Rotational thromboelastometry assessment of ballanced crystalloid, hydroxyethyl starch and gelatin effects on coagulation: a randomized trial / Tromboelastometria rotacional na avaliação dos efeitos de cristaloides balanceados, hidroxietilamido e gelatina na coagulação: estudo randômico

Abstract Background and objectives Modern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry. Methods Blood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500 mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation. Results In Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p > 0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p < 0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p < 0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p > 0.05). Conclusion Extem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.

Resumo Justificativa e objetivos Os cristaloides e coloides modernos são soluções balanceadas e cada vez mais utilizadas no período perioperatório. No entanto, não há estudos que avaliem seu efeito negativo na coagulação do sangue total e o intenso debate sobre a solução que cause um efeito mínimo na coagulopatia permanece. O objetivo de nosso estudo foi avaliar o efeito das soluções líquidas modernas na coagulação do sangue total com o uso da tromboelastometria rotacional. Métodos De acordo com a randomização, amostras de sangue foram colhidas de 30 pacientes durante a artroscopia de joelho, antes e após a administração de 500 mL de cristaloides, hidroxietilamido e gelatina. A tromboelastometria rotacional (testes Extem, Intem e Fibtem) foi utilizada para avaliar o efeito negativo das soluções líquidas na coagulação do sangue total. Resultados No teste Extem, a fase de iniciação da formação de coágulos de fibrina representada pelo parâmetro CT não foi influenciada por qualquer solução líquida (p > 0,05). A velocidade da formação de coágulos representada pelo CFT e pelo ângulo α foi prejudicada pelo hidroxietilamido e pela gelatina, mas não pelos cristaloides (p < 0,05). A força do coágulo formatado representado pelo parâmetro MCF foi prejudicada tanto no teste Extem quanto no teste Fibtem pelo HES e no teste Fibtem também pelos cristaloides (p < 0,05). O teste Intem não foi influenciado negativamente por nenhuma solução cristaloide ou coloide em nenhum parâmetro (p > 0,05). Conclusão O teste Extem parece ser sensível ao efeito de coagulopatia dos coloides e cristaloides modernos. O hidroxietilamido apresentou o efeito negativo mais óbvio na formação do coágulo, seguido pela gelatina e finalmente pelos cristaloides. O teste Intem parece ser insensível ao efeito adverso dos coloides e cristaloides modernos.

Conservative treatment of Angle Class III malocclusion with anterior crossbite

Angle Class III malocclusion is characterized by anteroposterior dental discrepancy which might be associated or not with skeletal changes. Class III molar relationship is associated with vertical or lingually tipped mandibular incisors and a usually concave profile. These characteristics seriously affect facial esthetics and most frequently are the reason why patients seek orthodontic treatment. This case was presented to the committee of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO) as part of the requisites to become a BBO Diplomate.

A má oclusão de Classe III de Angle é caracterizada por uma discrepância dentária anteroposterior, que pode ou não estar acompanhada por alterações esqueléticas. Observa-se uma relação molar de Classe III associada ao posicionamento vertical ou retroinclinado dos incisivos inferiores e, geralmente, perfil facial côncavo. Esse aspecto gera grande comprometimento estético na face, sendo justamente esse o fator que, na maioria das vezes, motiva o paciente a procurar pelo tratamento ortodôntico. O presente caso clínico foi apresentado à Diretoria do Board Brasileiro de Ortodontia e Ortopedia Facial (BBO) como parte dos requisitos para a obtenção do título de Diplomado pelo BBO.

A giant carotid aneurysm with intrasellar extension: a rare cause of panhypopituitarism

No abstract available.

Effect of intraoperative HES 6% 130/0.4 on the need for blood transfusion after major oncologic surgery: a propensity-matched analysis

OBJECTIVES: To evaluate the effect of the intraoperative use of hydroxyethyl starch on the need for blood products in the perioperative period of oncologic surgery. The secondary end-points included the need for other blood products, the clotting profile, the intensive care unit mortality and length of stay. METHODS: Retrospective observational analysis in a tertiary oncologic ICU in Brazil including 894 patients submitted to oncologic surgery for a two-year period from September 2007. Patients were grouped according to whether hydroxyethyl starch was used during surgery (hydroxyethyl starch and No-hydroxyethyl starch groups) and compared using a propensity score analysis. A total of 385 propensity-matched patients remained in the analysis (97 in the No-hydroxyethyl starch group and 288 in the hydroxyethyl starch group). RESULTS: A higher percentage of patients in the hydroxyethyl starch group required red blood cell transfusion during surgery (26% vs. 14%; p = 0.016) and in the first 24 hours after surgery (5% vs. 0%; p = 0.015) but not in the 24- to 48-hour period after the procedure. There was no difference regarding the transfusion of other blood products, intensive care unit mortality or length of stay. CONCLUSION: Hydroxyethyl starch use in the intraoperative period of major oncologic surgery is associated with an increase in red blood cell transfusions. There are no differences in the need for other blood products, intensive care unit length of stay or mortality. .

Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures

OBJECTIVE: The ideal solution for fluid management during neurosurgical procedures remains controversial. The aim of this study was to compare the effects of a 7.2% hypertonic saline - 6% hydroxyethyl starch (HS-HES) solution and a 6% hydroxyethyl starch (HES) solution on clinical, hemodynamic and laboratory variables during elective neurosurgical procedures. METHODS: Forty patients scheduled for elective neurosurgical procedures were randomly assigned to the HS-HES group orthe HES group. Afterthe induction of anesthesia, patients in the HS-HES group received 250 mL of HS-HES (500 mL/h), whereas the patients in the HES group received 1,000 mL of HES (1000 mL/h). The monitored variables included clinical, hemodynamic and laboratory parameters. Chictr.org: ChiCTR-TRC-12002357 RESULTS: The patients who received the HS-HES solution had a significant decrease in the intraoperative total fluid input (p<0.01), the volume of Ringer's solution required (p<0.05), the fluid balance (p<0.01) and their dural tension scores (p<0.05). The total urine output, blood loss, bleeding severity scores, operation duration and hemodynamic variables were similar in both groups (p>0.05). Moreover, compared with the HES group, the HS-HES group had significantly higher plasma concentrations of sodium and chloride, increasing the osmolality (p<0.01). CONCLUSION: Our results suggest that HS-HES reduced the volume of intraoperative fluid required to maintain the patients undergoing surgery and led to a decrease in the intraoperative fluid balance. Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures.

Albumin for End-Stage Liver Disease

Albumin has been widely used in patients with cirrhosis in an attempt to improve circulatory and renal functions. The benefits of albumin infusions in preventing the deterioration in renal function associated with large-volume paracentesis, spontaneous bacterial peritonitis, and established hepatorenal syndrome in conjunction with a vasoconstrictor are well established. While some of these indications are supported by the results of randomized studies, others are based only on clinical experience and have not been proved in prospective studies. The paucity of well-designed trials, the high cost of albumin, the lack of a clear-cut survival benefit, and fear of transmitting unknown infections make the use of albumin controversial. The recent development of the molecular adsorbent recirculating system, an albumin dialysis, is an example of the capacity of albumin to act by mechanisms other than its oncotic effect. Efforts should be made to define the indications for albumin use, the dose required, and predictors of response, so that patients gain the maximum benefit from its administration.

Hidroxietilalmidón (Hextend®) en solución electrolítica balanceada en el choque hipovolémico hemorrágico / Use of hetastarch in a balanced electrolyte solution - Hextend®- in the resuscitation of the patient in hypovolemic hemmorrhagic shock: review of the international literature

Hextend® is a preparation of hetilstarch in a balanced electrolyte solution that contains 143 mEq/L of sodium, 124mEq/L of chloride, 5 mEq/L of calcium 3 mEq/L of potassium 0.9 mEq/L of magnesium, 0.99 g/L of glucose and 24 mEq/L of lactate. It has a volume of distribution similar to blood volume which enables it to stay in the intravascular compartment until it is renally cleared or absorbed by the reticuloendothelial system. It shows a bimodal pattern of clearance with a half life during the first 8 hrs of its infusion of 4.2 hrs and during the 7 days following of 38.2 hrs. Hextend® is currently one of the preferred resuscitation solutions in the hypovolemic patient showing a better profile of effects over hemostasis and acid base status and conferring a better survival over similar patients resuscitated with crystalloids or other synthetic colloids. Hextend® provides an adequate fluid that is effective in the resuscitation of the trauma patient in hypovolemic hemorrhagic shock and promises to become the fluid of choice in the routine management of these patients. There is a need of more randomized prospective studies in the field of trauma using Hextend ® and its combination with the inflammatory cascade modifiers such as ethyl pyruvate among others.

Hextend® es una combinación de hetilalmidón balanceada en una solución de electrolitos que contiene 143 mEq/L de sodio, 124 mEq/L de cloro, 5 mEq/L de calcio, 3 mEq/L de potasio, 0,9 mEq/L de magnesio, 0,99 g/L de glucosa y 24 mEq/L de lactato. Posee un volumen de distribución equivalente al volumen sanguíneo manteniéndose en el compartimento vascular hasta ser excretado vía renal o absorbido por el sistema retículo-endotelial. Estas características le confieren un patrón farmacocinético bimodal con una vida media de 4,2 horas durante las primeras 8 hrs de infusión y de 38,2 h durante los primeros 7 días. Hextend® es actualmente una de las soluciones de reanimación con mejor perfil de efectos sobre la hemostasia y el equilibrio ácido base del paciente en choque hipovolémico y confiere un aumento de la sobrevida, comparado con controles resucitados con cristaloides u otros coloides sintéticos. Esta combinación de hetilalmidón en una solución amortiguadora electrolítica posee mínimos efectos sobre la función hemostática y plaquetaria por lo que actualmente es preferido frente a soluciones cristaloides y otros coloides utilizados en el pasado en la reanimación de pacientes politraumatizados en estado de choque hipovolémico hemorrágico. A su vez, promete transformarse en el fluido de elección en el manejo rutinario de estos pacientes. En relación al uso de este producto es imperativo realizar un mayor número de estudios prospectivos randomizados. La literatura internacional augura un esplendoroso futuro al uso de Hextend®, como también a su posible combinación con modificadores de la cascada inflamatoria, entre otros con el etil piruvato.

Patterns of renal dopamine release to regulate diuresis and natriuresis during volume expansion: Role of renal monoamine-oxidase / Perfiles de secreción de dopamina renal en la expansión de volumen para regular diuresis y natriuresis: Rol de la monoaminoxidasa renal

Diuretic and natriuretic effects of renal dopamine (DA) are well established. However, in volume expansion the pattern of renal DA release into urine (U DA V) and the role of enzymes involved in DA synthesis/degradation have not yet been defined. The objective was to determine the pattern of U DA V during volume expansion and to characterize the involvement of monoamine-oxidase (MAO) and aromatic amino-acid decarboxylase (AADC) in this response. In this study male Wistar rats were expanded with NaCl 0.9% at a rate of 5% BWt per hour. At the beginning of expansion three groups received a single drug injection as follows: C (vehicle, Control), IMAO (MAO inhibitor Pargyline, 20 mg/kg BWt, i.v.) and BNZ (AADC inhibitor Benserazide, 25 mg/kg BWt, i.v.). Results revealed that in C rats U DA V (ng/30 min/100g BWt) increased in the first 30 min expansion from 11.5 ± 1.20 to 21.8 ± 3.10 (p < 0.05) and decreased thereafter. IMAO showed a similar pattern but significantly higher than C at 30 min expansion (32.5 ± 2.20, p < 0.05). IMAO greatly reduced MAO activity from 8.29 ± 0.35 to 1.1 ± 0.03 nmol/mg tissue/hour and significantly increased diuresis and natriuresis over controls. BNZ abolished the early U DA V peak to 3.2±0.72 (p < 0.01) and though, U DA V increased over C after 60 min expansion, natriuresis and diuresis were diminished by BNZ treatment. Results indicate that an increment in renal DA release into urine occurs early in expansion and in a peak-shaped way. In this response MAO plays a predominant role.

La dopamina (DA) intrarrenal ejerce efectos diuréticos y natriuréticos. Sin embargo, en los estado de expansión de volumen aún no está bien definido el patrón de liberación de dopamina renal hacia la orina y si cumplen un rol las enzimas involucradas en la síntesis o degradación de la amina. El objetivo del presente trabajo fue determinar el patrón de excreción urinaria de DA (U DA V) durante la expansión de volumen, caracterizando la participación de las enzimas monoaminooxidasa (MAO) y decarboxilasa de aminoácidos aromáticos (AADC) en esta respuesta. Para ello ratas Wistar macho fueron expandidas de volumen con NaCl 0.9% al 5% del peso corporal por hora durante dos horas y divididas en tres grupos, los que al comienzo de la expansión recibieron: C (vehículo, Control), IMAO (Pargilina, inhibidor de MAO, 20 mg/kg PC, i.v.) y BNZ (Benserazida, inhibidor de AADC, 25 mg/kg PC, i.v.). Se observó que en C la U DA V (ng/30min/100gPC) aumentó durante los primeros 30 minutos de expansión de 11.5 ± 1.20 a 21.8 ± 3.10 (p < 0.05), disminuyendo posteriormente. IMAO mostró un patrón de liberación similar pero significativamente mayor que C a los 30 min de expansión (32.5 ± 2.20, p < 0.05). En este grupo la actividad de MAO disminuyó de 8.29 ± 0.35 a 1.1 ± 0.03 nmol/mg tejido/hora y aumentaron la diuresis y natriuresis por sobre los controles. En BNZ, el pico de U DA V observado a los 30 min de la expansión disminuyó a 3.2 ± 0.72 (p < 0.01), aunque luego de 60 minutos fue mayor que en C. BNZ disminuyó tanto la diuresis como la natriuresis. Podemos concluir que al comienzo de la expansión de volumen se produce un pico de excreción de dopamina renal hacia la orina. La enzima MAO juega un rol fundamental en esta respuesta.

Acidosis hiperclorémica: mito y realidad / Hyperchloremic acidosis

La acidosis metabólica es una alteración ácido-base frecuentemente observada en pacientes críticos. Aunque en situaciones extremas este desorden en sí mismo es amenazante para la vida, la presencia de una acidosis metabólica leve no siempre es nociva y puede ser un reflejo de la adaptación fisiológica del organismo a la injuria aguda. Diferentes autores han documentado el desarrollo de acidosis metabólica hiperclorémica asociada al aporte de grandes cantidades de solución salina 0,9 por ciento. Algunos consideran que se trata de una condición benigna y autolimitada, mientras otros sostienen que la acidosis hiperclorémica puede deteriorar la perfusión renal y esplácnica, sin embargo su relevancia clínica real es aún incierta. En un afán de evitar la aparición de acidosis hiperclorémica y sus potenciales efectos adversos, se han desarrollado cristaloides y coloides en formulaciones modificadas para que se asemejen más a la composición del plasma. En este artículo de revisión analizaremo slos mecanismos de producción de la acidosis metabólica hiperclorémica en base al abordaje físico-químico de Stewart; la evidencia existente sobre el impacto de este trastorno sobre las variables de desenlace de los pacientes críticos, y el rol clínico de las nuevas “soluciones balanceadas”.

Metabolic acidosis is an acid-base alteration frequently observed in critically ill patients. Even in extreme situations this disorder in itself is life threatening, the presence of a mild metabolic acidosis is not always harmful and may be the result of physiological adaptation of the organism to acute injury. Several authors have documented the development of hyperchloremic metabolic acidosis associated with the infusion of large amounts of 0.9 percent normal saline. Some consider this to be a benign and transient, while others argue that hyperchloremic acidosis can impair renal and splanchnic perfusion, but her real clinical relevance remains uncertain. In an effort to prevent the development of hyperchloremic acidosis and its potential adverse effects have been development formulations of crystalloid and colloid modified to more closely resemble the composition of the plasma. In this review article will discuss the mechanism of production of hyperchloremic metabolic acidosis by the physicochemical approach Stewart, the existing evidence on the impact of this disorder on the outcome variables in critically ill patients, and clinical role of new “balanced solutions”.

Prevention of hypotension during propofol induction: a comparison of preloading with 3.5% polymers of degraded gelatin (Haemaccel) and intravenous ephedrine.

The present study compared the efficacy of preloading with colloid "Haemaccel" with vasoconstrictor (intravenous ephedrine sulphate) in preventing hypotension during propofol induction. This prospective, randomized study included 120 patients of Amercan Society of Anaesthesiologists (ASA) physical status I and II ageing 21 to 50 years of both gender coming for routine surgery. Patients were randomly allocated into three groups with 40 patients in each. Group A (control) did not receive any study medication, group B received Haemaccel (10 ml/kg intravenously over 10-15 minutes) and group C received injection ephedrine (0.2 mg/kg iv) prior to induction of anaesthesia. Propofol (2.5 mg/kg iv) was used for induction of anaesthesia. Heart rate and blood pressure were recorded before induction (baseline) and then every minute for 5 minutes after administering propofol. Anaesthesia was continued with standard technique thereafter. Hypotension was defined as fall in systolic blood pressure more than 20% from the basal value. The incidence of hypotension in Haemaccel (23.1%) or ephedrine group (22.5%) was significantly less than the control group (67.5%, P<0.01). We conclude that though preloading with colloid (Haemaccel) or prior injection of sympathomimetic (ephedrine) are not fully efficacious in preventing hypotension caused by propofol induction, both decrease the incidence in significant number of patients with heart rate less than baseline value in the colloid group.

Operating room use of hypertonic solutions: a clinical review

Hyperosmotic-hyperoncotic solutions have been widely used during prehospital care of trauma patients and have shown positive hemodynamic effects. Recently, there has been a growing interest in intra-operative use of hypertonic solutions. We reviewed 30 clinical studies on the use of hypertonic saline solutions during surgeries, with the majority being cardiac surgeries. Reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions in this population. Well-designed clinical trials are highly needed, particularly in aortic aneurysm repair surgeries, where hypertonic solutions have shown many beneficial effects. Examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies.

Does preloading with colloids prevent hemodynamic changes when neurosurgical patients are subsequently changed to the seated position?

OBJECTIVE: This prospective, randomized, double-blind study was designed to determine and compare the usefulness of preloading colloids (Haemaccel) 10 ml/Kg before positioning whether it can prevent hemodynamic changes during seated positioning or not. MATERIAL AND METHOD: The authors studied 20 patients by randomly dividing them into 2 groups. The control group was given crystalloid as maintenance and deposit replacement but the study group was given extra colloids 10 ml/Kg 30 minutes before starting general anesthesia. Both groups were monitored and given anesthesia, balanced technique. Systolic and diastolic blood pressures, heart rate, central venous pressure (CVP) at different time intervals in the sitting position for 30 minutes were recorded. Statistical analysis was done by Student t-test, Chi-square test and ANOVA (p-value < 0. 05 considered significant). RESULTS: The results showed that systolic blood pressure at 15, 20, 30 minutes and CVP at 15, 25, 30 minutes after positioning in the study group was maintained significantly compared to the control group and there were no significant changes in diastolic blood pressure and heart rate. There were no other complications during the sitting period. CONCLUSION: It is concluded that preloading colloid fluid prior to repositioning could prevent the decrease of systolic blood pressure and central venous pressure during sitting positioning without other complications.

Cord blood from collection to expansion: feasibility in a regional blood bank.

This article reviews the various aspect of the experimental phase preceding the establishment of an umbilical cord blood (UCB) bank within a regular blood bank, a situation totally different from that of de novo establishing a cord blood bank having human and financial resources. An ethically approved two-year study has been conducted to determine the technical feasibility, and the practical problems that might be encountered such as public compliance, the additional workload, introduction of new activities ranging from collection and processing to progenitor expansion, infectious disease testing, development of a quality control system, record keeping and documentation, development of specific procedures and definitions of requirements. The cost benefit aspect, which will ultimately depend on the frequency of units release, was not considered in this study.

Soluciones cristaloides y coloides, como sustitutas de la sangre en el cebado del circuito extracorpóreo durante la cirugía cardiovascular / Crystalloid and colloidal solutions as blood substitutes in the priming of the extracorporeal circuit during cardiovascular surgery

Se realizó un estudio cualitativo donde se exponen las características principales, objetivos de aplicación y las ventajas que ofrecen las diferentes soluciones coloidales y electrolíticas utilizadas en el cebado del circuito extracorpóreo. Como objetivo principal se exponen los argumentos necesarios que permiten al perfusionista combinar determinadas soluciones, para conservar la osmolaridad, la presión oncótica del plasma, mejorar el flujo microcirculatorio y evitar las transfusiones de sangre y hemoderivados innecesarias. También se mencionan diferentes técnicas para conservar el nivel del hematócrito, como son el uso de hemofiltros, concentrador de células y la aplicación de la cardioplejia sanguínea, que aunque su principal objetivo es la protección miocárdica, también sustituye los grandes volúmenes de líquido que caracteriza el uso de la cardioplejia cristaloide(AU)

The chief characteristics, objectives of application and the advantages the colloidal and electrolytic solutions used in the priming of the extracorporeal circuit offer are explained in this qualitative study. The necessary arguments that allow the perfusionist to combine certain solutions to conserve osmolarity, the oncotic pressure of plasma, to improve the microcirculatory flow and to avoid blood transfusions and unnecessary hemoderivatives, are dealt with as the fundamental aim. Reference is made to different techniques used to conserve the haematocrit level, such as: the use of haemofilters, cell concentrator and the application of blood cardioplegia, whose main goal is the myocardial protection, but it also substitutes the great volumes of fluid that characterize the use of crystalloid cardioplegia(AU)

Efficacy and Safety of Large Volume Paracentesis in Cirrhotic Patients with Spontaneous Bacterial Peritonitis: A Randomized Prospective Study / 대한간학회지

BACKGROUND/AIMS: Large volume paracentesis (LVP) associated with plasma volume expansion is known to be an effective and safe therapy for tense or refractory ascites in cirrhosis. Spontaneous bacterial peritonitis (SBP) is one of the frequent infections in patients with cirrhosis. We conducted a study to assess the efficacy and safety of large volume paracentesis in cirrhotic patients with SBP. METHODS: We randomly assigned 40 patients with cirrhosis and SBP to either treatment with LVP (21 patients) or general management (19 patients). LVP was defined as drainage of ascitic fluid of more than 4 liters in a single tap or loss of shifting dullness after paracentesis. LVP was performed within 48 hours after the diagnosis of SBP in the LVP group. Cefotaxime was given daily in doses that varied according to the serum creatinine level in both groups. Albumin was given at a dose of 6-8 g per 1 liter of removed ascites in the LVP group. RESULTS: After seven days of treatments, the blood chemistry test, and WBC (PMN) counts and protein concentration in the ascitic fluid were not different between the two groups. Among them, the WBC (PMN) counts were decreased significantly in both groups and protein concentrations tended to increase. Durations of abdominal tenderness and pain were shorter in the LVP group but the differences were statistically not significant. Admission periods, resolution rates of SBP after seven days of treatment, complication rates and in-hospital mortality rates were not different between the two groups. CONCLUSIONS:: The two treatment methods demonstrated almost the same effectiveness and safety. The symptoms were improved slightly faster in the LVP group. We concluded that large volume paracentesis is not an absolute contraindication and can be a tolerable and safe therapy in some selected cirrhotic patients with tense ascites and SBP.

Síndrome hemorragíparo por exposición a raticida: comunicación de un caso / Bleeding disorder caused by exposure to a rodenticide: report of 1 case

We report a 22 years old male, admitted to the emergency room due to a life threatening coagulation disorder, with prothrombin times fluctuation between 5 and 37 percent and very low activity of factors II, VII, IX and X. In the month prior to the admission, the patient had used the rodenticide difethialone, without any precaution to avoid accidental exposure. The patient was maintained with fresh frozen plasma until oral vitamin K1 was obtained. This medication corrected the coagulation disorder

Ascitic fluid filtration and intravenous infusion versus total-volume paracentesis with infusion of plasma expander in cirrhosis with tense or intractable ascites.

BACKGROUND: Patients with cirrhotic ascites have low serum albumin levels, and paracentesis of ascitic fluid could compromise them further. AIM: We compared the therapeutic efficacy of ascitic fluid filtration and concentrate infusion (AFI) versus total-volume paracentesis (TVP) with colloid infusion in control of tense or intractable cirrhotic ascites. METHODS: Ten patients underwent AFI; their ascitic fluid was filtered repeatedly through hollow-fiber hemodialyzer, and the concentrate reinfused intravenously. In ten patients TVP was done with simultaneous intravenous colloid infusion. Follow-up was done weekly and the study terminated if the patient needed diuretics or developed complications. RESULTS: Pre-study parameters were similar in the two groups. In the AFI and TVP groups, the duration of procedure was median 12 hours and 5.5 hours; fluid removed by paracentesis was 10.2 L and 8.0 L, respectively; and fluid infused intravenously was 0.5 L [with mean (SD) protein content 5.7 (1.3) g/dl] and 1.1 L, respectively. Glomerular filtration rates were lower than normal in the two groups but did not change significantly with the procedure; body weight remained significantly lower up to week 3 and week 2, respectively. The study was terminated at median week 3 (range 1-8) and week 2 (1-4), respectively. Fever was an accompaniment of AFI and one patient developed peritonitis. CONCLUSION: Patients undergoing AFI remained diuretic-free longer; the procedure is cost-effective but needs to be further evaluated to minimize the side-effects.