Effects of Plasma-Lyte® and 0. 9% saline in renal function after deceased-donor kidney transplant: a randomized controlled trial

Abstract Background The influence of different crystalloid solutions infused during deceased-donor kidney transplant on the incidence of delayed graft function remains unclear. We investigated the influence of Plasma-Lyte® vs. 0.9% saline on the incidence of delayed graft function in deceased-donor kidney transplant recipients. Methods We conducted a single-blind randomized controlled trial of 104 patients aged 18 to 65 years who underwent deceased-donor kidney transplant under general anesthesia. Patients were randomly assigned to receive either Plasma-Lyte® (n = 52) or 0.9% saline (n = 52), at the same infusion volume, for intraoperative fluid replacement. The primary outcome was the occurrence of delayed graft function. Secondary outcomes included metabolic and electrolytic changes at the end of surgery. Results Two patients in the Plasma-Lyte® group and one in the 0.9% saline group died postoperatively and were not included for analysis. The incidence of delayed graft function in Plasma-Lyte® and 0.9% saline groups were 60.0% (95% Confidence Interval [95% CI 46.2-72.4]) and 74.5% (95% CI 61.1-84.4), respectively (p= 0.140). Mean (standard deviation) values of immediate postoperative pH and serum chloride levels in Plasma-Lyte® and 0.9% saline groups were 7.306 (0.071) and 7.273 (0.061) (p= 0.013), and 99.6 (4.2) mEq.L-1 and 103.3 (5.6) mEq.L-1, respectively (p< 0.001). All other postoperative metabolic and electrolyte variables were not statistically different at the immediate postoperative period (p> 0.05). Conclusion In deceased-donor kidney transplant recipients, the incidence of delayed graft function is not influenced by Plasma-Lyte® or 0.9% saline used for intraoperative fluid replacement.

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! / Control de Daños Prehospitalario: ¡Para Los Cristaloides, Para La Hipotermia Y…! ¡Para El Sangrado!

Abstract Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Resumen La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.

Whole blood for blood loss: hemostatic resuscitation in damage control / Sangre total: la nueva alternativa en la resucitación hemostática

Abstract Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

Resumen El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.

Comparison of the effects of albumin and crystalloid on mortality among patients with septic shock: systematic review with meta-analysis and trial sequential analysis

ABSTRACT BACKGROUND: This study aimed to compare the effects on mortality of albumin and crystalloid, used for fluid resuscitation among adult patients with septic shock, through conducting a meta-analysis and trial sequential analysis (TSA). DESIGN AND SETTING: Meta-analysis and TSA conducted at Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China. METHODS: Data were collected from several major databases including MEDLINE, EMBASE, Clinical Trials.gov and Cochrane Central Register of Controlled Trials. Studies that compared the effects of albumin therapy versus crystalloid therapy on mortality among adult septic shock patients were eligible for inclusion in the analyses. The study name, year of publication, country of the trial, albumin concentration, type of crystalloid and all reported mortalities at different follow-up endpoints were extracted. RESULTS: Compared with crystalloid, albumin did not decrease all-cause mortality at the final follow-up. However, in TSA, the required information size was not achieved in all groups, which means that the effect size was not definitive and further RCTs are needed to confirm or deny these findings CONCLUSIONS: Compared with crystalloid solutions, albumin was unable to decrease all-cause mortality. However, TSA indicated that these results could be false-negative. Additional randomized controlled trials are needed to clarify this discrepancy.

The impact of the initial fluid resuscitation with different ratio of crystalloid and colloid on the prognosis of patients with moderate severe acute pancreatitis / 中华胰腺病杂志

Objective To investigate the impact of the initial fluid resuscitation with different ratio of crystalloid and colloid on the prognosis of patients with moderate severe acute pancreatitis (MSAP).Methods A retrospective analysis was made by reviewing the clinical data of 72 patients with the diagnosis of MSAP from January 2015 to July 2017 in Shanghai Changhai Hospital.According to crystalloid-colloid ratio,which was the total volume of crystalloid fluid versus colloid fluid in the first 7d at admission,patients were randomly divided into low crystalloid-colloid ratio group (＜ 4.5),middle crystalloid-colloid ratio group (4.5-7.5),and high crystalloid-colloid ratio group (＞ 7.5).The parameters of the fluid resuscitation,the cases progressing into severe acute pancreatitis (SAP),the incidence of multiple organs dysfunction syndrome (MODS) and mechanical ventilation,pancreatic necrosis and infection rate,30-day mortality,the duration of systemic inflammatory response syndrome(SIRS) and the time reaching full amount of enteral nutrition were analyzed.Results There was no statistically significant difference in gender,age,etiology and APACHE Ⅱ score within 24 h at admission in each group,which were comparable.Within the first 7 d,there were no statistic difference in the total volume of fluid infusion and the speed of resuscitation in the three groups.While the total fluid volume in the first 24 h and 72 h [(3 095 ± 1 253) ml vs (2 524 ± 751) ml,(8 005 ± 7 269) ml vs (6 667 ± 1 498)ml],the total volume of crystalloid fluid in the first 7 d [(14 485 ± 3 917) ml vs (11 544 ±2 639) ml],crystalloid-colloid ratio (12.7 ± 4.9 vs 6.0 ± 1.0),the cases of SAP (12 vs 4),MODS (41.7 ％vs 16.0％) in high ratio group were significantly higher than those in middle ratio group,but the total volume of colloid fluid was significantly lower [(996 ± 528) ml vs (1 968 ± 574) ml].In addition,the duration of SIRS [(16.5 ± 15.2) d vs (8.2 ± 6.4) d],and the time reaching full amount of enteral nutrition [(7.2 ±3.6) d vs (4.8 ± 2.4) d] in high crystalloid-colloid ratio group were higher than those in middle crystalloid-colloid ratio group (all P ＜ 0.05).Comparing with middle crystalloid-colloid ratio group,there were no significant difference in the mechanical ventilation rate,pancreatic necrosis and infection rate and 30-day mortality in high ratio group.The total volume of colloid fluid was significantly higher [(3 680 ± 1 310) vs (1 968 ±574)] and the crystalloid-colloid ratio was significantly lower [(3.2 ±0.9) vs (6.0 ± 1.0)] in low ratio group than that in middle ratio group,and there were no statistical differences on other parameters.Conclusions For the patients with MSAP,early fluid resuscitation with the crystatloid-colloid ratio of (4.5-7.5) can decrease the incidence of SAP and MODS,shorten the duration of SIRS,and promote the recovery of intestinal mucosal barrier function.

Volume kinetics of lactated Ringer's solution during induction of epidural versus general anesthesia in elderly patients / 中华麻醉学杂志

Objective To compare the volume kinetics of lactated Ringer' s solution during induction of general and epidural anesthesia in elderly patients.Methods Forty ASA Ⅰ or Ⅱ patients,aged 66-86 yr,weighing 45-86 kg,undergoing elective surgery,were studied.In epidural anesthesia group (n =20),lactated Ringer' s solution was infused intravenously starting from 10 min before epidural anesthesia was performed with local anesthetics.In general anesthesia group (n =20),lactated Ringer' s solution 1000 ml was infused intravenously over 60 min starting from 20 min before induction of anesthesia.Arterial blood samples were obtained every 5 min for measurement of hemoglobin concentrations.The plasma dilution,volume increase,and volume expansion efficacy were calculated.Results The plasma dilution,volume increase and volume expansion were significantly higher at 30-60 min of lactated Ringer' s solution infusion in general anesthesia group than in epidural anesthesia group (P ＜ 0.05 or 0.01).Conclusion The volume expansion of lactated Ringer' s solution is greater in elderly patients during induction of general anesthesia than that during induction of epidural anesthesia.