Intraoperatorive hydroxyethyl starch: a safe therapy or a poison? / Almidones intraoperatorios: ¿medicamentos o venenos?

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Measurement of Blood Volume in Adult Rhesus Macaques (Macaca mulatta).

Most biomedical facilities that use rhesus macaques (Macaca mulatta) limit the amount of blood that may be collected for experimental purposes. These limits typically are expressed as a percentage of blood volume (BV), estimated by using a fixed ratio of blood (mL) per body weight (kg). BV estimation ratios vary widely among facilities and typically do not factor in variables known to influence BV in humans: sex, age, and body condition. We used indicator dilution methodology to determine the BV of 20 adult rhesus macaques (10 male, 10 female) that varied widely in body condition. We measured body composition by using dual-energy X-ray absorptiometry, weight, crown-to-rump length, and body condition score. Two indicators, FITC-labeled hydroxyethyl starch (FITC-HES) and radioiodinated rhesus serum albumin ((125)I-RhSA), were injected simultaneously, followed by serial blood collection. Plasma volume at time 0 was determined by linear regression. BV was calculated from the plasma volume and Hct. We found that BV calculated by using FITC-HES was consistently lower than BV calculated by using (125)I-RhSA. Sex and age did not significantly affect BV. Percentage body fat was significantly associated with BV. Subjects categorized as having 'optimal' body condition score had 18% body fat and 62.1 mL/kg BV (by FITC-HES; 74.5 mL/kg by (125)I-RhSA). Each 1% increase in body fat corresponded to approximately 1 mL/kg decrease in BV. Body condition score correlated with the body fat percentage (R(2) = 0.7469). We provide an equation for calculating BV from weight and body condition score.

Contribution of Raman spectroscopy in nephrology: a candidate technique to detect hydroxyethyl starch of third generation in osmotic renal lesions.

BACKGROUND AND OBJECTIVES: HydroxyEthyl Starch (HES) has been one of the most commonly used colloid volume expanders in intensive care units for over 50 years. The first and second generation HES, with a high molecular weight (≥200 kD) and a high degree of substitution (≥0.5), has been associated with both renal dysfunction and osmotic nephrosis-like lesions in histological studies. Recently, third generation HES (130 kD/<0.5) has also been shown to impair renal function in critically ill adult patients although tubular accumulation of HES has never been proven in the human kidney. Our objective was to demonstrate the potential of Raman micro-imaging to bring out the presence of third generation-HES in the kidney of patients having received the volume expander. DESIGN: Four biopsies presenting osmotic nephrosis-like lesions originated from HES-administrated patients with impaired renal function were compared with HES-negative biopsies (n = 10) by Raman microspectroscopy. RESULTS: The first step was dedicated to the identification of a specific vibration of HES permitting the detection of the cellular and tissue accumulation of the product. This specific vibration at 480 cm(-1) is assigned to a collective mode of the macromolecule; it is located in a spectral region with a limited contribution from biological materials. Based on this finding, HES distribution within tissue sections was investigated using Raman micro-imaging. Determination of HES positive pixels permitted us to clearly distinguish positive cases from HES-free biopsies (proportions of positive pixels from the total number of pixels: 23.48% ± 28 vs. 0.87% ± 1.2; p = 0.004). CONCLUSIONS: This study shows that Raman spectroscopy is a candidate technique to detect HES in kidney tissue samples currently manipulated in nephrology departments. In addition, on the clinical aspect, our approach suggests that renal impairment related to third generation HES administration is associated with osmotic nephrosis-like lesions and HES accumulation in the kidney.

TNF-alpha induced shedding of the endothelial glycocalyx is prevented by hydrocortisone and antithrombin.

BACKGROUND: Healthy vascular endothelium is clothed by the endothelial glycocalyx. This structure plays a key role in the regulation of inflammation and vascular permeability and is known to be degraded by ischemic and inflammatory stress. Our aim was to show whether hydrocortisone and antithrombin stabilize the glycocalyx and, therefore, the vascular barrier, against damage induced by the inflammatory stimulus TNF-alpha, thus improving the cardio-vascular situation. METHODS: Isolated guinea pig hearts were perfused with Krebs-Henseleit buffer for 20 min at constant flow (baseline perfusion pressure 70 cmH(2)O). Hydrocortisone in a stress dose (10 microg/ml) or antithrombin in a physiological dose (1 U/ml) were then applied for 15 min before infusion of TNF-alpha (4 ng/ml, 10 min). Coronary net fluid filtration was assessed directly by measuring transudate formation on the epicardial surface. Hearts were perfusion-fixed to visualize the glycocalyx. RESULTS: TNF-alpha induced severe degradation of the glycocalyx, increased coronary resistance, heightened vascular leak and permeability to hydroxyethyl starch and caused mast-cell degranulation. Hydrocortisone and antithrombin both reduced all of these effects. Electron microscopy revealed a mostly intact glycocalyx after treatment with either drug. CONCLUSIONS: Both hydrocortisone and antithrombin clearly preserve the endothelial glycocalyx in the face of inflammatory degradation initiated by TNF-alpha, however, with different mechanisms. This is an important new facet in the pathophysiology and therapy of sepsis, since preservation of the glycocalyx should help prevent vasoconstriction, tissue edema as well as leukocyte and platelet adhesion, thus mitigating inflammation and tissue hypoxia.

A molecular rotor as viscosity sensor in aqueous colloid solutions.

BACKGROUND: Molecular rotors exhibit viscosity-dependent quantum yield, allowing non-mechanical determination of fluid viscosity. We analyzed fluorescence in the presence of viscosity-modulating macromolecules several orders of magnitude larger than the rotor molecule. METHOD OF APPROACH: Fluorescence of aqueous starch solutions with a molecular rotor in solution was related to viscosity obtained in a cone-and-plate viscometer. RESULTS: In dextran solutions, emission intensity was found to follow a power-law relationship with viscosity. Fluorescence in hydroxyethylstarch solutions showed biexponential behavior with different exponents at viscosities above and below 1.5 mPa s. Quantum yield was generally higher in hydroxyethylstarch than in dextran solutions. The power-law relationship was used to backcalculate viscosity from intensity with an average precision of 2.2% (range of -5.5% to 5.1%). CONCLUSIONS: This study indicates that hydrophilic molecular rotors are suitable as colloid solution viscosity probes after colloid-dependent calibration.

Optimizing storage stability of lyophilized recombinant human interleukin-11 with disaccharide/hydroxyethyl starch mixtures.

Optimal storage stability of a protein in a dry formulation depends on the storage temperature relative to the glass transition temperature (T(g)) of the dried formulation and the structure of the dried protein. We tested the hypothesis that optimizing both protein structure and T(g)--by freeze-drying recombinant human interleukin-11 (rhIL-11) with mixtures of disaccharides and hydroxyethyl starch (HES)--would result in increased storage stability compared with the protein lyophilized with either disaccharide or hydroxyethyl starch alone. The secondary structure of the protein in the dried solid was analyzed immediately after lyophilization and after storage at elevated temperatures by infrared spectroscopy. After rehydration, aggregation was monitored by size exclusion chromatography. Oxidation levels and cleavage products were quantified by reversed-phase chromatography. For the formulation with HES alone, which has a relatively high T(g), storage stability of rhIL-11 was poor, because HES failed to inhibit lyophilization-induced unfolding. The sugar formulations inhibited unfolding, and had intermediate T(g) values and storage stabilities. Addition of hydroxyethyl starch to sucrose or trehalose increased T(g) without affecting the capacity of the sugar to inhibit protein unfolding during lyophilization. Optimal storage stability of lyophilized rhIL-11 was achieved by using a mixture of disaccharide and polymeric carbohydrates.

Mass spectrometry of partially methylated alditol acetates derived from hydroxyethyl starch.

The degradation and derivatization of hydroxyethyl starch to partially methylated alditol acetates (PMAAs) allows its detection by gas chromatography/mass spectrometry. The derivatization was performed by permethylation of the carbohydrate, hydrolysis of the permethylated polysaccharide, reduction of the resulting monosaccharides to alditoles and finally acetylation. A close similarity in the fragmentation of the PMAAs obtained was observed in both electron ionization (EI) and chemical ionization (CI) mass spectra owing to the comparable structures of the derivatives. CI measurements permitted the recognition of introduced hydroxyethyl groups in the glucose residues by detection of [M(+)+1]-60 signals. Investigations concerning the EI fragmentation schemes allowed secure determinations of monohydroxyethyl monosaccharides and differentiations between the possible positions (C-2, C-3 and C-6) of the substituted hydroxyethyl groups. Proposed generations of the main fragment ions are presented.

Spectroscopic approach to capillary-alveolar membrane damage induced acute lung injury.

BACKGROUND: Acute (or adult) respiratory distress syndrome (ARDS) is often associated with a high mortality rate in the critical care population. The term acute lung injury (ALI), a primitive phase of ARDS, was introduced by the European and American consensus groups to provide early diagnoses of ARDS. The pathophysiological characterization of ALI/ARDS - an increased pulmonary capillary-alveolar membrane barrier permeability - is generally not included in current intensive care unit diagnosis criteria. OBJECTIVES: To apply the infrared (IR) spectroscopic technique, in combination with the administration of hydroxyethyl starch (HES), to patients with ALI and ARDS. PATIENTS AND METHODS: This retrospective study involved 67 patients from the intensive care unit at the Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba. The methodology was based on the IR spectroscopic determination of HES in patient's bronchial washing fluid. Exaggerated infiltration of HES into the alveolar space was taken as evidence of damage to the pulmonary capillary-alveolar membrane, which in turn provided a diagnosis of ALI/ARDS. RESULTS: The accuracy of determining pulmonary HES leakage in severe lung injury (Partial pressure of arterial oxygen/fraction of inspired oxygen [PaO2/FiO2] less than 100 mmHg [n=10]), was 100%. The subgroups with PaO2/FiO2 between 100 and 200 mmHg (n=23), and PaO2/FiO2 between 200 and 300 mmHg (n=22), 56.5% and 77.3%, respectively, showed IR positive for HES leakage. CONCLUSIONS: The proposed IR bronchial washing assay is very sensitive in determining the pulmonary HES leakage in severe lung injury. It is also suitable for evaluating pulmonary leakage at an early phase of the injury, a fact that is particularly important for supportive treatment. The method is advantageous because no radioactive tracers are employed, little sample preparation is required, and it is rapid and minimally invasive, making it convenient to use in the critical care environment.

Desferrioxamine suppresses experimental allergic encephalomyelitis induced by MBP in SJL mice.

Data from several studies indicate that free radicals have a pathogenic role in experimental allergic encephalomyelitis (EAE). Iron can contribute to free radical damage by catalyzing the formation of hydroxyl radical, inducing secondary initiation of lipid peroxidation and by promoting the oxidation of proteins. The iron chelator, desferrioxamine, can limit these oxidative reactions and it can scavenge peroxynitrite independent of iron chelation. Two previous studies have examined the therapeutic value of desferrioxamine in EAE. One study observed an effect when disease was induced by spinal cord homogenates (J. Exp. Med. 160, p. 1532, 1984), but a second study found no therapeutic value of desferrioxamine for myelin basic protein (MBP)-induced EAE (J. Neuroimmunol. 17, p. 127, 1988). In the second study, the drug was only administered during the preclinical stages of disease. Since desferrioxamine scavenges free radicals and prevents their formation, we hypothesized that the drug should be given during the active stage of disease to have therapeutic value. We first demonstrated that the drug enters the CNS around inflammatory cells in EAE animals. In animals treated during the active stage of MBP-induced EAE, the clinical signs were significantly reduced compared to vehicle-treated animals. The iron-bound form of this drug, ferrioxamine, was without therapeutic value. A derivative of desferrioxamine, hydroxylethyl starch (HES)-desferrioxamine, has a greater plasma half-life than desferrioxamine and it was also tested. Although there was a suggestion of improvement in these animals, the effects were less than that observed for desferrioxamine which may be related to the greater molecular size of HES-desferrioxamine. In summary, these data suggest that chelation of iron is an effective therapeutic target for EAE.

Histological and immunohistochemical investigations of hydroxyethyl-starch deposits in rat tissues.

Tissue storage of hydroxyethyl starch (HES), a widely used artificial colloid, has been reported. In order to clarify whether storage of HES can be detected in tissues by immunohistochemical methods, use was made of a polyclonal rabbit anti-HES antiserum. Thirteen days after a single intravenous injection of HES rats were sacrificed and liver, spleen, lymph node, lung, kidney and skin were removed. On paraffin sections in all organs the anti-HES antiserum stained mainly cells which could be attributed to the mononuclear phagocyte system, as confirmed by the use of the antimacrophage monoclonal antibody ED1. The use of a polyclonal anti-HES antiserum may allow analysis of long-term storage and possible side effects in various tissues of man.

[Determination of the molecular weight of microbial polysaccharides using high performance exclusion chromatography]. / Opredelenie molekuliarnykh mass mikrobnykh polisakharidov s pomoshch'iu vysokoéffektivnoi ékskliuzionnoi khromatografii.

An automatic method of determining the molecular weight parameters (Mw, Mn) of microbial polysaccharides such as dextran, pullulan was developed based on the use of high performance size-exclusion chromatography on the two types of columns: Zorbax PSM 60 + 300 + 1000 and SynChropack GPC 100 + 500 + 1000. The Mw and Mn values were determined for a number of domestic and foreign dextran preparations. Changes in the molecular weight of pullulan and hydroxyethylstarch resulted from acid and enzymatic hydrolysis were estimated.

[Physico-chemical and biological properties of a new plasma substitute based on hydroxyethylated starch]. / Fiziko-khimicheskie i biologicheskie svoistva novogo plazmozamenitelia na osnove oksiétilirovannogo krakhmala.

Samples of hydroxyethylstarch of M 100-160 kDa, Mn 50-60 kDa and substitution degree 0.6-0.7 were prepared and characterized. Hydroxyethylstarch was shown to be susceptible to cleavage by amylolytic enzymes. All samples of hydroxyethylstarch at 2-4% concentration were compatible with perfluorohydrocarbon emulsion "Perftoran" and exhibited high haemodynamic efficiency. The 6 and 10% solutions of hydroxyethylstarch in 0.9% aqueous sodium chloride normalized haemodynamics in massive blood losses. Hydroxyethylstarch was completely removed from blood-stream. The preparations were shown to be nontoxic.

Determination of sodium caprylate in plasma volume expanders by gas chromatography.

A quantitative gas chromatographic method for the determination of the sodium (caprylate) octanoate, antimicrobial in the plasma volume expanders hydroxyethyl starch and human serum albumin, has been developed. The sodium caprylate and the internal standard were converted to pentafluorobenzyl derivatives. The reaction mixture was extracted with methylene chloride and chromatographed on a 1.8-m OV-17 column at 170 degrees C with flame ionization detection. The method is linear over the concentration range studied (40-700 micrograms/ml). The method is precise (coefficient of variation less than 2%).

Studies on hydroxyethyl starch. Part I: Molecular characterization by size exclusion chromatography coupled with low-angle laser light scattering.

Two commercially available hydroxyethyl starch (HES) preparations (in clinical use as plasma expanders) specified with Mw = 450,000/MS = 0.7 and Mw = 200,000/MS = 0.5, respectively, and three experimental HES-samples (supposingly similar to the commercial product with the specification 450,000/0.7, except of one with MS = 0.5) were studied. The latter were prepared via acid or enzymatic hydrolysis of waxy-maize starch. Each of the samples was characterized by its intrinsic viscosity and molar substitution, and was studied with low-angle laser light scattering (LALLS) and with size exclusion chromatography (SEC) coupled with LALLS. The weight-average molecular weight Mw of the commercial samples was found to be 60-80% higher than the value given in the product declaration. This discrepancy can be explained by the argument that previous measurements were not carried out at sufficiently small scattering angles to enable reliable extrapolation to zero angle. The calibration functions Mw(v) of the individual HES-samples measured by SEC/LALLS-coupling are identical over a broad range of the elution volume v and are used for calibration of conventional SEC in a subsequent paper. The small, but detectable differences in the Mw(v)-functions indicate interesting differences between these HES-preparations with respect to the effective hydrodynamic density of the branched HES-molecules.

Studies on hydroxyethyl starch. Part II: Changes of the molecular weight distribution for hydroxyethyl starch types 450/0.7, 450/0.5, 450/0.3, 300/0.4, 200/0.7, 200/0.5, 200/0.3 and 200/0.1 after infusion in serum and urine of volunteers.

32 volunteers, none of whom showed any symptoms for kidney, liver or pancreas disease, were given by infusion 500 ml of various type of hydroxyethyl starch (HES) at a concentration of 6% (450/0.7, 450/0.5, 450/0.3, 300/0.4) as well as of 10% (200/0.7, 200/0.5, 200/0.3, 200/0.1) over a period of 30 min. After infusion both the Mw and the Mn diminished. The rate of elimination of HES from serum entirely depended on molar substitution and not on Mw. The quotient Mw/Mn decreased considerably over the entire test period. The lower molecular weight limit in serum remained relatively the same at 60,000 Daltons. Maximum molecular weight limit of urine, too, was 60,000 Daltons.