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Kidney International Jul 2017In various human diseases, an increase in capillary permeability to proteins leads to the loss of protein-rich fluid from the intravascular to the interstitial space.... (Review)
Review
In various human diseases, an increase in capillary permeability to proteins leads to the loss of protein-rich fluid from the intravascular to the interstitial space. Although sepsis is the disease most commonly associated with this phenomenon, many other diseases can lead to a "sepsis-like" syndrome with manifestations of diffuse pitting edema, exudative serous cavity effusions, noncardiogenic pulmonary edema, hypotension, and, in some cases, hypovolemic shock with multiple-organ failure. The term capillary leak syndrome has been used to describe this constellation of disease manifestations associated with an increased capillary permeability to proteins. Diseases other than sepsis that can result in capillary leak syndrome include the idiopathic systemic capillary leak syndrome or Clarkson's disease, engraftment syndrome, differentiation syndrome, the ovarian hyperstimulation syndrome, hemophagocytic lymphohistiocytosis, viral hemorrhagic fevers, autoimmune diseases, snakebite envenomation, and ricin poisoning. Drugs including some interleukins, some monoclonal antibodies, and gemcitabine can also cause capillary leak syndrome. Acute kidney injury is commonly seen in all of these diseases. In addition to hypotension, cytokines are likely to be important in the pathophysiology of acute kidney injury in capillary leak syndrome. Fluid management is a critical part of the treatment of capillary leak syndrome; hypovolemia and hypotension can cause organ injury, whereas capillary leakage of administered fluid can worsen organ edema leading to progressive organ injury. The purpose of this article is to discuss the diseases other than sepsis that produce capillary leak and review their collective pathophysiology and treatment.
Topics: Acute Kidney Injury; Animals; Capillaries; Capillary Leak Syndrome; Capillary Permeability; Diagnosis, Differential; Fluid Therapy; Hemodynamics; Humans; Plasma Substitutes; Pleural Effusion; Predictive Value of Tests; Risk Factors; Sepsis; Sodium Potassium Chloride Symporter Inhibitors; Treatment Outcome
PubMed: 28318633
DOI: 10.1016/j.kint.2016.11.029 -
Kidney International Jul 2019Fluid therapy, which is provided to restore and maintain tissue perfusion, is part of routine management for almost all critically ill patients. However, because either... (Review)
Review
Fluid therapy, which is provided to restore and maintain tissue perfusion, is part of routine management for almost all critically ill patients. However, because either too much or too little fluid can have a negative impact on patient outcomes, fluid administration must be titrated carefully for each patient. The "salvage, optimization, stabilization, de-escalation" (SOSD) mnemonic should be used as a general guide to fluid resuscitation, and fluid administration should be adapted according to the course of the disease. In the initial salvage phase, lifesaving fluid should be administered generously. Once hemodynamic monitoring is available, fluid administration should be optimized by determining the patient's fluid status and the need for further fluid. This determination can be difficult, however; clinical indicators of hypovolemia, such as heart rate, blood pressure, and urine output, may not detect early hypovolemia, and edema is a late sign of fluid overload. Dynamic tests of fluid responsiveness such as pulse pressure or stroke volume variation can be used in only a small percentage of critically ill patients, and thus a fluid challenge technique is most frequently used to assess ongoing fluid requirements. Once a patient has been stabilized, efforts should start to concentrate on removing excess fluid. Which fluid should be used remains a matter of some debate. Crystalloid solutions are cheaper than colloid solutions, but colloid solutions remain in the intravascular space for a longer period, making edema less likely. Thus crystalloids and colloids should be used together, especially in patients likely to require large fluid volumes. Human albumin is a natural colloid and may have beneficial effects in patients with sepsis in addition to its volume effects. Fluids should be prescribed as are other medications, taking into account individual patient factors, disease processes, and other treatments.
Topics: Colloids; Critical Illness; Fluid Therapy; Humans; Hypovolemia; Isotonic Solutions; Monitoring, Physiologic; Plasma Substitutes; Resuscitation; Treatment Outcome
PubMed: 30926137
DOI: 10.1016/j.kint.2018.11.047 -
The Cochrane Database of Systematic... Feb 2013Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and there is ongoing debate about the relative... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.
OBJECTIVES
To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.
SEARCH METHODS
We searched the Cochrane Injuries Group Specialised Register (17 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library) (Issue 10, 2012), MEDLINE (Ovid) 1946 to October 2012, EMBASE (Ovid) 1980 to October 2012, ISI Web of Science: Science Citation Index Expanded (1970 to October 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to October 2012), PubMed (October 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles.
SELECTION CRITERIA
Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials involving pregnant women and neonates.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.
MAIN RESULTS
We identified 78 eligible trials; 70 of these presented mortality data.COLLOIDS COMPARED TO CRYSTALLOIDS: Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19). Modified gelatin - 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). COLLOIDS IN HYPERTONIC CRYSTALLOID COMPARED TO ISOTONIC CRYSTALLOID: Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06).
AUTHORS' CONCLUSIONS
There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.
Topics: Albumins; Blood Proteins; Colloids; Critical Illness; Crystalloid Solutions; Dextrans; Fluid Therapy; Gelatin; Humans; Hydroxyethyl Starch Derivatives; Isotonic Solutions; Plasma Substitutes; Randomized Controlled Trials as Topic; Rehydration Solutions; Resuscitation
PubMed: 23450531
DOI: 10.1002/14651858.CD000567.pub6 -
British Journal of Anaesthesia Mar 2012I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling's original model of semi-permeable capillaries subject to hydrostatic... (Review)
Review
I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling's original model of semi-permeable capillaries subject to hydrostatic and oncotic pressure gradients within the extracellular fluid. Fluid therapy to support the circulation relies on applying a physiological paradigm that better explains clinical and research observations. The revised Starling equation based on recent research considers the contributions of the endothelial glycocalyx layer (EGL), the endothelial basement membrane, and the extracellular matrix. The characteristics of capillaries in various tissues are reviewed and some clinical corollaries considered. The oncotic pressure difference across the EGL opposes, but does not reverse, the filtration rate (the 'no absorption' rule) and is an important feature of the revised paradigm and highlights the limitations of attempting to prevent or treat oedema by transfusing colloids. Filtered fluid returns to the circulation as lymph. The EGL excludes larger molecules and occupies a substantial volume of the intravascular space and therefore requires a new interpretation of dilution studies of blood volume and the speculation that protection or restoration of the EGL might be an important therapeutic goal. An explanation for the phenomenon of context sensitivity of fluid volume kinetics is offered, and the proposal that crystalloid resuscitation from low capillary pressures is rational. Any potential advantage of plasma or plasma substitutes over crystalloids for volume expansion only manifests itself at higher capillary pressures.
Topics: Basement Membrane; Blood Proteins; Capillary Permeability; Endothelium, Vascular; Extracellular Matrix; Fluid Therapy; Glycocalyx; Humans; Microcirculation; Models, Cardiovascular; Plasma Substitutes
PubMed: 22290457
DOI: 10.1093/bja/aer515 -
Minerva Anestesiologica Dec 2005Adequate restoration of intravascular volume remains an important therapeutic manoeuvre in managing the surgical, medical and the critically ill intensive care patient.... (Review)
Review
Adequate restoration of intravascular volume remains an important therapeutic manoeuvre in managing the surgical, medical and the critically ill intensive care patient. Definition of the ideal volume replacement strategy still remains one of the burning problems. The choice between colloid and crystalloid solutions continues to generate controversy. The highly controversial crystalloid/colloid dispute has been enlarged to a colloid/colloid debate because aside of the natural colloid albumin several non-protein (synthetic) colloids are available as plasma substitutes (e.g. dextrans, gelatins, hydroxyethyl starch [HES] solutions). Due to their varying physico-chemical properties, these solutions widely differ with regard to their pharmacokinetic and pharmacodynamic properties as well as to their hemodynamic efficacy and side-effects. HES is the most intensively studied plasma substitute. The different HES preparations are defined by concentration, molar substitution (MS), mean molecular weight (MW), and the C2/C6 ratio of substitution. Two new HES specification, a third-generation HES with a lower Mw and a lower MS (6% HES 130/0.4) than all other HES preparation and a first-generation HES prepared in a balanced solution, may be promising by improving the therapy of the hypovolemic patient. Albumin cannot be recommended for correction of hypovolemia because of ist extreme costs and because it can easily be replaced by other no-protein colloids. Dextrans should also not be used any more due to the negative effects on coagulation and its high anaphylactic potency. The historical crystalloid/colloid controversy has been focused primarily on outcome. There is increasing evidence that outcome (mortality) is not the correct measure when assessing the ideal volume replacement strategy. New concepts about critical care such as organ perfusion and organ function, the role of inflammation, immunological aspects, and wound healing may change this point of view. Volume replacement has been hitherto often based on art, dogma and personal beliefs. Further well-performed studies in this area will help more to shed new light on the ideal volume replacement strategy of the hypovolemic patient than more meta-analyses that are pooling old-to-very old studies to solve this problem.
Topics: Blood Volume; Colloids; Critical Care; Crystalloid Solutions; Fluid Therapy; Humans; Isotonic Solutions; Plasma Substitutes
PubMed: 16288182
DOI: No ID Found -
Anaesthesia Apr 2014
Topics: Anti-Bacterial Agents; Humans; Plasma Substitutes; Polygeline; Vancomycin
PubMed: 24641651
DOI: 10.1111/anae.12650 -
Anaesthesiology Intensive Therapy 2018Fluid therapy is one of the most important treatments in patients with traumatic brain injury (TBI) as both hypo- and hypervolaemia can cause harm. The main goals of... (Review)
Review
Fluid therapy is one of the most important treatments in patients with traumatic brain injury (TBI) as both hypo- and hypervolaemia can cause harm. The main goals of fluid therapy for patients with TBI are to optimize cerebral perfusion and to maintain adequate cerebral oxygenation. The avoidance of cerebral oedema is clearly essential. The current weight of evidence in the published literature suggests that albumin therapy is harmful and plasma substitutes have failed to demonstrate superiority over crystalloids solutions. Crystalloids are the most common fluids administered in patients with TBI. However, differences in their composition may affect coagulation and plasma tonicity and acid-base homeostasis. The choice of the ideal crystalloid fluid in TBI should be made based on tonicity, type of buffer used and volume status. Hypotonic fluids buffered with substances altering blood coagulation should be avoided in clinical practice. The prescriber remains faced with choices about the tonicity and pH buffering capability of fluid therapy, which we review here.
Topics: Brain Injuries, Traumatic; Crystalloid Solutions; Fluid Therapy; Humans; Plasma Substitutes
PubMed: 29165777
DOI: 10.5603/AIT.a2017.0067 -
Critical Care (London, England) May 2020Burn injury is associated with a long-standing inflammatory reaction. The use of albumin solutions for plasma volume support is controversial because of concerns of...
BACKGROUND
Burn injury is associated with a long-standing inflammatory reaction. The use of albumin solutions for plasma volume support is controversial because of concerns of increased capillary leakage, which could aggravate the commonly seen interstitial oedema.
METHODS
In the present open controlled clinical trial, an intravenous infusion of 20% albumin at 3 mL/kg was given over 30 min to 15 burn patients and 15 healthy volunteers. Blood samples and urine were collected for 5 h. Plasma dilution, plasma albumin and colloid osmotic pressure were compared. Mass balance calculations were used to estimate plasma volume expansion and capillary leakage of fluid and albumin.
RESULTS
The patients were studied between 4 and 14 (median, 7) days after the burn injury, which spread over 7-48% (median, 15%) of the total body surface area. The albumin solution expanded the plasma volume by almost 15%, equivalent to twice the infused volume, in both groups. The urinary excretion exceeded the infused volume by a factor of 2.5. Capillary leakage of albumin occurred at a rate of 3.4 ± 1.5 g/h in burn patients and 3.7 ± 1.6 g/h in the volunteers (P = 0.61), which corresponded to 2.4 ± 1.0% and 2.5 ± 1.2% per hour of the intravascular pool (P = 0.85). The median half-life of the plasma volume expansion was 5.9 (25th-75th percentiles 2.7-11.7) h in the burn patients and 6.9 (3.4-8.5) h in the volunteers (P = 0.56).
CONCLUSIONS
Albumin 20% was an effective volume expander in patients at 1 week post-burn. No relevant differences were found between burn patients and healthy volunteers.
TRIAL REGISTRATION
EudraCT 2016-000996-26 on May 31, 2016.
Topics: Adult; Burns; Capillary Leak Syndrome; Female; Humans; Male; Plasma Substitutes; Plasma Volume; Serum Albumin, Human
PubMed: 32366324
DOI: 10.1186/s13054-020-02855-0 -
British Journal of Anaesthesia Dec 2017The approach to i.v. fluid therapy for hypovolaemia may significantly influence outcomes for patients who experience a systemic inflammatory response after sepsis,... (Review)
Review
The approach to i.v. fluid therapy for hypovolaemia may significantly influence outcomes for patients who experience a systemic inflammatory response after sepsis, trauma, or major surgery. Currently, there is no single i.v. fluid agent that meets all the criteria for the ideal treatment for hypovolaemia. The physician must choose the best available agent(s) for each patient, and then decide when and how much to administer. Findings from large randomized trials suggest that some colloid-based fluids, particularly starch-based colloids, may be harmful in some situations, but it is unclear whether they should be withdrawn from use completely. Meanwhile, crystalloid fluids, such as saline 0.9% and Ringer's lactate, are more frequently used, but debate continues over which preparation is preferable. Perhaps most importantly, it remains unclear how to select the optimal dose of fluid in different patients and different clinical scenarios. There is good reason to believe that both inadequate and excessive i.v. fluid administration may lead to poor outcomes, including increased risk of infection and organ dysfunction, for hypovolaemic patients. In this review, we summarize the current knowledge on this topic and identify some key pitfalls and some areas of agreed best practice.
Topics: Administration, Intravenous; Colloids; Fluid Therapy; Humans; Hydroxyethyl Starch Derivatives; Hypovolemia; Isotonic Solutions; Plasma Substitutes; Ringer's Solution
PubMed: 29161385
DOI: 10.1093/bja/aex293 -
Annals of the Royal College of Surgeons... Jan 1954
Topics: Blood Substitutes; Convulsive Therapy; Dextrans; Plasma Substitutes
PubMed: 13125237
DOI: No ID Found