Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses.

BACKGROUND: Crystalloids and different component colloids, used for volume resuscitation, are sometimes associated with various adverse effects. Clinical trial findings for such fluid types in different patients' conditions are conflicting. Whether the mortality benefit of balanced crystalloid than saline can be inferred from sepsis to other patient group is uncertain, and adverse effect profile is not comprehensive. This study aims to compare the survival benefits and adverse effects of seven fluid types with network meta-analysis in sepsis, surgical, trauma, and traumatic brain injury patients. METHODS: Searched databases (PubMed, EMBASE, and Cochrane CENTRAL) and reference lists of relevant articles occurred from inception until January 2020. Studies on critically ill adults requiring fluid resuscitation were included. Intervention studies reported on balanced crystalloid, saline, iso-oncotic albumin, hyperoncotic albumin, low molecular weight hydroxyethyl starch (L-HES), high molecular weight HES, and gelatin. Network meta-analyses were conducted using random-effects model to calculate odds ratio (OR) and mean difference. Risk of Bias tool 2.0 was used to assess bias. Confidence in Network Meta-Analysis (CINeMA) web application was used to rate confidence in synthetic evidence. RESULTS: Fifty-eight trials (n = 26,351 patients) were identified. Seven fluid types were evaluated. Among patients with sepsis and surgery, balanced crystalloids and albumin achieved better survival, fewer acute kidney injury, and smaller blood transfusion volumes than saline and L-HES. In those with sepsis, balanced crystalloids significantly reduced mortality more than saline (OR 0.84; 95% CI 0.74-0.95) and L-HES (OR 0.81; 95% CI 0.69-0.95) and reduced acute kidney injury more than L-HES (OR 0.80; 95% CI 0.65-0.99). However, they required the greatest resuscitation volume among all fluid types, especially in trauma patients. In patients with traumatic brain injury, saline and L-HES achieved lower mortality than albumin and balanced crystalloids; especially saline was significantly superior to iso-oncotic albumin (OR 0.55; 95% CI 0.35-0.87). CONCLUSIONS: Our network meta-analysis found that balanced crystalloids and albumin decreased mortality more than L-HES and saline in sepsis patients; however, saline or L-HES was better than iso-oncotic albumin or balanced crystalloids in traumatic brain injury patients. TRIAL REGISTRATION: PROSPERO website, registration number: CRD42018115641).

Resuscitation Fluid Choices to Preserve the Endothelial Glycocalyx.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

The use of colloid probe microscopy to predict aerosolization performance in dry powder inhalers: AFM and in vitro correlation.

The atomic force microscope (AFM) colloid probe technique was utilized to measure cohesion forces (separation energy) between three drug systems as a function of relative humidity (RH). The subsequent data was correlated with in vitro aerosolization data collected over the same RH range. Three drug-only systems were chosen for study; salbutamol sulphate (SS), triamcinolone acetonide (TAA), and di-sodium cromoglycate (DSCG). Analysis of the AFM and in vitro data suggested good correlations, with the separation energy being related inversely to the aerosolization performance (measured as fine particle fraction, FPF(LD)). In addition, the relationship between, cohesion, RH, and aerosolization performance was drug specific. For example, an increase in RH between 15% and 75% resulted in increased cohesion and decreased FPF(LD) for SS and DSCG. In comparison, for TAA, a decrease in cohesion and increased FPF(LD) was observed when RH was increased (15-75%). Linear regression analysis comparing AFM with in vitro data indicated R(2) values > 0.80, for all data sets, suggesting the AFM could be used to indicate in vitro aerosolization performance.

Evaluation of a new composite dressing for the management of chronic leg ulcer wounds.

OBJECTIVES: A new composite dressing (Versiva, ConvaTec) combines three technologies: hydrocolloid, hydrofibre and a foam-film layer. This study aimed to assess the safety of the dressing in the management of patients with venous leg ulcers. Clinical performance was also assessed. METHOD: This multicentre, non-randomised, open-label, phase II study assessed the safety (via adverse-effect reporting) and performance, including weartime, absorption, dressing integrity, ease of use and wound progression, of Versiva. Up to 10 dressing changes were assessed within a five-week study period. RESULTS: In 75 dressing changes of 11 ulcers, the mean wear time was approximately five days. No or minimal leakage was observed in 81% of changes. In 93%, the dressing was 'very easy' to remove, with no trauma to surrounding skin. Most changes (77%) were painless. CONCLUSION: Versiva met or exceeded the investigators' expectations for exudate absorption, protection of peri-wound skin and reduction in wound pain and ulcer area. Healing or marked improvement was observed in 82% of leg ulcers within the five-week study. The relatively long wear-time of five days represents a cost-effective advantage for this dressing compared with other available adhesive foams for the management of chronic wounds.

Controlled, randomized clinical trial of 2 hydrocolloid dressings in the management of venous insufficiency ulcers.

A prospective, randomized study was conducted to compare the performance of 2 hydrocolloid dressings, hydrocolloid A and hydrocolloid B, in the treatment of venous insufficiency ulcers. A total of 31 patients were enrolled at 2 clinical sites. Complete wound closure (100% epithelialization) was observed in 59% of the patients treated with hydrocolloid A, compared with complete wound closure in 15% of the patients in the hydrocolloid B group (P

An in-vitro study of the pressure-relieving properties of four wound dressings for foot ulcers.

This in-vitro study reports on a selection of mechanical tests on four wound dressings: Allevyn (Smith and Nephew), Biatain (Coloplast), Lyofoam (Seton Scholl) and Tielle (Johnson and Johnson). The aim of the study was to investigate these dressings in the laboratory by subjecting them to dry and wet compression tests, shearing tests and a cyclical test. As predicted, all dressings performed differently in the range of tests, with Lyofoam deforming the most when subjected to compression testing (5.6 mm). During wet compression, differences in the physical properties of all the materials tested were identified. During shearing testin, Allevyn and Tielle withstood the greatest shear deflection before failure, but Biatain withstood the greatest force before failing. During the cyclical testing, Lyofoam only reduced by 1% of its original thickness, while Biatain reduced by 30%. No one dressing performed better in all the tests. However, as an all-round 'pressure-relieving' dressing, Allevyn consistently outperformed the others in the study.

The influence of four wound dressings on the kinetics of human walking.

OBJECTIVES: This in vivo study (the second phase of a research project first described in the February issue of Journal of Wound Care) reports on the influence of various wound dressings on the dynamics of human walking. Allevyn (Smith and Nephew), Biatain (Coloplast), Lyofoam (Seton Scholl) and Tielle (Johnson and Johnson) were used in this study. The investigation aimed to assess the ground reaction forces in the foot while the dressings were applied to the plantar surface of the foot. METHOD: A strain gauge force plate system was used. Six subjects with 'normal' gait patterns and no foot pathology were recruited into the study. Eight trials were recorded for each subject. The peak push-off force, in the vertical component of the ground reaction force, and the maximum braking and propulsive forces in the medial-lateral component of the ground reaction force were estimated and reported. RESULTS: Among the various dressings tested, Allevyn performed closest to barefoot in the peak push-off force and demonstrated an increased braking force at the deceleration point in the gait cycle. CONCLUSION: These findings may have implications for clinicians selecting wound dressings for the treatment of certain foot ulcerations. However, further clinical research is warranted in this area.

Dressing selection for the treatment of coumarin necrosis.

The correct dressing selection is of vital importance in producing as rapid a healing response as possible. John Timmons demonstrates the effects of a new dressing for the treatment of coumarin necrosis. Coloplast, the manufacturers of the dressing, Biatain Adhesive, supported the author while he was treating the patient.

The cleaning of polymer colloids.

The current state of knowledge of the cleaning of polymer colloids is reviewed with regard to a wide range of cleaning and characterisation techniques. The type, level and quantity of impurities involved with different polymer latex formulations varies widely. Even for similar formulations, differences in the nature and number of functional groups reported are often a consequence of sometimes subtle differences in the cleaning procedures employed. Not only may surface functionality be affected but also monomer and oligomer extraction procedures may lead to morphological changes in the particles. No single technique alone is likely to be able to remove all impurities. Care is needed to avoid the introduction of new impurities from the equipment, materials and water used as well as possible contamination from atmospheric carbon dioxide, bacteria and fungi. These factors also need to be considered in the storage of latex particle standards.

A study to compare two film dressings used as secondary dressings.

Dressings manufactured from adhesive polymeric films have been used extensively in wound management for about 20 years. This report describes the results of a trial designed to compare the performance of two such dressings, used as secondary dressings, in a multi-centre randomised controlled community study involving 100 patients. Independent analysis of the study data revealed that, after adjusting for other effects, no genuine difference was demonstrated between the dressings in terms of their ability to resist wrinkling or prevent maceration (the primary outcome variable).

Heel pressure relieving devices how effective are they?

This study of patients hospitalized for hip replacement or treatment of hip dislocation or fractured neck or shaft of the femur compared the efficacy of three approaches to the care of the patients' heels. A control group of 15 patients received routine nursing care and treatment groups of 15 and 20 patients received routine nursing care combined with the use of hydrocolloid dressing and eggcrate foam respectively. The combination of routine nursing care and the use of eggcrate foam was found to be more effective method of maintaining skin integrity than nursing care alone or nursing care combined with the use of hydrocolloid dressing. The study findings support the use of eggcrate foam as a heel pressure relieving device and it is recommended that its use is initiated from the time patients are admitted to hospital.

The cytocompatibility of hydrocolloid dressings.

The purpose of this study was to evaluate the effect on fibroblast proliferation of hydrophilic particles isolated from six commercial hydrocolloid dressings. The hydrophobic adhesive matrix of six hydrocolloid dressings was removed using a reflux extraction method with an organic solvent (xylene). The remaining hydrophilic particles were dissolved in complete cell growth medium containing 10% (v/v) foetal calf serum and added to confluent human dermal fibroblasts grown in monolayer in final concentrations of 0.1 and 0.01% (w/v). Control cells received growth medium alone. The fibroblasts were incubated with the hydrophilic particles and the thymidine analogue 5-bromo-2'-deoxyuridine (BrdU) for 24 hours. The incorporation of BrdU into DNA was used as a measure of cell proliferation and determined using an ELISA kit. The results were expressed in percentage of control-treated wells and analysed using analysis of variance. Apart from Comfeel Plus, the hydrophilic particles of hydrocolloid dressings significantly inhibited fibroblast proliferation at 0.1% compared to control-treated fibroblasts (p < 0.05).

A comparison of two dressings in pressure sore management.

This study compared a polyurethane foam dressing with a hydrocolloid dressing for ease of application and removal, adhesion, conformability, absorbency and wear time. A randomised study was carried out, including 61 patients with stage two or three pressure sores in five centres in the UK. Dressings were applied for up to 30 days and assessments were carried out at each dressing change. The results indicated that both dressings are easy and convenient to apply; absorbency and ease of removal were significantly better with the polyurethane foam dressing than the hydrocolloid dressing; wear times were similar.

Tegasorb hydrocolloid dressing: advanced formulation.

Tegasorb advanced formulation hydrocolloid dressing from 3M Healthcare can be used on a variety of wounds, e.g. leg ulcers and donor sites. It encourages a moist wound-healing environment and can be used in all stages of wound healing, from black necrotic tissue to the epithelializing wound. Tegasorb is a well-established hydrocolloid dressing that has recently been relaunched as an advanced formulation.

Evaluation of a hydrocolloid dressing.

A hydrocolloid dressing was compared to adhesive skin tapes on children's postoperative wounds. A total of 170 children of varying ages were randomised in two parallel groups, in nine centres of plastic, thoracic, gastrointestinal, urogenital and orthopaedic surgery. Skin closure was satisfactory in both groups, with 76 (89.4%) healthy closures without dehiscence in the hydrocolloid group and 81 (95.3%) in the control group; a relationship was found between partial closures/dehiscence and the type of surgical procedure. No product-related maceration, infection or adverse event was reported during the study and both groups showed very satisfactory cosmetic results.

31P NMR spectroscopic analysis of wound healing: the effect of hydrocolloid therapy.

With the advent of managed care, wound care professionals have limited time to heal chronic wounds. They need to know whether the repair process is progressing or stagnating in response to treatments. Phosphorus-31 (31P) nuclear magnetic resonance (NMR) spectroscopic measurements of chronic wound biochemistry yields rapid knowledge of whether a wound is generating, storing, or using energy. We used 31P NMR analysis on biopsy samples to explore the energy status of two chronic non-healing leg ulcers, before and after the first week of treatment with two low-pH hydrocolloid materials. Energy generation (i.e., energy "charge") was initially low in both wounds and was significantly elevated after 1 week of treatment. Earlier work has shown that leg ulcer pathophysiology is altered during the first week of hydrocolloid treatment. This work traces the origins of such effects deeper into the cellular biochemistry and correlates the measures with the final healing outcome. 31P NMR spectroscopy may provide a real-time biochemical "fingerprint" that shows clinicians the healing status of a questionable wound. Further study is needed to confirm the reliability and validity of 31P NMR spectroscopy as a predictor of healing outcomes in other wound environments.

In vitro assessment of water vapour transmission of synthetic wound dressings.

The water vapour transmission rate (WVTR) of 14 commercially available wound dressings (11 hydrocolloids, 2 hydrogels and 1 polyurethane film) was evaluated over 24 and 48 h periods using a modified ASTM standard method (ASTM E96-90). For the 48 h studies a novel microcomputer-controlled apparatus was employed. The dressings exhibited a wide range of WVTRs (76-9360 g m-2 d-1 at 24 h under forced air convection of 0.4 m s-1). The influence of air velocity of 0.4 m s-1 was not significant if the WVTR of the dressing was less than 880 g m-2 d-1 when measured under static air conditions. The influence of outer barrier layers and additional bandages on WVTR was also examined.

A comparative study of wound dressings on full-thickness wounds in micropigs.

Eight full-thickness (to the depth of adipose tissue) skin wounds were surgically inscribed on the backs of four Yucatan micropigs (32 wound sites in total). Wound sites were created to allow for controlled comparative evaluation between wound sites, wound dressings, and specified postoperative healing time. The wounds were dressed with either ClearSite hydrogel dressing (New Dimensions in Medicine, Dayton, Ohio) or Duoderm hydrocolloid wound dressing (ConvaTec Inc., Princeton, New Jersey). Tracings and photographs of each wound site were made and computerized planimetry was done to compare the rate of epithelialization for like wounds and like wound dressings. Histomorphometric measurements were also made to compare the effects of the dressing on the wounds at the cellular level. The results of this study indicate that the wounds covered with the hydrogel dressing exhibited a more rapid rate of closure and reepithelialization as compared with the hydrocolloid wound dressing.

A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers.

To compare the efficacy and the cost-effectiveness of moist gauze dressings and a hydrocolloid wafer dressing (DuoDERM CGF), 70 patients with 97 pressure ulcers that were stage II and/or stage III were randomly assigned to one of two treatment methods: moist gauze dressings or hydrocolloid dressings. Efficacy was defined as the number of ulcers that completely healed. In this debilitated, poorly nourished group of patients, one ulcer completely healed in the moist gauze dressing group, and 11 healed in the hydrocolloid group. The per diem cost of the moist gauze dressing was $12.26; the per diem cost of the hydrocolloid dressing was $3.55.