Durasphere® EXP: a non-biodegradable agent for treatment of primary Vesico-Ureteral reflux in children

ABSTRACT Introduction: Durasphere® EXP (DEXP) is a compound of biocompatible and non--biodegradable particles of zirconium oxide covered with pyrolytic carbon. The aim of this study is to evaluate the durability of off-label use of DEXP in the treatment of primary vesicoureteral reflux in children. Materials and Methods: Patients who underwent subureteric injection of DEXP for the correction of primary VUR were retrospectively reviewed. Patients aged >18 years as well as those who had grade-I or -V VUR, anatomic abnormalities (duplicated system, hutch diverticulum), neurogenic bladder or treatment refractory voiding dysfunction were excluded. Radiologic success was defined as the resolution of VUR at the 3rd month control. Success was radiographically evaluated at the end of the first year. Results: Thirty-eight patients (9 boys, 29 girls; mean age, 6.3±2.7 years) formed the study cohort. Forty-six renal units received DEXP (grade II: 22; grade III: 18; grade IV: 6). Mean volume per ureteric orifice to obtain the mound was 0.70±0.16mL. First con- trol VCUG was done after 3 months in all patients. After the first VCUG, 6 patients had VUR recurrence. Short-term radiologic success of DEXP was 84.2%. Rate of radiologic success at the end of the first year was 69.4% (25/32). Lower age (p:0.006) and lower amount of injected material (p:0.05) were associated with higher success rates at the end of 1 year. Conclusion: This is the first study to assess the outcomes of DEXP for treatment of primary VUR in children. After 1 year of follow-up, DEXP had a 69.4% success rate.

The outcomes of two different bulking agents (dextranomer hyaluronic acid copolymer and polyacrylate-polyalcohol copolymer) in the treatment of primary vesico-ureteral reflux

ABSTRACT Purpose Subureteral injection of bulking agents in the endoscopic treatment of vesicoureteral reflux is widely accepted therapy with high success rates. Although the grade of vesicoureteric reflux and experience of surgeon is the mainstay of this success, the characteristics of augmenting substances may have an effect particularly in the long term. In this retrospective study, we aimed to evaluate the clinical outcomes of the endoscopic treatment of vesicoureteric reflux (VUR) with two different bulking agents: Dextranomer/hyaluronic acid copolymer (Dx/HA) and Polyacrylate polyalcohol copolymer (PPC). Materials and Methods A total 80 patients (49 girls and 31 boys) aged 1-12 years (mean age 5.3 years) underwent endoscopic subureteral injection for correction of VUR last six years. The patients were assigned to two groups: subureteral injections of Dx/HA (45 patients and 57 ureters) and PPC (35 patients and 45 ureters). VUR was grade II in 27 ureters, grade III in 35, grade IV in 22 and grade V in 18 ureters. Results VUR was resolved in 38 (66.6%) of 57 ureters and this equates to VUR correction in 33 (73.3%) of the 45 patients in Dx/HA group. In PPC group, overall success rate was 88.8% (of 40 in 45 ureters). Thus, Thus, this equates to VUR correction in 31 (88.5%) of the 35 patients. Conclusions Our short term data show that two different bulking agent injections provide a high level of reflux resolution and this study revealed that success rate of PPC was significantly higher than Dx/HA with less material.

Physicochemical Properties and Interfacial Adaptation of Root Canal Sealers

This study compared the physicochemical properties and interfacial adaptation to canal walls of Endo-CPM-Sealer, Sealapex and Activ GP with the well-established AH Plus sealer. The following analyses were performed: radiopacity, pH variation and solubility using samples of each material and scanning electron microscopy of root-filled bovine incisors to evaluate the interfacial adaptation. Data were analyzed by the parametric and no-parametric tests (α=0.05). All materials were in accordance with the ANSI/ADA requirements for radiopacity. Endo-CPM-Sealer presented the lowest radiopacity values and AH Plus was the most radiopaque sealer (p=0.0001). Except for ActiV GP, which was acidic, all other sealers had basic chemical nature and released hydroxyl ions. Regarding solubility, all materials met the ANSI/ADA recommendations, with no statistically significant difference between the sealers (p=0.0834). AH Plus presented the best adaptation to canal walls in the middle (p=0.0023) and apical (p=0.0012) thirds, while the sealers Activ GP and Endo-CPM-Sealer had poor adaptation to the canal walls. All sealers, except for ActiV GP, were alkaline and all of them fulfilled the ANSI/ADA requirements for radiopacity and solubility. Regarding the interfacial adaptation, AH Plus was superior to the others considering the adaptation to the bovine root canal walls.

Este estudo comparou as propriedades físico-químicas e a adaptação interfacial às paredes do canal dos cimentos Endo-CPM-Sealer, Sealapex e Activ GP com o bem estabelecido cimento AH Plus. As seguintes análises foram realizadas: radiopacidade, variação de pH e de solubilidade utilizando amostras de cada material, e microscopia eletrônica de varredura utilizando incisivos bovinos obturados para avaliar a adaptação interfacial. Os dados foram analisados utilizando testes paramétricos e não-paramétricos (α=0,05). Todos os materiais estavam de acordo com os requerimentos da ANSI/ADA para radiopacidade, sendo que o Endo-CPM-Sealer apresentou os menores valores de radiopacidade e o AH Plus foi o cimento mais radiopaco (p=0,0001). Exceto o Activ GP, que foi ácido, todos os outros cimentos apresentaram natureza química básica e liberaram íons hidroxila. Com relação à solubilidade, todos os materiais estavam de acordo com as recomendações da ANSI /ADA, sem diferença significante entre os cimentos (p=0,0834). O AH Plus apresentou a melhor adaptação às paredes do canal nos terços médio (p=0,0023) e apical (p=0,0012), enquanto que os cimentos Activ GP e Endo-CPM-Sealer apresentaram uma pobre adaptação às paredes do canal. Em conclusão, todos os cimentos, exceto o Activ GP, foram alcalinos e todos preencheram os requerimentos da ANSI/ADA para radiopacidade e solubilidade. Com relação à adaptação interfacial, o AH Plus foi superior aos demais para adaptação às paredes do canal radicular de incisivos bovinos.

Endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer and dextranomer/hyaluronic acid in adults

Purpose Aim of this study is to examine the effectiveness of dextranomer/hyaluronic acid copolymer and polyacrylate polyalcohol copolymer in endoscopic treatment of vesicoureteral reflux disease in adult patients with and without chronic renal failure. Materials and Methods Thirty two patients (12 female, 20 male) with a total of 50 renal units were treated for vesicoureteral reflux. There were 26 (81%) chronic renal failure patients. The success of treatment was evaluated by voiding cystouretrography at 3rd and 12th months after subureteric injection. The persistence of reflux was considered as failure. Patients were divided into two groups according to injected material. Age, sex, grade of reflux and treatment results were recorded and evaluated. Results Reflux was scored as grade 1 in seven (14%), grade 2 in 16 (32%), grade 3 in 21 (42%) and grade 4 in six (12%) renal units. There was not patient with grade 5 reflux. Fourteen renal units (28%) were treated with dextranomer/hyaluronic acid copolymer (group 1) and 36 renal units (72%) were treated with polyacrylate polyalcohol copolymer (group 2). The overall treatment success was achieved at 40 renal units (80%). The treatment was successful at 11 renal units (79%) in group 1 and 29 renal units (81%) in group 2 (p = 0.71). There was not statistically significant difference between two groups with patients with chronic renal failure in terms of treatment success (p = 1.00). Conclusions The effectiveness of two bulking agents was similar in treatment of vesicoureteral reflux disease in adult patients and patients with chronic renal failure. .

Clinical Value of Persistent but Downgraded Vesicoureteral Reflux after Dextranomer/Hyaluronic Acid Injection in Children

We aimed to investigate the clinical value of persistent but downgraded vesicoureteral reflux (VUR) after dextranomer/hyaluronic acid (Dx/HA) injection in children. The medical records of 128 children (195 ureters) who underwent Dx/HA injections for VUR were reviewed. The incidences of pre- and post-operative febrile urinary tract infections (UTIs) were analyzed in children with or without persistent VUR on voiding cystourethrography (VCUG) 3 months postoperatively. The surgical results of VUR persistent children who underwent a single additional injection were assessed. The VUR resolved completely in 100 ureters (51.3%), was persistent in 95 ureters, and newly developed in 2 ureters. The incidence of pre/post-operative febrile UTIs were 0.35 +/- 0.39 per year and 0.07 +/- 0.32 per year in VUR resolved children (P < 0.001), and 0.76 +/- 1.18 per year and 0.20 +/- 0.61 per year in VUR persistent children (P < 0.001). A single additional Dx/HA injection (44 ureters) resolved VUR in 29 ureters (65.9%), and also reduced the VUR to grade I in 7 ureters (15.9%), II in 4 (9.1%), and III in 4 (9.1%). Even in children with persistent VUR after Dx/HA injection, the incidence of febrile UTIs decreased markedly. The VUR grade significantly decreases after single additional Dx/HA injection.

Resolution of UTIs Post Deflux Injections for VUR May Be due to the Cure of BBD

No abstract available.

Desarrollo de un nanosistema para la liberación de fármacos intravítreo / Development of intravitreal nanosistema for drugs release

La inyección intravítrea ha sido la vía de administración más eficaz para el tratamiento de enfermedades vitreorretinianas. Su práctica continua, no es agradable para los pacientes y a su vez podría causar complicaciones indeseadas. El presente trabajo tuvo como objetivo desarrollar un nanosistema de liberación polímero-terapéutico (conjugado)/nanopartícula, utilizando Dextrano y Quitosano como polímeros transportadores biodegradables, hidrosolubles y compatibles a nivel ocular así como Hemisuccinato de Metilprednisolona como fármaco modelo. Primeramente, el fármaco fue capaz de unirse covalentemente a dos Dextranos de pesos moleculares 10 y 70 kDa. En función del contenido del componente activo y perfil de liberación, se seleccionó el Hemisuccinato de Metilprednisolona-Dextrano 10 kDa para elaborar las nanopartículas de Quitosano por el método de gelificación iónica empleando tripolifosfato sódico como agente entrecruzante. Por último, las nanopartículas fueron cubiertas con lactosa aplicando el secado por atomización. Se evaluó morfología, distribución de tamaño de las partículas, carga superficial, contenido y eficacia de captura del fármaco. Las partículas esféricas presentaron superficies lisas y uniformes. El pH tuvo influencia en el tamaño de las partículas observándose una distribución bimodal a pHs ≈ pKa del Quitosano y unimodal con un rango entre 130 - 170 nm a pHs < pKa. La variación de los potenciales Zeta entre los compuestos involucrados en la reacción, indicaron la posible ocurrencia de la misma. Al comparar la liberación del conjugado con las Nanopartículas a pH fisiológico, se observó que la encapsulación retrasó la liberación del fármaco alrededor de un 50%. Las nanopartículas recubiertas formaron micropartículas de 1.780 ± 0,5 nm, lo que favoreció su dispersibilidad en agua. Este nuevo nanosistema, evidenció su posible potencial en el desarrollo de formulaciones de liberación intravítrea, que reduzca la frecuencia de administración, ofreciendo una excelente alternativa que proporcione un mayor grado de satisfacción y mejore la calidad de vida del paciente.

Hallazgos ultrasonográficos en el tratamiento endoscópico del reflujo vésicoureteral / Ultrasound findings in the endoscopic treatment of vesicoureteral reflux

The use of endoscopio treatment in children with vesicoureteral reflux (VUR) requires ultra-sonographic controls. Radiologists should be aware of common findings to evaluate them properly and thus avoid misdiagnosis. A retrospective review of medical records, surgical protocols and images of 50 children treated with endoscopio injection of Deflux (dextranomer/hyaluronic acid copolymer) was conducted between years 2005 and 2008; 23 patients were discarded due to lack of controls. The following parameters were recorded: age, clinical diagnosis, location and type of injection, volume injected, time elapsed until the first control, ultrasonographic features, and excretory systems dilation. We analyzed 27 cases (45 refluxing kidney-ureter units, KUUs); age: ranging from 8 months to 17 years; VUR: 18 bilateral and 9 unilateral (6 right, 3 left). Urétera! orifice injection (STING): 12 KUUs; intramural distal ureter (HIT): 6; combined technique: 27 Deflux injected volume: 0.4 to 1.3 cc per each KUU. US control: from 1 week to 2 months post-procedure. Display: adequate in 35 KUUs (77.8 percent), regular in 9 KUUs (20 percent) and poor in 1 KUU (2.2 percent). Configuration: rounded in 30 KUUs, lobular in distal ureter in 10 KUUs, and mixed in 5 KUUs. No evidences of excretory system dilatation: in 37 KUUs (82.2 percent) and 8 cases with some degree of dilation (1 severe, symptomatic case).

El uso del tratamiento endoscópico en niños con reflujo vesicoureteral (RVU) requiere controles ultrasonográficos. Los radiólogos deben conocer los hallazgos habituales para evaluarlos adecuadamente y evitar diagnósticos erróneos. Se realizó una revisión retrospectiva de fichas, protocolos quirúrgicos e imágenes de 50 niños tratados con inyección endoscópica de Deflux (copolímero de dextranómero en ácido hialurónico), entre los años 2005 - 2008; 23 se descartaron por falta de controles. Se registró: edad, diagnóstico clínico, sitio y tipo de inyección, volumen inyectado, tiempo hasta control, características ultrasonográficas y dilatación de sistemas excretores. Se analizan 27 casos (45 unidades riñón-uréter refluyentes, URUR); edades: 8 meses-17 años; RVU: 18 bilateral y 9 unilateral (6 derechos, 3 izquierdos). Inyección en meato ureteral (STING): 12 URUR, intramural uréter distal (HIT): 6, técnica combinada: 27 Deflux, volumen inyectado: 0,4-1,3 cc por cada URUR. US de control: 1 semana - 2 meses post-procedimiento. Visualización: buena 35 URUR (77,8 por ciento), regular 9 (20 por ciento) y deficiente 1 (2,2 por ciento). Configuración: redondeada 30 URUR, lobulada en uréter distal 10 y mixta en 5. Sin dilatación del sistema excretor: 37 URUR (82,2 por ciento) y 8 con algún grado (1 importante, sintomático).

Blood loss and transcapillary refill in uncontrolled treated hemorrhage in dogs

Objetive: This study evaluated retroperitoneal hematomas produced by bilateral injury of iliac arteries (uncontrolled hemorrhage), blood volume loss, transcapillary refill, the effects of volume replacement on retroperitoneal bleeding and the hemodynamic changes with and without treatment. Methods: Initial blood volume was determined with Tc99m-labelled red cells, and bleeding was evaluated by means of a portable scintillation camera positioned over the abdomen. Previously splenectomized mongrel dogs (16.8 ± 2.2 kg) were submitted to hemorrhage for 30 minutes and randomized into three groups: I - no treatment (n=7); II - treatment with 32 mL/kg of Lactated Ringer's for three to five minutes (n=7); and III - treatment with 4 mL/kg of 7.5 percent NaCl plus 6.0 percent dextran 70 for three to five minutes (n=7). They were studied for an additional 45 minutes. Results: Volume replacement produced transitory recovery in hemodynamic variables, including mean pulmonary artery pressure, pulmonary capillary wedge pressure and cardiac index, with significant increase in dogs treated with 32 mL/kg of Lactated Ringer's and 7.5 percent NaCl plus 6.0 percent dextran 70 (p<0.001, against no treatment), along with a decrease (p<0.001) in the systemic vascular resistance index. Groups II and III had significant initial decreases in hematocrit and hemoglobin. The treated dogs (groups II and III) presented rebleeding, which was greater during treatment with 32 mL/kg of Lactated Ringer's (group II). Conclusions: Despite the rebleeding observed in treated groups, the utilization of hypertonic saline solution with dextran proved to be effective in the initial reanimation, producing evident transcapillary refill, while the Lactated Ringer's solution produced capillary extravasation and was ineffective in the initial volume replacement in this model of uncontrolled hemorrhage.

Choice of colloidal solutions in dengue hemorrhagic fever patients.

BACKGROUND: DHF is characterized by plasma leakage and abnormal hemostasis. About 20% of DHF patients do require colloidal solution in addition to conventional crystalloid solution for the treatment. There is only one colloidal solution, 10% Dextran-40 in NSS that proved to be effective for this group of DHF patients. OBJECTIVE: To compare 10% dextran-40 in NSS with 10% Haes-steril in NSS in the management of DHF cases with severe plasma leakage for their effectiveness and impact on renal function, hemostasis, disease severity, and complications. MATERIAL AND METHOD: DHF patients admitted to Dengue Unit, QSNICH, who do not respond to conventional crystalloid solution, are randomly assigned to receive either dextran or haes-steril. Clinical and laboratory comparison are recorded and analyzed using SPSS for Window version 14.0. RESULTS: There are 104 DHF patients enrolled in the study; 57 are assigned in dextran and 47 in haes-steril group. The mean ages are 8.6 +/- 3.9 years. About half of the patients in both groups require one dose of colloidal solution and 25% require 2 and 3 doses (p = 0.138). The average amount of IV fluid infused in dextran and haes-steril group are 119.4 and 129.3 ml (p = 0.227). The average drop in Hct after the bolus dose of both colloid are 7.9 and 8.5% (p = 0.381). About 80% of the patients in each group have shock (p = 0.843). The mean elevation of AST are 598 and 822 U (p = 0.548) while ALT elevation are 182 and 306 U (p = 0.265) in dextran and haes-steril group, respectively. BUN and creatinine are within normal limits and are decreased after the use of colloidal solutions. The amount of urine on day 1, 2 and 3 after the use of both colloidal solutions are not different. Coagulogram studies (PT, PTT and TT) in both groups are not different. Patients with significant bleeding and who require blood transfusions are 15.8 and 19.2% in dextran and haes-steril group (p = 0.423).The incidence of fluid overload in dextran and haes-steril group are 35.1 and 40.4% (p = 0.360). Other complications are not different between dextran and haes-steril group as follows: hypocalcaemia, hyponatremia, hypokalemia and acidosis. The overall severity and complications in both groups of patients are much higher than in DHF patients who respond to conventional crystalloid solution. No allergic reaction was found after the use of both colloidal solutions. CONCLUSION: 10% Haes-steril is as effective as 10% dextran-40 in the treatment of DHF patients who have severe plasma leakage. There are no differences in DHF disease severity and complications in both groups but the disease severity and complications, especially fluid overload are observed to be more comparative with admitted DHF patients. Both colloidal solutions are safe in DHF patients with no allergic reaction observed and no interference in renal functions and hemostasis.

Tratamiento endoscópico del reflujo vesicoureteral primario en sistemas únicos y dobles / Endoscopic treatment for primary vesicoureteral reflux in single and duplex system

El tratamiento endoscópico en el reflujo vésicoureteral primario es una alternativa disponible desde hace ya un tiempo. En nuestro hospital estamos usando el Deflux (copolimero de dextranomero en ácido hialurónico) desde 2002. En este trabajo revisamos la efectividad de este procedimiento en pacientes con distintos tipos y grados de reflujo. Método: Analizamos en forma prospectiva 25 pacientes, con 38 uréteres refluyentes, inyectados desde enero 2002 hasta diciembre 2005 que contaran con ecografía y uretrocistografía post operatoria. Resultados: El 86 por ciento (21) eran de sexo femenino, y su edad promedio fue de 6,1 años (2 a 14). El resultado fue exitoso en 73,6 por ciento (N=28) de los casos con una inyección, la cantidad de sustancia inyectada no fue relevante en el resultado. Se obtuvo mucho mejor resultado en los grados bajos, alcanzando 100 por ciento de resolución en los grados 1 y 2, (N=15) al igual que en los casos de uréter simple y unilateral (N=10). El peor resultado fue obtenido en los casos de uréter doble, resolviéndose sólo en 1 de 6 uréteres. El procedimiento fue siempre ambulatorio y no tuvimos complicaciones perioperatorias. Conclusiones: Nos parece que el tratamiento endoscópico con Deflux es un muy buen tratamiento para el reflujo vésicoureteral primario como alternativa tanto al tratamiento médico, como al quirúrgico, especialmente en los casos unilaterales y en sistemas únicos. Los autores recomiendan esta técnica en el moemnto de aconsejar a los padres.

Purpose: Effectivety for endoscopic treatment for primary reflux has been under discussion as a single procedure. In the last 3 years our unit have been used Deflux, (dextranomer copolymer in hialuronic acid) for this pathology. The aim of this study is to analyze the results of our experience. Material and Methods: Since 2002, a prospective protocol for VUR has been applied. We reviewed the last 25 cases treated with DefluxTM injection who had ultrasound and cistography. Results: 86% (N=21) were females and with a mean age of 6.1 years (range 2-14) the success rate with a single injection was 73.6% (N=28). The amount of deflux injected was irrelevant in the result . The results in the low grades reflux (I-II) reaching the 100% (N=15). The worse result was in the double system cases with just one successful case out of 6 injected. The procedure was in outpatient bases. There were no periprocedures complications. Conclusions: The endoscopic treatment for VUR with Deflux , is a good alternative to medical treatment especially in single ureter with low grade. Therefore the authors recommend this technique at the time of counseling parents.

Efeito do dextran sobre a intensidade das aderências peritoneais intra-abdominais pós-operatórias: estudo experimental em ratos / Effect of dextran on postoperative peritoneal adhesions: experimental study in rats

Os autores pesquisam o efeito do Dextran 40 sobre a formação de aderências pós-operatórias em um modelo experimental em ratos. Vinte ratos Wistar foram divididos de forma aleatória em dois grupos. Ambos os grupos foram submetidos a laparotomia mediana e realizada escarificação serosa do peritônio visceral do intestino grosso e peritônio parietal adjacente. O grupo 1 (controle), formado por dez animais que não receberam tratamento complementar, e o grupo 2, formado por dez animais nos quais administrou-se Dextran 40 na cavidade peritoneal. No vigésimo dia de pós-operatório, os animais foram mortos e submetidos a nova laparotomia mediana e retirada dos segmentos intestinais previamente escarificados. A análise histológica das peças operatórias demonstrou menor formação de fibrose no grupo de animais nos quais foi utilizado Dextran 40 (grupo 2), quando comparados ao grupo controle (p<0,05). Os autores concluem que o Dextran 40 interfere no processo de fibrinogênese reduzindo as aderências intra-abdominais pós-operatórias

Hypertonic saline resuscitation

Treatment of severe hemorrhage offers few theoretical problems, but in practice, severe blood loss usually occurs out of hospital, often in more or less inaccessible scenarios. Controversy rages over ideal fluid, ideal volume, and minimum O2 carrying capacity, but all agree that pre-hospital, isotonic resuscitation is unfeasible. The effects of highly hypertonic 7.5 per cent NaCl (HS) was first described in 1980, when we showed that it induced immediate and long lasting hemodynamic restoration. The addition of 6 per cent dextran-70 to (HSD) significantly enhances the duration and intensity of volume expansion, with no loss of hemodynamic effects. HS/HSD restores cardiac output, arterial pressure, base excess and oxygen availability, induce pre-capillary vasodialtion, moderate hypersmolarity and hypernatermia, reversal of high glucose and lactate. It interferes with endocrine secretions when administered to animals in hemorrhagic hypotension. HS acts through transient plasma volume expansion, positive inotropic effect on cardiac contractility, precapillary vasodilation through a direct action on vascular smoth muscle. Expansion of circulating volume is part of the mechanism, the extra volume coming from the intracellular compartment fluid, especially from endothelial and red blood cells, which facilitate microcirculatory flow. The new field of interactions of hypertonicity with the immune mechanisms may provide insight into the long lasting effects of hypertronic solutions. Randomized double blind prospective studies on the effects of HS, or HSD, used as first treatment of shock show that both are safe and free from collateral, toxic effects. These studies show an early significant rise in arterial blood pressure and a non-significant trend towards higher levels of survival. HSD administration to patients about to undergo cardiopulmonary bypass for cardiac surgery results in higher cardiac output before, and immediately following cardiopulmonary bypass, as well as zero fluid balance.

Manejo de líquidos en el shock traumático / Liquid management in traumatic shock

La injuria traumática puede alterar de muchas maneras la relación transporte de oxígeno/consumo de oxígeno, pudiendo conducir a una situación de shock. El uso de fluidos de reanimación intravenosa durante el tratamiento inicial puede restablecer la perfusión a nivel tisular, mejorando el transporte de oxígeno arterial. Luego de la evaluación inicial debe iniciarse la resucitación con la infusión de 2000 ml de soluciones cristaloides en el adulto, y/o de 20 ml/kg en el paciente pediátrico. En muchos casos debe adicionarse sangre y/o soluciones coloidales para mantener la hemodinamia. El cuidadoso monitoreo del paciente, incluso con la medición de PVC, PWCP, TAM, etc., permite brindarle la mejor opción de tratamiento.

The crystalloid vs colloid controversy in the era os hypertonic/hyperoncotic resuscitations: is the debate over?

The crystalloid vs. colloid controversy has been further complicated by the inclusion of hypertonic levels of sodium chloride (HTS) in both types of regimens. In this paper the recent literature on the controversy is reviewed. Colloids raise the intravascular colloid osmotic pressure and increase the fluid retention in the vessels. Crystalloids however, distribute into the interstitial and intravascular spaces at a ratio of approximately 3 to 1. It is therefore necessary to infuse a large volume of crystalloids in order to complete resuscitation. The advantage of colloids over isotonic crystalloids focuses primarily on the incidence of pulmonary edema. In an analysis of clinical trials, however, colloids were not proven to be superior to crystalloids. The use of HTS decreases the amount of crystalloid required for resuscitation. Pulmonary and systemic vasodilation, an increase in cardiac output and stroke volume, decreased intracranial pressure and an enhanced immunologic response have been noted experimentally, and the clinical evidence seems to corroborate these findings. HTS with dextran (HSD) has been used in an attempt to combine the rapid cellular fluid shift of hypertonicity with the vascular fluid shift of colloids. The experimental evidence is compelling. Whereas HTS has proven itself to be a superior resuscitation regimen, HSD has not yet warranted in a clinical setting the optimism which its experimental studies seem to indicate.

Hypertonic volume therapy: feasibility in the prevention and treatment of multiple organ failure and sepsis

As soluçoes salinas hipertônicas em pequeno volume, aplicadas em "bolo", empregaram-se originalmente no tratamento do choque hemorrágico e traumático grave, demonstrando a rápida restauraçao hemodinâmica e do fluxo sangüíneo orgânico regional. Os mecanismos de açao sao diversos - 1. manutençao de débito cardíaco elevado (estímulo direito do miocárdio; aumento do volume intravascular); 2. manutençao da vasodilataçao arterial periférica (efeito da hiperosmolaridade; aumento do volume plasmático); 3. reduçao do endema tecidual (fluxo de liquido do intertício decorrente do gradiente osmótico). Estes eventos promovem a recuperaçao da acentuada alteraçao na microcirculaçao, que freqüentemente sao também observadas na sepse. MATERIAL E MÉTODOS: O uso destas soluçoes tem sido objeto de vários estudos em modelos experimentais de endotoxemia hiperdinâmica aguda, entretanto, um maior número de estudos clínicos sao necessários para melhor compreensao dos efeitos positivos, ou eventualmente deletérios, da utilizaçao das soluçoes cristalóides hipertônicas em pequeno volume na terapêutica da sepse e falência de mútiplos orgaos. OBJETIVO: O objetivo deste artigo 'e analisar o conceito de uso de soluçoes hipertônicas e o seu potencial no tratamento da intensa e deterioraçao da microcirculaçao, que ocorre na sepse e no choque endotóxico.