The risk associated with hyperoncotic colloids in patients with shock

Objective  Crystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypooncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician’s choice. Participants and setting  International prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded. Measurements and results  Influence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians’ preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24–4.97)] and hyperoncotic albumin [OR: 5.99 (2.75–13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42–5.47)]. Conclusions  This study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This study was presented in part at the 17th annual congress of the European Society of Intensive Care Medicine, Berlin, 10–13 October 2004 [1]. This article is discussed in the editorial available at: doi:.     

Effect of administration of pre-warmed intravenous fluids on the frequency of hypothermia following spinal anesthesia for Cesarean delivery

Study ObjectiveTo determine whether administration of pre-warmed colloid followed by pre-warmed crystalloid solution prevents the development of hypothermia in patients undergoing Cesarean delivery.DesignRandomized, double-blind, placebo-controlled study.Patients30 parturients scheduled to undergo elective Cesarean delivery during spinal anesthesia.InterventionsPatients assigned to the warmed fluid group (n=15) received pre-warmed colloid with average molecular weight of 70,000 daltons and substitution ratio of 0.55, followed by pre-warmed crystalloid (kept in warmed storage maintained at 41 °C) during surgery. Patients assigned to the unwarmed fluid group (n=15) received non-warmed infusion. All patients received 400 mL before spinal anesthesia followed by another 300 mL before delivery of the newborn. After completion of a 1,000 mL infusion of colloid fluid, acetate Ringer's solution was infused.MeasurementsCore temperature measured at the tympanic membrane, and forearm and fingertip skin temperatures were recorded just after arrival at the operating room (baseline), after administration of spinal anesthesia (spinal ), at incision (incision), at delivery of the newborn (delivery), and at 15, 30, and 45 minutes after delivery. Rectal temperature of the baby, Apgar scores at one and 5 minutes after delivery, and umbilical artery pH were evaluated.Main ResultsCore temperature was significantly higher in the warmed fluid group from the time of delivery to 45 minutes after delivery. Apgar scores at one minute after delivery and umbilical arterial pH were significantly higher in the warmed fluid group.ConclusionAdministration of pre-warmed intravenous colloid followed by crystalloids maintained core temperature during Cesarean delivery and induced higher Apgar scores and umbilical arterial pH.     

Choosing a volume expander in critical care medicine

The debate concerning the choice of crystalloids or colloids for resuscitation of the critically ill child is still unsettled. Moreover, the use of albumin in critically ill patients has been increasingly questioned because of the lack of clear-cut advantages over crystalloids as well as the concern for cost and the very minor risk of infection. Despite several meta-analyses addressing these issues, there is no data that supports the use of albumin unequivocally in any specific disease states. The suggestion that the use of albumin increases mortality in critically ill patients is not supported by data. There may be niche areas such as hypoalbuminic states, cirrhosis and burns where albumin may have distinct benefits. Alternatively synthetic colloids may be useful, however, concerns about coagulation problems and organ dysfunction persists.     

Evaluation of human albumin use in a university hospital in Belgium

In 1996 — 1997, a drug use evaluation )DUE) of human albumin was conducted in the Ghent University Hospital )Belgium) to determine the pattern and appropriateness of the albumin use. The DUE was followed by permanent review of the albumin consumption. This paper describes how the DUE was carried out and how the albumin use in our hospital changed over time.Method: The study was based on criteria for indications and end of treatment, accepted by consensus of the physicians prescribing albumin. Albumin treatment episodes were classified as appropriate or inappropriate according to these criteria.Results: For 115 treatment episodes in 90 patients, the researchers found 21 )18.3%) deviations from the developed criteria. After analysis, half out of them were considered as minor. Most deviations involved starting treatment too early )n = 17). Follow-up results indicated that the overall consumption of albumin dropped by 50.1% from 1994 to 1999, while the consumption of colloid solutions during the same period remained stable.Conclusion: A good compliance with internally developed criteria for indications and end of treatment with human albumin was observed. Discussion with the clinicians involved led to the development of stricter criteria and a continuous decrease in albumin consumption.     

非穿透小梁手术失败原因与再次手术部位选择

目的　观察非穿透小梁手术联合透明质酸生物胶植入术治疗开角型青光眼的临床效果 ,探讨手术失败原因和再次手术部位的选择。方法　对 13例 ( 13只眼 )非穿透小梁手术联合透明质酸生物胶植入术失败且药物控制眼压不佳的开角型青光眼患者 ,行滤过道再通术。再次手术前行超声生物显微镜 (ultrsoundbiomicroscopy ,UBM)检查 ,观察房水外流阻力发生部位 ,并予以解除 ;术中局部应用丝裂霉素 ;术后定期随访眼压。结果　UBM检查发现非穿透小梁手术联合透明质酸生物胶植入术失败后 ,虽然滤过泡实性变 ,但浅层巩膜瓣下仍有液腔存在。其中 9例因结膜瓣及浅层巩膜瓣瘢痕化造成房水外流受阻 ,深层巩膜床无明显瘢痕 ;3例非穿透小梁网表面增殖膜形成 ,其中 1例原非穿透小梁手术区范围过窄 ;1例原非穿透小梁手术处有微穿孔 ,虹膜根部与小梁相贴。再通术后随访6～ 2 4个月 ,平均 ( 14 0± 5 8)个月。随访期末 ,10例不用任何降眼压药物 ,眼压 <2 1mmHg( 1mmHg=0 133kPa) ,平均 ( 14 1± 3 7)mmHg;1例局部应用降眼压药 ,眼压控制在 15mmHg左右 ;2例再通术后 6个月手术失败 ,最终改行小梁切除术。 2例出现术后并发症 ,其中 1例前房积血 2mm ,术后 5d吸收 ;1例撕除增殖膜时 ,小梁穿孔 ,再行小的虹膜根部切除。结论　结膜瓣     

32P-胶体灌注治疗慢性上颌窦炎动物模型的实验研究

目的 探讨^32P-胶体灌注治疗慢性上颌窦炎动物模型的作用机制及治疗效果。方法 选择雄性绵羊慢性上颌窦炎动物模型24只，采取上颌窦前外侧壁开窗术，按不同剂量分组将^32P-痰体注入动物模型上颌窦腔内，注药后定期观察窦内细菌变化和黏膜的组织学变化，以体征、细菌培养、病理检查等项指标判定治疗效果。结果 ^32P-胶体灌注治疗后，窦腔内菌种及慢性炎性细胞数量消失或明显减少，纤毛上皮结构基本完好。灌注治疗6个月后，治愈率达到83_3％，各组间比较具有非常显著性差异。结论实验证明了^32P-胶体的抑菌作用和促进慢性炎症消退的作用，并确定了^32P-胶体窦内用药的适宜剂量。放射生物学分布监测显示，对其他重要组织器官无任何影响。