-
Der Anaesthesist Feb 2021Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major... (Review)
Review
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
Topics: Abdomen; Fluid Therapy; Hemodynamic Monitoring; Humans; Hypovolemia; Perioperative Care
PubMed: 33034685
DOI: 10.1007/s00101-020-00867-7 -
International Journal of Molecular... Dec 2023This narrative review critically examines the role of albumin in sepsis management and compares it to its well-established application in liver cirrhosis. Albumin, a key... (Review)
Review
This narrative review critically examines the role of albumin in sepsis management and compares it to its well-established application in liver cirrhosis. Albumin, a key plasma protein, is effective in the management of fluid imbalance, circulatory dysfunction, and inflammation-related complications. However, its role in sepsis is more intricate and characterized by ongoing debate and varied results from clinical studies. In sepsis, the potential benefits of albumin include maintaining vascular integrity and modulating inflammation, yet its consistent clinical efficacy is not as definitive as that in cirrhosis. This review evaluated various clinical trials and evidence, highlighting their limitations and providing practical insights for clinicians. It emphasizes identifying sepsis patient subgroups that are most likely to benefit from albumin therapy, particularly exploring the correction of hypoalbuminemia. This condition, which is significantly corrected in patients with cirrhosis, may have similar therapeutic advantages in sepsis. The potential effectiveness of albumin in the low-volume resuscitation and deresuscitation phases of sepsis management was noted. Given the safety concerns observed in cirrhosis, such as pulmonary edema and hypervolemia associated with albumin therapy, cautious integration of albumin into sepsis treatment is mandatory. Personalized albumin therapy is advocated for tailoring strategies to the specific needs of each patient, based on their clinical presentation and underlying conditions. The need for further research to delineate the role of albumin in sepsis pathophysiology is underscored. The review emphasizes the importance of conducting trials to assess the effectiveness of albumin in correcting hypoalbuminemia in sepsis, its impact on patient outcomes, and the establishment of appropriate dosing and administration methods. This approach to albumin use in sepsis management is posited as a way to potentially improve patient outcomes in this complex clinical scenario while being mindful of the lessons learned from its use in cirrhosis.
Topics: Humans; Hypoalbuminemia; Albumins; Sepsis; Liver Cirrhosis; Water-Electrolyte Imbalance; Inflammation
PubMed: 38139434
DOI: 10.3390/ijms242417606 -
Kidney360 Aug 2022
Topics: Humans; Kidney Failure, Chronic; Renal Dialysis; Ultrafiltration
PubMed: 36176654
DOI: 10.34067/KID.0003402022 -
Cureus Apr 2021Intravenous fluids (IVFs) are the most commonly used drugs in hospitalized patients. Knowledge of the indications and pharmacokinetics of IVFs is critical for all... (Review)
Review
Intravenous fluids (IVFs) are the most commonly used drugs in hospitalized patients. Knowledge of the indications and pharmacokinetics of IVFs is critical for all medical disciplines. Isotonic saline (normal saline, 0.9% NS) is the most utilized intravenous solution. Isotonic saline effectively expands the intravascular compartment, as one-quarter of the infusate goes intravascularly, while the remaining three-quarters go into the interstitial space. The proper use of IVFs in different clinical scenarios is paramount. IVFs differ with regard to their half-life, intravascular volume expansion, preparation, and cost. Crystalloids are more commonly utilized due to their relatively low cost and availability. Colloids are very advantageous in cases of shock or hemorrhage, as they remain in the intravascular space, thus facilitating an increase in blood pressure (BP) prior to blood administration. Colloids are also advantageous in cases of burns and severe hypoglobulinemia. Human albumin (5%, 20%, and 25%) is the most used colloid solution. It remains intravascularly provided and there is no capillary leak as in systematic inflammation. The goal in hospitalized patients is timely and adequate intravenous fluid resuscitation. Utilization of a large volume of isotonic saline may lead to hypervolemia, hypernatremia, hyperchloremia, metabolic acidosis, and hypokalemia. The use of balanced intravenous solutions has been advocated to avoid these complications.
PubMed: 34040918
DOI: 10.7759/cureus.14619 -
The Tohoku Journal of Experimental... Sep 2020Denys-Drash syndrome is characterized by progressive nephropathy, gonadal dysgenesis, and Wilms tumor caused by a WT1 gene mutation. Infants with Denys-Drash syndrome...
Denys-Drash syndrome is characterized by progressive nephropathy, gonadal dysgenesis, and Wilms tumor caused by a WT1 gene mutation. Infants with Denys-Drash syndrome frequently experience severe hypertension, but detailed clinical manifestations have yet to be clarified. Cases of infantile-onset Denys-Drash syndrome with severe hypertension at our hospital were retrospectively analyzed and the pathogenesis of hypertension was investigated. Six infants who received the diagnosis of Denys-Drash syndrome at the median age of 10 days (range: 2-182 days) were enrolled. Five infants had the complication of severe hypertension within a few days of diagnosis. All the patients showed rapid progression to end-stage renal disease and urgently required dialysis due to anuria/oliguria and hypervolemia with a median duration of 7.5 days (range: 0-17 days) on the day after diagnosis. Even under dialysis, all the patients continued to need antihypertensive treatment. Five patients underwent a preventive nephrectomy for Wilms tumor, and one patient underwent a nephrectomy due to progression to Wilms tumor. Two patients developed hypotension after a nephrectomy. The main causes of hypertension were hypervolemia in the predialysis stage, renin-associated hypertension in the dialysis stage, and multiple factors, including increased plasma catecholamine-associated hypertension in the postnephrectomy dialysis stage. At last the follow-up after bilateral nephrectomy, four of the five patients required antihypertensive treatment. Not all the patients showed target organ complications caused by hypertension. Severe hypertension is a common complication of infantile-onset Denys-Drash syndrome. The possibility of hypotension after nephrectomy should be considered in patients with Denys-Drash syndrome.
Topics: Age of Onset; Denys-Drash Syndrome; Humans; Hypertension; Hypotension; Infant; Infant, Newborn; Nephrectomy; Organ Specificity
PubMed: 32863338
DOI: 10.1620/tjem.252.45 -
Global Heart 2023Cardiovascular disease (CVD) is a major cause of death in Malawi. In rural districts, heart failure (HF) care is limited and provided by non-physicians. The causes and...
BACKGROUND
Cardiovascular disease (CVD) is a major cause of death in Malawi. In rural districts, heart failure (HF) care is limited and provided by non-physicians. The causes and patient outcomes of HF in rural Africa are largely unknown. In our study, non-physician providers performed focused cardiac ultrasound (FOCUS) for HF diagnosis and longitudinal clinical follow-up in Neno, Malawi.
OBJECTIVES
We described the clinical characteristics, HF categories, and outcomes of patients presenting with HF in chronic care clinics in Neno, Malawi.
METHODS
Between November 2018 and March 2021, non-physician providers performed FOCUS for diagnosis and longitudinal follow-up in an outpatient chronic disease clinic in rural Malawi. A retrospective chart review was performed for HF diagnostic categories, change in clinical status between enrollment and follow-up, and clinical outcomes. For study purposes, cardiologists reviewed all available ultrasound images.
RESULTS
There were 178 patients with HF, a median age of 67 years (IQR 44 - 75), and 103 (58%) women. During the study period, patients were enrolled for a mean of 11.5 months (IQR 5.1-16.5), after which 139 (78%) were alive and in care. The most common diagnostic categories by cardiac ultrasound were hypertensive heart disease (36%), cardiomyopathy (26%), and rheumatic, valvular or congenital heart disease (12.3%).At follow-up, the proportion of New York Heart Association (NYHA) class I patients increased from 24% to 50% (p < 0.001; 95% CI: 31.5 - 16.4), and symptoms of orthopnea, edema, fatigue, hypervolemia, and bibasilar crackles all decreased (p < 0.05).
CONCLUSION
Hypertensive heart disease and cardiomyopathy are the predominant causes of HF in this elderly cohort in rural Malawi. Trained non-physician providers can successfully manage HF to improve symptoms and clinical outcomes in limited resource areas. Similar care models could improve healthcare access in other rural African settings.
Topics: Humans; Female; Aged; Adult; Middle Aged; Male; Retrospective Studies; Malawi; Heart Failure; Cardiomyopathies; Health Services Accessibility
PubMed: 37334396
DOI: 10.5334/gh.1210 -
Critical Care (London, England) May 2016Maintenance fluids in critically ill brain-injured patients are part of routine critical care. Both the amounts of fluid volumes infused and the type and tonicity of... (Review)
Review
Maintenance fluids in critically ill brain-injured patients are part of routine critical care. Both the amounts of fluid volumes infused and the type and tonicity of maintenance fluids are relevant in understanding the impact of fluids on the pathophysiology of secondary brain injuries in these patients. In this narrative review, current evidence on routine fluid management of critically ill brain-injured patients and use of haemodynamic monitoring is summarized. Pertinent guidelines and consensus statements on fluid management for brain-injured patients are highlighted. In general, existing guidelines indicate that fluid management in these neurocritical care patients should be targeted at euvolemia using isotonic fluids. A critical appraisal is made of the available literature regarding the appropriate amount of fluids, haemodynamic monitoring and which types of fluids should be administered or avoided and a practical approach to fluid management is elaborated. Although hypovolemia is bound to contribute to secondary brain injury, some more recent data have emerged indicating the potential risks of fluid overload. However, it is acknowledged that many factors govern the relationship between fluid management and cerebral blood flow and oxygenation and more research seems warranted to optimise fluid management and improve outcomes.
Topics: Brain Injuries; Cerebrovascular Circulation; Critical Care; Critical Illness; Fluid Therapy; Humans
PubMed: 27240859
DOI: 10.1186/s13054-016-1309-2 -
Heart Failure Reviews Sep 2023Studies over recent years have redeveloped our understanding of uremic cardiomyopathy, defined as left ventricular hypertrophy, congestive heart failure, and associated... (Review)
Review
Studies over recent years have redeveloped our understanding of uremic cardiomyopathy, defined as left ventricular hypertrophy, congestive heart failure, and associated cardiac hypertrophy plus other abnormalities that result from chronic kidney disease and are often the cause of death in affected patients. Definitions of uremic cardiomyopathy have conflicted and overlapped over the decades, complicating the body of published evidence, and making comparison difficult. New and continuing research into potential risk factors, including uremic toxins, anemia, hypervolemia, oxidative stress, inflammation, and insulin resistance, indicates the increasing interest in illuminating the pathways that lead to UC and thereby identifying potential targets for intervention. Indeed, our developing understanding of the mechanisms of UC has opened new frontiers in research, promising novel approaches to diagnosis, prognosis, treatment, and management. This educational review highlights advances in the field of uremic cardiomyopathy and how they may become applicable in practice by clinicians. Pathways to optimal treatment with current modalities (with hemodialysis and angiotensin-converting enzyme inhibitors) will be described, along with proposed steps to be taken in research to allow evidence-based integration of developing investigational therapies.
Topics: Humans; Uremia; Cardiomyopathies; Heart Failure; Hypertrophy, Left Ventricular; Cardiomegaly
PubMed: 37173614
DOI: 10.1007/s10741-023-10318-1 -
Anaesthesia Jan 2020The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability,... (Review)
Review
The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.
Topics: Acute Kidney Injury; Anesthesia; Humans; Postoperative Complications; Risk Factors; Surgical Procedures, Operative
PubMed: 31903567
DOI: 10.1111/anae.14932 -
Ochsner Journal 2014Stroke is a leading cause of death and disability worldwide. Aneurysmal subarachnoid hemorrhage (aSAH), a significant cause of hemorrhagic stroke, continues to have poor... (Review)
Review
BACKGROUND
Stroke is a leading cause of death and disability worldwide. Aneurysmal subarachnoid hemorrhage (aSAH), a significant cause of hemorrhagic stroke, continues to have poor prognosis. Early diagnosis and treatment are key to improving outcomes. Subarachnoid hemorrhage (SAH) and aSAH are often accompanied by multiple comorbidities, making anesthetic management of these patients complex.
METHODS
This article summarizes the goals of anesthetic management of patients with cerebral aneurysm, including preoperative considerations, intraoperative management, and postoperative considerations.
RESULTS
Hemodynamic monitoring is an important aspect of management. Use nicardipine, labetalol, and esmolol to avoid increases in blood pressure that may cause aneurysm rupture, and avoid low blood pressure as this may decrease cerebral perfusion pressure. Nimodipine is recommended for vasospasm prophylaxis in all patients with aSAH. The hypertension arm of Triple H therapy (hypertension, hypervolemia, hemodilution) is the most important to improve cerebral perfusion. Erythropoietin has shown some promise in lowering the incidence of vasospasm and delayed cerebral ischemia. Albumin is the preferred colloid.
CONCLUSION
Anesthetic management of patients with aSAH and SAH is a complex endeavor. Careful consideration of individual patient status, optimal techniques, and the safest evidence-based methods are the best options for successfully treating these life-altering conditions.
PubMed: 25249809
DOI: No ID Found