Repercusión del cebado con coloides y la ultrafiltración sobre el sangrado posoperatorio y la transfusión sanguínea en cirugía cardiaca. Ensayo clínico aleatorizado / Effect of priming solution and ultrafiltration on post-operative bleeding and blood transfusion in cardiac surgery. Randomized controlled trial

Objetivo. Valorar la eficacia del cebado del sistema de circulación extracorpórea con albúmina-manitol asociado a ultrafiltración para reducir el sangrado posoperatorio y las necesidades transfusionales en cirugía cardiaca, así como su repercusión sobre los balances hídricos, los parámetros de coagulación y hematimetría, la reintervención por sangrado y la estancia en UCI y hospitalaria. Material y métodos. Ciento treinta y cuatro pacientes programados en cirugía cardiaca fueron aleatorizados para recibir en el cebado Ringer lactato 1.500 mL (grupo C), o 250 mL de manitol 20%, 150 mL de albúmina 20% y 1.100 mL de Ringer lactato asociado a ultrafiltración (grupo T). Se determinaron el volumen de sangrado, las transfusiones, los balances hídricos, los parámetros de coagulación y la hematimetría hasta las 48 h del posoperatorio. Resultados. Encontramos una reducción en el grupo T del sangrado posoperatorio, 1.165 ± 789 mL frente a 992 ± 662 mL (p = 0,17), y de la transfusión de hematíes, 694 ± 843 mL frente a 413 ± 605 mL (p = 0,03). El balance hídrico intraoperatorio y posoperatorio fue significativamente menos positivo en el grupo T, con un balance global de 2.292 ± 2.152 mL frente a 5.388 ± 2.834 mL (p < 0,001). Hubo valores superiores de hemoglobina y hematocrito intraoperatorio (p < 0,001), al ingreso en UCI (p = 0,001) y a las 6 h (p = 0,05) en el grupo T, e inferiores de INR a las 6 h (p = 0,01) y 24 h (p = 0,02). Las tasas de reintervención y estancia en UCI fueron superiores en el grupo C, pero no significativas. Conclusiones. El cebado del sistema de circulación extracorpórea con manitol, albúmina y Ringer lactato, asociado a ultrafiltración, mejora significativamente los balances hídricos intraoperatorio y posoperatorio y reduce el volumen de transfusión de sangre, con una repercusión no significativa sobre el sangrado posoperatorio, reintervenciones por sangrado y estancia en UCI (AU)

Objective. Assess the effectiveness of priming the extracorporeal circulation system with albumin-mannitol combined with ultrafiltration during extracorporeal circulation to reduce post-operative bleeding and transfusion requirements in heart surgery, as well as its impact on the fluid balance, coagulation and hematocrit parameters, re-operation for bleeding, ICU, and hospital length of stay. Material and methods. A total of 134 patients scheduled for heart surgery were randomized to receive Ringer's lactate 1,500 mL in the priming reservoir (group C), or mannitol 20% 250 mL, albumin 20% 150 mL and Ringer's lactate 1,100 mL combined with ultrafiltration (group T). Bleeding volume, transfusions, fluid balance, coagulation, and hematology parameters were determined until 48 h in the post-operative period. Results. There was a reduction of postoperative bleeding in group T, 1,165 ± 789 mL vs 992 ± 662 mL (P = .17), and red blood cell concentrate transfusions, 694 ± 843 mL vs 413 ± 605 mL (P = .03). Intra-operative and post-operative fluid balance was significantly less positive in group T, with an overall balance of 2,292 ± 2,152 mL vs 5,388 ± 2,834 mL (P < .001). There were higher values of hemoglobin and hematocrit, intraoperative (P < .001), on admission to ICU (P = .001), and at 6 h (P = .05) in group T, and lower INR at 6 h (P = .01) and 24 h (P = .02). Re-operation rate and length of stay in ICU were higher in group C, but not statiscally significant. Conclusions. The priming of extracorporeal reservoir with mannitol, albumin, and Ringer's lactate, combined with ultrafiltration, significantly improves intra- and post-operative fluid balance, resulting in a reduction in blood transfusions, with no significant decrease in post-operative bleeding, re-operation bleeding rate, and length of stay in the ICU (AU)

[Effect of priming solution and ultrafiltration on post-operative bleeding and blood transfusion in cardiac surgery. Randomized controlled trial]. / Repercusión del cebado con coloides y la ultrafiltración sobre el sangrado posoperatorio y la transfusión sanguínea en cirugía cardiaca. Ensayo clínico aleatorizado.

OBJECTIVE: Assess the effectiveness of priming the extracorporeal circulation system with albumin-mannitol combined with ultrafiltration during extracorporeal circulation to reduce post-operative bleeding and transfusion requirements in heart surgery, as well as its impact on the fluid balance, coagulation and hematocrit parameters, re-operation for bleeding, ICU, and hospital length of stay. MATERIAL AND METHODS: A total of 134 patients scheduled for heart surgery were randomized to receive Ringer's lactate 1,500mL in the priming reservoir (group C), or mannitol 20% 250mL, albumin 20% 150mL and Ringer's lactate 1,100mL combined with ultrafiltration (group T). Bleeding volume, transfusions, fluid balance, coagulation, and hematology parameters were determined until 48h in the post-operative period. RESULTS: There was a reduction of postoperative bleeding in group T, 1,165±789mL vs 992±662mL (P=.17), and red blood cell concentrate transfusions, 694±843mL vs 413±605mL (P=.03). Intra-operative and post-operative fluid balance was significantly less positive in group T, with an overall balance of 2,292±2,152mL vs 5,388±2,834mL (P<.001). There were higher values of hemoglobin and hematocrit, intraoperative (P<.001), on admission to ICU (P=.001), and at 6h (P=.05) in group T, and lower INR at 6h (P=.01) and 24h (P=.02). Re-operation rate and length of stay in ICU were higher in group C, but not statiscally significant. CONCLUSIONS: The priming of extracorporeal reservoir with mannitol, albumin, and Ringer's lactate, combined with ultrafiltration, significantly improves intra- and post-operative fluid balance, resulting in a reduction in blood transfusions, with no significant decrease in post-operative bleeding, re-operation bleeding rate, and length of stay in the ICU.

Experience in management of 51 non-functioning pituitary adenomas: indications for post-operative radiotherapy.

OBJECT: The indications for additional radiotherapy (RT) after surgery for non-functioning pituitary adenoma are controversial. The goal of this retrospective study was to evaluate the outcome of surgically treated patients, with or without post- operative irradiation. METHODS: Review of cases treated for non-functioning pituitary adenoma. Fifty-one patients were identified, with a mean post-operative follow-up of 6.4+/-3.5 yr. Twenty-nine patients showed residual tumor after surgery and 22 did not. Serial endocrine, visual and radiological evaluations were made after treatment to assess the efficacy and toxicity of surgery and RT. Twenty-seven patients with residual tumor after surgery received RT (22 of them during the post-operative period and 5 after an interval of several yr: 3 because of increased tumor size and 2 with stable residual lesion); tumors in 14 of these patients decreased in size, 11 appeared to be stable on imaging and one patient showed some increase in tumor size (one patient was not followed-up). The residual tumors of the 2 non-irradiated patients remained stable after 5 and 7 yr, respectively. Twenty-two patients without residual disease after surgery (11 with post-operative irradiation, 1 with RT 5 yr after transsphenoidal surgery because of tumor recurrence, and 10 without RT) have shown no evidence of tumor regrowth on serial images. CONCLUSIONS: Radiotherapy can be avoided in patients with complete macroscopic resection and absence of residual tumor in post-operative images; they must be carefully followed using imaging techniques and, in the case of recurrence, they should be re-operated and/or irradiated.

Petrosal sinus sampling for diagnosis of Cushing's disease: evidence of false negative results.

OBJECTIVE: While inferior petrosal sinus (IPS) sampling correctly diagnoses pituitary-dependent Cushing's syndrome if a significant ratio of plasma ACTH between the IPS and the peripheral blood is demonstrated, little has been said about the significance of a negative ratio in Cushing's disease (e.g. a false-negative result). This study evaluates the results of IPS sampling in patients with Cushing's disease, and compares them with both imaging findings and transsphenoidal examination. DESIGN: The results of IPS sampling were retrospectively compared with both imaging findings and transsphenoidal examination. IPS samples were obtained before and 2, 5 and 10 minutes after intravenous administration of 100 micrograms of CRH. PATIENTS: Thirty-two patients with Cushing's disease were evaluated. All subsequently underwent transphenoidal examination of the pituitary gland. MEASUREMENTS: The ratio of the ACTH concentrations at the IPS and in the peripheral blood (IPS:P ratio), and the ratio of the ACTH concentrations between the IPSs (interpetrosal ratio) were calculated. Radiographic evaluation of the pituitary gland was performed with magnetic resonance imaging (MRI, 29 cases) or computed tomography imaging (CT, 3 cases). RESULTS: Transsphenoidal examination of the pituitary gland revealed a microadenoma in 27 cases. Radiological imaging showed a signal compatible with a microadenoma in 22 cases (68.8%), and correctly located the tumour at the side found at surgery in 14 of the 22 cases with positive transsphenoidal findings (MRI 13 cases, CT 1 case, overall 63.6%). Successful bilateral catheterization was accomplished in 30 patients (93.8%). Samples before and after CRH stimulation were drawn in 24 cases. No major complications were observed with the technique. IPS catheterization correctly predicted Cushing's disease (by means of a significant IPS: P ACTH ratio) in 27 of the 30 patients (90%) with basal sampling, and in 23 of the 24 cases with samples drawn before and after CRH administration (95.8%). Taking into account the 12 patients with a lateral microadenoma shown at transsphenoidal examination, IP sinus ACTH ratio was in agreement with the side recorded by the neurosurgeon in 8/12 cases (66.7%). MRI correctly located the tumour in 8/12 patients (66.7%). One patient showed no significant IPS: P ACTH ratio in any set of samples. His MRI showed no sign of a microadenoma. Two years later, another pituitary MRI evaluation showed a midline hypodense signal. The transsphenoidal examination revealed a microadenoma and the post-operative plasma cortisol and urinary free cortisol fell to 293 nmol/l and 100 nmol/24 h, respectively. CONCLUSIONS: Only when a significant IPS:P ACTH ratio is present can Cushing's disease be established by IPS sampling. The absence of a significant IPS: P ACTH ratio does not necessarily imply ectopic secretion of ACTH, nor does it exclude Cushing's disease. The results of lateralization by IPS sampling do not remove the need for a thorough transsphenoidal examination of the contents of the sella turcica.