos clínicos bem delineados, randomizados e controlados, multicêntricos e pragmáticos.

ABSTRACT Timely fluid administration is crucial to maintain tissue perfusion in septic shock patients. However, the question concerning which fluid should be used for septic shock resuscitation remains a matter of debate. A growing body of evidence suggests that the type, amount and timing of fluid administration during the course of sepsis may affect patient outcomes. Crystalloids have been recommended as the first-line fluids for septic shock resuscitation. Nevertheless, given the inconclusive nature of the available literature, no definitive recommendations about the most appropriate crystalloid solution can be made. Resuscitation of septic and non-septic critically ill patients with unbalanced crystalloids, mainly 0.9% saline, has been associated with a higher incidence of acid-base balance and electrolyte disorders and might be associated with a higher incidence of acute kidney injury. This can result in greater demand for renal replacement therapy and increased mortality. Balanced crystalloids have been proposed as an alternative to unbalanced solutions in order to mitigate their detrimental effects. Nevertheless, the safety and effectiveness of balanced crystalloids for septic shock resuscitation need to be further addressed in a well-designed, multicenter, pragmatic, randomized controlled trial.

The effect of NaCl 0.9% and NaCl 0.45% on sodium, chloride, and acid-base balance in a PICU population / Efeito do NaCl a 0,9% e do NaCl a 0,45% sobre o sódio, cloreto e equilíbrio ácido-base em uma população de UTIP

ABSTRACT OBJECTIVES: To study the effect of two intravenous maintenance fluids on plasma sodium (Na), and acid-base balance in pediatric intensive care patients during the first 24 h of hospitalization. METHODS: A prospective randomized controlled study was performed, which allocated 233 patients to groups: (A) NaCl 0.9% or (B) NaCl 0.45%. Patients were aged 1 day to 18 years, had normal electrolyte concentrations, and suffered an acute insult (medical/surgical). Main outcome measured: change in plasma sodium. Parametric tests: t-tests, ANOVA, X 2 statistical significance level was set at a = 0.05. RESULTS: Group A (n = 130): serum Na increased by 2.91 (±3.9) mmol/L at 24 h (p < 0.01); 2% patients had Na higher than 150 mmol/L. Mean urinary Na: 106.6 (±56.8) mmol/L. No change in pH at 0 and 24 h. Group B (n = 103): serum Na did not display statistically significant changes. Fifteen percent of the patients had Na < 135 mmol/L at 24 h. The two fluids had different effects on respiratory and post-operative situations. CONCLUSIONS: The use of saline 0.9% was associated with a lower incidence of electrolyte disturbances.

RESUMO OBJETIVO: Estudar o efeito de dois fluidos de manutenção intravenosos sobre o sódio (Na) plasmático e o equilíbrio ácido-base em pacientes de terapia intensiva pediátrica durante as primeiras 24 horas de internação. MÉTODOS: Foi feito um estudo controlado randomizado prospectivo. Alocamos aleatoriamente 233 pacientes para os grupos: (A) NaCl a 0,9% e (B) NaCl a 0,45%. Os pacientes com um dia a 18 anos apresentavam concentrações normais de eletrólitos e sofriam de insulto agudo (médico/cirúrgico). Principal resultado: variação no sódio plasmático. Testes paramétricos: teste t, Anova, qui-quadrado. O nível de relevância estatística foi estabelecido em a = 0,05. RESULTADOS: Grupo A (n = 130): o Na sérico aumentou 2,91 (± 3,9) mmol L-1 em 24 h (p < 0,01); 2% dos pacientes apresentaram Na acima de 150 mmol L-1. Concentração média de Na na urina: 106,6 (± 56,8) mmol L-1. Sem alteração no pH em 0 e 24 horas. Grupo B (n = 103): o Na sérico não apresentou alterações estatisticamente significativas; 15% dos pacientes apresentaram Na < 135 mmol L-1 em 24 h. Os dois fluidos tiveram efeitos diferentes sobre as situações respiratória e pós-operatória. CONCLUSÃO: O uso de solução fisiológica a 0,9% foi associado à menor incidência de distúrbios eletrolíticos.

Fluid therapy for septic shock resuscitation: which fluid should be used? / Fluidoterapia para a ressuscitação no choque séptico: qual tipo de fluido deve ser utilizado?

Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may be necessary to achieve those hemodynamic goals. Nonetheless, even though fluid administration is one of the most common interventions offered to critically ill patients, the most appropriate type of fluid to be used remains controversial. According to recently published clinical trials, crystalloid solutions seem to be the most appropriate type of fluids for initial resuscitation of septic shock patients. Balanced crystalloids have theoretical advantages over the classic solutions, but there is not enough evidence to indicate it as first-line treatment. Additionally, when large amounts of fluids are necessary to restore the hemodynamic stability, albumin solutions may be a safe and effective alternative. Hydroxyethyl starches solutions must be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy and increased mortality. Our objective was to present a narrative review of the literature regarding the major types of fluids and their main drawbacks in the initial resuscitation of the septic shock patients.

A ressuscitação precoce de pacientes com choque séptico tem o potencial de reduzir sua morbidade e mortalidade. Os objetivos principais da ressuscitação no choque séptico incluem expansão volêmica, manutenção da perfusão tecidual e da oferta de oxigênio para os tecidos, guiados pela pressão venosa central, pressão arterial média, saturação venosa mista ou central de oxigênio e lactato arterial. Uma ressuscitação agressiva com fluidos, possivelmente em associação com vasopressores, inotrópicos e transfusão de concentrado de hemácias, pode ser necessária para atingir estes objetivos hemodinâmicos. Todavia, embora a administração de fluidos seja uma das intervenções mais comumente realizada em pacientes graves, o tipo de fluido mais apropriado para ser utilizado permanece controverso e incerto. De acordo com os estudos clínicos mais recentes, os cristaloides são os fluidos de escolha para serem utilizados na ressuscitação inicial de pacientes com choque séptico. As soluções cristaloides balanceadas possuem vantagens teóricas em relação as não balanceadas, porém ainda não há evidências suficientes para indicá-las como tratamento de primeira escolha. Além disso, albumina humana parece ser uma alternativa segura e efetiva quando grandes quantidades de fluidos são necessárias para o restabelecimento da estabilidade hemodinâmica. O uso de soluções de hidroxetilamido deve ser evitado em pacientes sépticos, devido ao maior risco de desenvolvimento de insuficiência renal aguda, necessidade de terapia de substituição renal e aumento de mortalidade. O objetivo deste estudo foi apresentar uma revisão narrativa da literatura sobre os principais tipos de fluidos e os problemas mais importantes na ressuscitação inicial de pacientes com choque séptico.

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions / Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões / Coloides versus cristaloides en fluidoterapia guiada por objetivos, revisión sistemática y metaanálisis. Demasiado pronto o demasiado tarde para obtener conclusiones

Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.

Foram feitos múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), muitos deles com o uso de coloides para aprimoramento da pré-carga. Após a decisão da Agência Europeia de Medicamentos, existe ainda controvérsia sobre seu uso, seus benefícios e sua possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas.

Se han realizado múltiples ensayos clínicos en fluidoterapia guiada por objetivos (FGO), muchos de ellos con el uso de coloides para la optimización de la precarga. Tras la decisión de la Agencia Europea del Medicamento, existe cierta controversia en cuanto a su utilización, beneficios y su posible contribución al fallo renal. El objetivo de esta revisión sistemática y metaanálisis es comparar el uso de coloides de última generación, derivados del maíz, con cristaloides en FGO para determinar las complicaciones y la mortalidad asociadas.

Solução salina isotônica como fluidoterapia de manutenção intravenosa para prevenir hiponatremia adquirida em crianças hospitalizadas / Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children

OBJETIVOS: Avaliar se o uso de soluções salinas hipotônicas como fluidoterapia de manutenção em crianças hospitalizadas aumenta o risco de hiponatremia, se a administração de fluidos isotônicos é capaz de proteger contra a hiponatremia adquirida e se as soluções isotônicas aumentam os riscos de efeitos deletérios como hipernatremia ou sobrecarga hídrica. FONTES DOS DADOS: Realizou-se uma pesquisa bibliográfica nas bases de dados PubMed (01/01/1969 a 13/07/2011), Embase (1989 a 2011) e Cochrane Library (1989 a 2011). Adicionalmente, referências foram incluídas dos estudos selecionados. SÍNTESE DOS DADOS: Crianças hospitalizadas têm riscos potenciais para hiponatremia, e o uso de soluções salinas hipotônicas é o principal fator de risco para esse agravo. As soluções salinas isotônicas têm mostrado efeito protetor para hiponatremia e, até o momento, sem efeitos deletérios significativos, como sobrecarga hídrica, hipernatremia ou flebites. CONCLUSÕES: As evidências indicam que a tradicional recomendação de Holliday & Segar quanto à fluidoterapia de manutenção para crianças doentes e hospitalizadas merece ser reconsiderada em virtude das evidências sobre os efeitos adversos dela advindos, assim como dos melhores resultados obtidos com o emprego das soluções isotônicas.

OBJECTIVES: This review aims to evaluate if the use of hypotonic saline solutions as maintenance intravenous fluid therapy in hospitalized children increases the risk of hyponatremia, if the administration of isotonic fluids is able to protect against acquired hyponatremia and if the isotonic solutions increase the risks of deleterious effects such as hypernatremia or fluid overload. SOURCES: We researched the relevant literature on the PubMed (Jan 01 1969 to Jul 13 2011), EMBASE (1989 to 2011) and Cochrane Library (1989 to 2011) databases. Furthermore, references of selected studies were included. SUMMARY OF THE FINDINGS: Hospitalized children are potentially at risk of developing hyponatremia and the use of hypotonic saline solutions is the main risk factor for this disease. Isotonic saline solutions have shown a protective effect against hyponatremia, and, so far, there have been no significant deleterious effects such as fluid overload, hypernatremia or phlebitis. CONCLUSIONS: The evidence found indicates that the traditional recommendation of Holliday and Segar to use maintenance fluid therapy for sick and hospitalized children deserves to be reconsidered due to the adverse effects found to arise from it, apart from the better results obtained by using isotonic solutions.

¿Es necesario hidratar artificialmente a los pacientes terminales? / Should we hydrate terminally ill patients?

Terminally ill patients frequently have difficulties with fluid and food intake. The indication of artificial hydration in these patients has been subject of intense debate in the past years and the clinical practice widely varies, mostly based on anecdotal data and not on clinical evidence about risks and benefits associated to artificial hydration in terminal patients. There are not only technical questions concerning benefits and risks associated to artificial hydration, but also questions related to the ethical principles and values involved. Several topics, such as the effect of artificial hydration alleviating symptoms or reversing neurological alterations as delirium, its life prolonging effect or if it promotes unnecessary suffering, are discussed. In this review we will analyze clinical benefits and risks associated to artificial hydration in terminal patients, making reference to some ethical principles involved.

Hyponatremia and hypernatremia: disorders of water balance.

Total body water and tonicity is tightly regulated by renal action of antidiuretic hormone (ADH), reninangiotensin-aldosterone system, norepinephrine and by the thirst mechanism. Abnormalities in water balance are manifested as sodium disturbances--hyponatremia and hypernatremia. Hyponatremia ([Na+ < 136 meq/ l]) is a common abnormality in hospitalized patients and is associated with increased morbidity and mortality. A common cause of hyponatremia is impaired renal water excretion either due to low extracellular fluid volume or inappropriate secretion of ADH. Clinical assessment of total body water and urine studies help in determining cause and guiding treatment of hyponatremia. Acute and severe hyponatremia cause neurological symptoms necessitating rapid correction with hypertonic saline. Careful administration and monitoring of serum [Na+] is required to avoid overcorrection and complication of osmotic demyelination. Vasopressin receptor antagonists are being evaluated in management of euvolemic and hypervolemic hyponatremia. Hypematremia ([Na+] > 145 meq/l) is caused by primary water deficit (with or without Na+ loss) and commonly occurs from inadequate access to water or impaired thirst mechanism. Assessment of the clinical circumstances and urine studies help determine the etiology, while management of hypernatremia involves fluid resuscitation and avoiding neurological complications from hypernatremia or its correction. Frequent monitoring of [Na+] is of paramount importance in the treatment of sodium disorders that overcomes the limitations of prediction equations.

Deshidratación hipernatremica en recién nacido por sales de rehidratación oral reporte de un caso / Hypernatremic deshydration in newborn by salts of oral rehydration: a case report

La deshidratación hipernatremica se define como una concentración sérica de sodio mayor de 150 mEq/L, representa el 20 por ciento de las deshidrataciones y refleja un déficit de agua extracelular con relación al contenido corporal de sodio con edema cerebral, hemorragia intracraneal, hidrocefalia y gangrena. Los factores de riesgo para deshidratación hipernatrémica son: niños menores de un año por inmadures renal y aumento del líquido extracelular, fiebre que aumenta la pérdida de agua libre y, fundamentalmente el ingreso incrementado de solutos con relación al contenido de agua libre, producto de la reshidratación oral con soluciones con alto contenido de sodio, formulas mal preparadas o alimentación al pecho exclusiva en madres con una aporte insuficiente de líquidos. Se trata de recién nacido de 13 días de vida quien presenta clínica de deshidratación y acidosis por síndrome diarreico agudo con antecedente de mala administración de Sales de rehidratación oral por parte de la madre con dilución inadecuada hiperosmolar. Hallazgos paraclínico, Hipernatremia, Hiperkalemia, acidosis metabólica e hipoxemia. Tratamiento: corrección de acidosis con solución 75 y rehidratación en 48 horas con solución hipoosmolar 0.22 por ciento. Presentamos este caso por ser una de las causas más frecuentes de deshidratación hipernatrémicas en recién nacidos, es importante exponer la necesidad de educación a las madres para la adecuada preparación de las sales de rehidratación oral, como método eficaz de prevenir la deshidratación. Y en aquellos casos de presentarse tal complicación, los médicos debemos conocer la adecuada correlación de las misma a modo de evitar las complicaciones.

Abdominal compartment syndrome monitoring in major burn patients with Siriraj device catheter.

Abdominal compartment syndrome (ACS) is consistently reported to have significant morbidity and mortality. Major burn patients who receive massive fluid resuscitation are at high-risk for this condition. Close monitoring of ACS is necessary for these patients. Prolonged unrelieved intra-abdominal pressure (IAP) at greater than 20 mmHg can produce significant morbidity and mortality. The most widely accepted and feasible way to measure IAP is via the draining port of a standard urinary catheter Siriraj burn unit developed its own device from simple equipment that can be found easily in the hospital. It proved to be useful, cheap, and effective in monitoring intra-abdominal pressure. The present study described techniques of using this device for monitoring and early detection of ACS. Five major burn patients > or = 40% Total body surface area (TBSA) was measured by IAP measurement via foley catheter using the Siriraj device catheter compared to direct measurement via peritoneal catheter. There was no difference of IAP between the two methods (p = 0.48). This suggested that Siriraj device catheter was useful, not invasive, and effective in reflection of actually IAP Siriraj burn unit suggested IAP measurement in all major burns > or = 40% TBSA to early recognize and treat intra-abdominal hypertension(IAH) that can lead to ACS. Early detection of this syndrome might decrease the adverse effects after increasing abdominal pressure that can cause organ dysfunction.

Parâmetros fisiológicos do desempenho de cavalos de alta performance hidratados voluntariamente com água ou solução isotônica contendo carboidrato / Physiological parameters of high performance horses watered spontaneously with regular (ordinary) water or isotonic solution containing carbohydrate

Durante 8 semanas, no verão, 4 cavalos de alta performance treinados para enduro, realizaram exercício de resistência recebendo 2 tipos diferentes de hidratação, água ou solução isotônica contendo carboidrato, com o objetivo de comparar seus parâmetros fisiológicos. Somente as variáveis Tr, Fc, Fr, peso e proteína total, consumo, glicose, os eletrólitos K, Ca e a enzima muscular CK apresentaram efeito de distância. Dos demais parâmetros avaliados não foram identificados os efeitos de tratamento e de interação da distância com o tratamento estudado (P>0,05), concluindo assim que a solução isotônica contendo carboidrato não teve influencia na performance dos animais, quando comparada com a água.

During eight weeks, in summer, four endurance trained high performance horses were worked in resistence exercise, recieving two different types of hydratatio, water or an isotonic solution containing carbohydrates, with the objective to compare their performance physiological parameters. Only the RT (rectal temperature), HR (heart rate), RR (respiratory rate), weight, total protein, glucose, the electrolytes K, Ca and the muscular enzyme CK presented distance effect. The others parameters evaluated, there weren’t any identified effects of treatment and of the interaction between distance and treatments, with a significancy level of 5%, and it was concluded that the isotonic solution containing carbohydrate didn’t have any significant influence on the animal’s performance when compared to water.

Bien utiliser les sels de rehydratation orale

N.A.