Impact of colloids or crystalloids in renal function assessed by NGAL and KIM-1 after hysterectomy: randomized controlled trial

Abstract Background Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. Methods This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg−1.h−1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. Results Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p= 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p= 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p= 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. Conclusion HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.

Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage / 中南大学学报(医学版)

OBJECTIVES@#In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage.@*METHODS@#This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups.@*RESULTS@#There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both @*CONCLUSIONS@#Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.

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.

Lumbar fusion with collagen type I and polyvinylpyrrolidone in combination with autograft. An experimental study in New Zealand rabbits / Colágena tipo I y polivinilpirrolidona en combinación con autoinjerto para artrodesis lumbar. Estudio experimental en conejos de Nueva Zelanda

Abstract: Introduction: Multiple strategies have been developed looking for upgrading the consolidation rate of spine arthrodesis with autolog bone graft, but no evidence exists that adhesion with Collagen type 1 and polyvinylpyrrolidone (FibroquelMR) have application on this field. Objective: Determine if collagen type 1 + Polyvinylpyrrolidone are effective as bone enhancer in posterolateral arthrodesis on rabbits. Method: Posterolateral arthrodesis in 15 New Zealand rabbits on level L5-L6 using autolog bone graft in left side (control group) and autolog bone graft + 1 ml FibroquelMR (study group) in right side of arthrodesis. Euthanasia and block resection of lumbar segment eight weeks post surgery. Radiographic analysis, manual exploration and light microscopy of fussed segments. Results: Radiographic consolidation was observed in 80% in control group and 95% in study group, interleaved trabecular pattern with bone continuity and normal characteristics in 12 left sides and 14 right sides. Conclusion: Collagen type 1 and polyvinylpyrrolidone use is likely to have positive effect in bone consolidation process, therefore it can be recommended to use it as a bone enhancer.

Resumen: Introducción: Existen diversas estrategias para aumentar la tasa de consolidación de la artrodesis de columna en presencia de injerto óseo autólogo, sin aún comprobar si la adhesión de Colágena tipo I y polivinilpirrolidona (FibroquelMR) tienen aplicaciones en este campo. Objetivo: Determinar la efectividad de la colágena tipo I con polivinilpirrolidona como potenciador óseo en artrodesis posterolateral de conejos. Métodos: Artrodesis posterolateral en 15 conejos de Nueva Zelanda L5-L6 colocando injerto autólogo del lado izquierdo (Control) e injerto autólogo + 1 ml FibroquelMR (Estudio) en el lado derecho de la artrodesis. Eutanasia con resección en bloque del segmento lumbar a las ocho semanas del postoperatorio. Análisis radiográfico, palpación manual y por microscopia de luz de los segmentos fusionados. Resultados: Se observó consolidación radiográfica en 80% en grupo control y 93% en el estudio, continuidad ósea con patrón trabecular intercalado y hueso de características normales en 12 del lado izquierdo y 14 en el lado derecho. Conclusiones: La utilización de Colágena tipo I y polivinilpirrolidona puede tener efectos positivos en el proceso de consolidación ósea por lo que se puede recomendar su utilización como reforzador óseo.

Efficacy of different fluids preload on propofol injection pain: A randomized, controlled, double-blinded study / 华中科技大学学报（医学）（英德文版）

Injection pain of propofol remains a common clinical problem. Previous studies demonstrated that propofol injection pain was alleviated by applying nitroglycerin ointment to the skin of injection site, which inspires us to test whether venous vasodilation induced by fluid preload could alleviate the pain. Different types or volumes of fluid preload were compared. 200 ASA I-II adult patients were randomly assigned to five groups of 40 each. A 20 G cannula was established on the dorsum or wrist of the hand. When fluid preload given with Plasma-Lyte A 100 mL (P100 group), 250 mL (P250 group), 500 mL (P500 group), 0.9% saline 500 mL (N500 group) or Gelofusine 500 mL (G500 group) was completed within 30 min, respectively, Propofol (0.5 mg/kg, 1%) was injected at a rate of 0.5 mL/s. A blind investigator assessed the pain using a four-point scale. Incidence of pain in P100, P250, and P500 groups was 87.5%, 57.5% and 35%, respectively (P<0.05). The median pain intensity score was significantly lower in P500 group than that in P250 and P100 groups (P<0.05 and P<0.01, respectively). Comparison of the effect of different types of solution preload indicated that the highest incidence of pain was in N500 group (62.5%) (N500 vs. P500, P=0.014; N500 vs. G500, P=0.007). The median pain intensity score in N500 group was higher than that in P500 group (P<0.05) and G500 group (P<0.05). There was no significant difference between P500 and G500 groups. It is suggested that Plasma-Lyte A or Gelofusine preload with 500 mL before propofol injection is effective in alleviating propofol-induced pain.

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.

Effect of protective solutions and hydroxyethyl starch in the attenuation of the injuries of ischemia and reperfusion of splanchnic organs

PURPOSE: Vogt´s antioxidant solution (red blood cells, Ringer's solution, sodium bicarbonate, mannitol, allopurinol and 50% glucose) or its modification including hydroxyethyl starch (HES) were tested for the prevention of splanchnic artery occlusion shock. METHODS: Seventy rats were distributed in treatment (3), control (1), and sham (3) groups. Ischemia and reperfusion were induced by celiac, superior mesenteric and inferior mesenteric arteries occlusion for 40 min, followed by 60 min reperfusion or sham procedures. Controls received saline, both treatment and sham groups received the Vogt's solution, modified Vogt's solution (replacing Ringer's solution by HES), or HES. Mean arterial blood pressure (MABP), ileal malondialdehyde (MDA) and plasmatic MDA were determined, and a histologic grading system was used. RESULTS: At reperfusion, MABP dropped in all I/R groups. Only HES treatment was able to restore final MABP to the levels of sham groups. Plasmatic MDA did not show differences between groups. Ileum MDA was significantly higher in the control and treatment groups as compared to the sham group. Histology ranking was higher in the only in control group. CONCLUSIONS: Hydroxyethyl starch was able to prevent hemodynamic shock but not intestinal lesions. Both treatments with Vogt's solutions did not show any improvement. .

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

No abstract available.

Fluid optimization with hydroxyethyl starch 130/0.4 compared with modified fluid gelatin guided by esoph- ageal doppler during major abdominal surgeries

Perioperative fluid therapy has a direct bearing on patient outcome and accordingly should be tailored individually. Thus the efficacy of HES 130/0.4 was fied fluid gelatin for volume expansion during major abdominal surgery guided by transesophageal Doppler [TED]. Fifty adult patients ASA physical status I-II undergoing major abdominal surgery were anesthetized with standard technique. In addition to basal fluid requirement, patients were randomly allocated into two equal groups [25 patients ; each] to receive 200 cc of either 6% HES 130/0.4 [HES group] or 3% modified fluid gel [GEL group] as intraoperative colloid replacement guided by TED. Heart ratenmean arterial blood pressure, central venous pressure, and Doppler derived measurements were recorded at the following timings: Tl; after induction, T2; after skin incision, T3; two hours after that and T4; at the end of surgery. Fluid administration and transfusion requirements were recorded. Laboratory tests for hemostasis, hepatic and renal functions weie continued till the fifth postoperative day. Both groups were comparable regarding Doppler derived data and fluid balance. Platelet count showed a significant drop [p<0.05] in group GEL in all postoperative days compared with baseline and with the group HES. Prothrombin time and INR showed a significant increase while prothrombin concentration showed a significant drop, throughout 5 postoperative days in group HES while in the 3 postoperative days in group GEL [p<0.05] but comparable between groups. Both groups showed postoperative drop in creatinine level and postoperative rise of liver function tests. HES 130/0.4 and modified gelatin have comparable fluid optimization effect guided by TED in major abdominalsurgeries. HES 130/0.4 has a more favorable effect on platelet counts than modified gelatin

Dehydration, hemodynamics and fluid volume optimization after induction of general anesthesia

OBJECTIVES: Fluid volume optimization guided by stroke volume measurements reduces complications of colorectal and high-risk surgeries. We studied whether dehydration or a strong hemodynamic response to general anesthesia increases the probability of fluid responsiveness before surgery begins. METHODS: Cardiac output, stroke volume, central venous pressure and arterial pressures were measured in 111 patients before general anesthesia (baseline), after induction and stepwise after three bolus infusions of 3 ml/kg of 6% hydroxyethyl starch 130/0.4 (n = 86) or Ringer's lactate (n = 25). A subgroup of 30 patients who received starch were preloaded with 500 ml of Ringer's lactate. Blood volume changes were estimated from the hemoglobin concentration and dehydration was estimated from evidence of renal water conservation in urine samples. RESULTS: Induction of anesthesia decreased the stroke volume to 62% of baseline (mean); administration of fluids restored this value to 84% (starch) and 68% (Ringer's). The optimized stroke volume index was clustered around 35-40 ml/m2/beat. Additional fluid boluses increased the stroke volume by ≥10% (a sign of fluid responsiveness) in patients with dehydration, as suggested by a low cardiac index and central venous pressure at baseline and by high urinary osmolality, creatinine concentration and ...

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. .

Injúria Renal Aguda no paciente politraumatizado / Acute Renal Injury in polytrauma patients

A Injúria Renal Aguda (IRA) no contexto do paciente politraumatizado ocorre, na maioria das vezes, por uma conjuntura de fatores que passam por eventos correlacionados à ressuscitação volêmica inicial, ao grau de resposta inflamatória sistêmica associada ao trauma, ao uso de contraste iodado para procedimentos diagnósticos, à rabdomiólise e à síndrome compartimental abdominal. Atualmente, passamos por uma fase de uniformização dos critérios diagnósticos da IRA com o Acute Kidney Injury Network (AKIN), sendo a referência mais aceita. Consequentemente, o estudo da IRA no politraumatismo também passa por uma fase de reformulação. Esta revisão da literatura médica visa trazer dados epidemiológicos, fisiológicos e de implicação clínica para o manuseio destes pacientes, bem como expor os riscos do uso indiscriminado de expansores volêmicos e particularidades sobre a instituição de terapia renal substitutiva em indivíduos sob risco de hipertensão intracraniana.

Acute Kidney Injury (AKI) in trauma is, in most cases, multifactorial. Factors related to the initial ressuscitation protocol, degree of the systemic inflamatory response to trauma, contrast nephropathy in diagnostic procedures, rhabdomyolysis and abdominal compartment syndrome are some of those factors. Nowadays a uniformization in diagnostic criteria for AKI has been proposed by the Acute Kidney Injury Network (AKIN) and as a result the incidence of AKI and its impact in outcomes in trauma patients also needs to be reconsider. In this review we aim to approach epidemiologic, physiologic and clinical relevant data in the critical care of patients victims of trauma and also to expose the risks of indiscriminate use of volume expanders and the interaction between renal replacement theraphy and intracranial hypertension.

The effect of 6% Hydroxyethyl starch vs. Ringer's lactate on acute kidney injury after renal ischemia in rats

PURPOSE: To compare fluid replacement therapy with Hydroxyethyl starch 6% (HES) versus Ringer's lactate (RL) in a rodent model of non-septic renal ischemia. METHODS: Forty male Wistar rats were randomized to receive HES 2 ml.kg-1.hr-1or RL 5 ml. kg-1.hr-1 that underwent 30 minutes of renal ischemia followed by reperfusion. Twelve hours after kidney ischemia, the kidneys were evaluated for histological changes. Serum NGAL levels were obtained at different times of the experimental protocol. RESULTS: Rodents in the HES group had a median (IQR) grade of renal injury 3 (3 to 5) compared to 2 (2 to 4) in the RL group (p=0.03). NGAL levels were not associated with the severity of kidney injury. CONCLUSION: Hydroxyethyl starch administration caused more kidney injury than Ringer's lactate in a non-infectious model of renal hypoperfusion.

Comparison of rheologic properties between Ca-alginate hydrogel microspheres suspension and whole blood / 生物医学工程学杂志

Starting from the form of red blood cells and the hematocrit (Hct, about 45 vol% of whole blood), we tried to prepare a kind of microspheres suspension to imitate non-Newtonian fluid property of whole blood, exploring its potentiality to be applied in blood viscosity quality control substance. In our study, we produced Ca-alginate hydrogel microspheres using emulsion polymerization, then we suspended the microspheres in 0.9 wt% NaCl solution to obtain a kind of liquid sample with the microspheres taking 45% volume. Then we used two types of viscometers to measure and analyse the changes of sample viscosity at different shear rate. We observed the forms of Ca-alginate hydrogel microspheres with microscope, and found them to be relatively complete, and their diameters to be normally distributed. Diameters of about 90% of the microspheres were distributed in a range from 6 to 22 micron. The samples were examined with viscometer FASCO-3010 and LG-R-80c respectively, both of which have shown a shear-thinning effect. After 5-week stability test, the CV of viscosity results corresponding to the two instruments were 7.3% to 13.8% and 8.9% to 14.2%, respectively. Although some differences existed among the results under the same shear rate, the general variation trends of the corresponding results were consistent, so the sample had the potentiality to be widely used in calibrating a different type of blood viscometer.

Plasma volume expanders: classification and characteristics of colloids

Fluid therapy remains an important therapeutic maneuver in managing surgical, medical, and the critically ill intensive care patient. However, the ideal volume replacement strategy remains under debate. The debate on whether patients should be managed with crystalloids, colloids, or both has for many years been mainly a debate about effectiveness. The dispute over crystalloids versus colloids has been enlarged to a colloid versus colloid debate because of the varying properties of different colloids. The natural colloid albumin and artificial colloids such as gelatin, dextran, and hydroxyethyl starch continue to enjoy widespread usage for clinical fluid management. Colloid is an effective plasma volume expander and is able to restore the hemodynamic profile with less total volume than crystalloid. However, colloid is associated with coagulation abnormalities, renal impairment, and allergic reactions. Albumin is considered to be one of the safe colloids. However, due to its cost, albumin cannot be recommended for hypovolemia. Gelatin and dextran can also cause coagulation abnormalities and renal impairment. Dextran is not used anymore due to its high anaphylactic potency. Each hydroxyethyl starch has different properties by concentration, mean molecular weight, molar substitution, and its C2/C6 ratio. New hydroxyethyl starches with a lower mean molecular weight and molar substitution than the old hydroxyethyl starch may be promising by improving volume management therapy with lower risks of coagulation abnormalities and renal impairment. The selection of colloid for plasma volume expansion should be based on the patients' clinical conditions and the characteristics of each colloid.

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.

A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery.

Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (P < 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12 th hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.

Albumina humana: usos e abusos / Human albumin: uses and abuses

A relevância da utilização de albumina em pacientes com doença aguda ou crônica permanece controversa. Apesar da importância fisiológica e dos potenciais efeitos benéficos, sua utilização é baseada na prática clínica e não sustentada nas evidências dos estudos clínicos. Resultados promissores de seu uso são confirmados na falência hepática, no infarto cerebral e, talvez, em situações de exceção na reposição volêmica de pacientes críticos.

The relevance of human albumin administration remains controversial. Albumin infusion has not proven to achieve clinical benefit in many acute and chronic disease states with a few exceptions in liver failure, cerebral infarction and may be in acute hypovolemia in the critical patients.

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.