Crystalloids For Resuscitation Research Articles

Impact of chloride-rich crystalloids on sepsis-associated community-acquired acute kidney injury recovery in critically ill patients.

The use of chloride-rich crystalloids for resuscitation is associated with acute kidney injury (AKI). We aimed to explore the impact of resuscitation with chloride-rich crystalloids compared to balanced crystalloids on kidney function recovery in patients presenting with sepsis-associated community-acquired AKI (SACA-AKI). This is a single-center, historical cohort study of the adult intensive care unit (ICU) patients who presented to the emergency department (ED) with sepsis-associated community-acquired-AKI at the Mayo Clinic, Rochester, MN, from January 2011 to April 2018. We divided the cohort into two groups based on the primary type of crystalloids they received in the ED and the first 48-h of ICU. The first group received primarily normal saline with < 25% balanced solutions, and the second group received at least ≥ 25% balanced crystalloids during the initial volume resuscitation. Among the 732 enrolled patients [mean age: 64 ± 17, males: 461(63%)], 255 (35%) were in the second group and were found to have higher positive fluid balance during the first 48-h of admission compared to the first group [median + 2.3 (IQR: 0.4; 4.5) vs. + 1.1 (IQR: - 0.8; + 2.9) L, p < 0.001]. The second group had a higher rate of kidney function recovery by multivariate logistic regression after adjustments for known recovery risk factors (OR 1.46; 95% CI 1.05-2.04, p = 0.02). The use of balanced crystalloids during the initial resuscitation is associated with higher odds of kidney function recovery in AKI patientswithsepsis-associated community-acquired AKI.

Indications for transfusion of blood components

Indications for transfusion of blood components

The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012

Component balanced resuscitation and avoidance of crystalloids in traumatically injured adults requiring massive transfusion are beneficial. Evidence for children is lacking. After institutional review board approval was obtained, the Department of Defense Trauma Database identified 1,311 injured children 14 years or younger requiring transfusion after an injury and admitted to a deployed US military hospital from 2002 to 2012. Logistic regression determined risk factors for high-volume (≥40 mL/kg) or massive (≥70 mL/kg) transfusions. The effects of crystalloid and balanced component resuscitation in the first 24 hours were assessed. Nine hundred seven patients had recorded data sufficient for analysis. Two hundred twenty-four children received high-volume transfusion, and 77 received massive transfusions. Mortality was significantly higher for massive transfusions and high-volume transfusions than others (25% vs. 10% and 19% vs. 9%, respectively). Age of less than 4 years, penetrating injury, and Injury Severity Score (ISS) greater than 15 were associated with high-volume transfusions; an ISS greater than 15 and penetrating injury were associated with massive transfusions. Increased crystalloid administration showed a significant positive association with hospital days and intensive care unit days for both massive and high-volume transfusions, as well as a significant positive association with increased ventilator days in patients with high-volume transfusions. Balanced component resuscitation was not associated with improved measured outcomes and was independently associated with a higher mortality when all transfused patients were considered. In this cohort, heavy reliance on crystalloid for resuscitation had an adverse effect on outcomes. Balanced component resuscitation did not improve outcomes and was associated with higher mortality when all transfused patients were considered. Further study is needed regarding efficacy and clinical triggers for the implementation of massive transfusion in children. Prognostic study, level IV.

Physiologically-guided Balanced Resuscitation: An Evidence-based Approach for Acute Fluid Management in Paediatric Major Trauma

Trauma is a major cause of death, and haemorrhage represents an important target for improving outcomes after severe injury. Volume replacement with crystalloids in resuscitation might become harmful in large amounts because of coagulopathy. A fine balance must be achieved between haemodynamic and haemostatic resuscitation. Permissive hypotension refers to permitting some degree of hypotension in such adult patients in an attempt to attain this fine balance. For patients who require a significant volume of blood product resuscitation, the term 'massive transfusion protocol' (MTP) is used. There is very little data on transfusion protocols for paediatric trauma patients, and children respond to hypovolemic shock in a different physiological manner compared to adults. Hence, concepts such as permissive hypotension may not be appropriate when treating children involved in major trauma. We recently embarked on a plan to streamline the management of blood transfusion in massive bleeding during paediatric trauma, to reduce the logistical problems associated with the transport of blood products from the blood bank to the patient. From this, we evolved a MTP for paediatric major trauma. Nonetheless, further studies will be needed to see if there is indeed improved outcome after MTP in paediatric major trauma as current evidence is extrapolated from adult studies.

Scandinavian clinical practice guideline on choice of fluid in resuscitation of critically ill patients with acute circulatory failure.

The task force on Acute Circulatory Failure of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine produced this guideline with recommendations concerning the use of crystalloid vs. colloid solutions in adult critically ill patients with acute circulatory failure. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to grade the quality of evidence and to determine the strengths of the recommendations. As efficacy and harm may vary in different subpopulations of patients with acute circulatory failure, we produced recommendations for general intensive care unit (ICU) patients and those with sepsis, trauma and burn injury. For general ICU patients and those with sepsis, we recommend using crystalloids for resuscitation rather than hydroxyethyl starch and we suggest using crystalloids rather than gelatin and albumin. For patients with trauma we recommend to use crystalloids for resuscitation rather than colloid solutions. For patients with burn injury we provide no recommendations as there are very limited data from randomised trials on fluid resuscitation in this patient population. We recommend using crystalloid solutions rather than colloid solutions for resuscitation in the majority of critically ill patients with acute circulatory failure.

Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation.

BackgroundThe objective of this systematic review and meta-analysis was to assess the relationship between the chloride content of intravenous resuscitation fluids and patient outcomes in the perioperative or intensive care setting.MethodsSystematic searches were performed of PubMed/MEDLINE, Embase and Cochrane Library (CENTRAL) databases in accordance with PRISMA guidelines. Randomized clinical trials, controlled clinical trials and observational studies were included if they compared outcomes in acutely ill or surgical patients receiving either high-chloride (ion concentration greater than 111 mmol/l up to and including 154 mmol/l) or lower-chloride (concentration 111 mmol/l or less) crystalloids for resuscitation. Endpoints examined were mortality, measures of kidney function, serum chloride, hyperchloraemia/metabolic acidosis, blood transfusion volume, mechanical ventilation time, and length of hospital and intensive care unit stay. Risk ratios (RRs), mean differences (MDs) or standardized mean differences (SMDs) and confidence intervals were calculated using fixed-effect modelling.ResultsThe search identified 21 studies involving 6253 patients. High-chloride fluids did not affect mortality but were associated with a significantly higher risk of acute kidney injury (RR 1·64, 95 per cent c.i. 1·27 to 2·13; P < 0·001) and hyperchloraemia/metabolic acidosis (RR 2·87, 1·95 to 4·21; P < 0·001). High-chloride fluids were also associated with greater serum chloride (MD 3·70 (95 per cent c.i. 3·36 to 4·04) mmol/l; P < 0·001), blood transfusion volume (SMD 0·35, 0·07 to 0·63; P = 0·014) and mechanical ventilation time (SMD 0·15, 0·08 to 0·23; P < 0·001). Sensitivity analyses excluding heavily weighted studies resulted in non-statistically significant effects for acute kidney injury and mechanical ventilation time.ConclusionA weak but significant association between higher chloride content fluids and unfavourable outcomes was found, but mortality was unaffected by chloride content.

The beginning of the end for damage control surgery

reported a 90 per cent survivalrate in ten patients with severe liverinjuries treated at the Ben Taub Gen-eralHospitalin1981.Damagecontrolsurgery has become widespread. It isnow performed with much greaterfrequency, raising the question ofwhether it is being overutilized.The philosophy of damage controldictates abbreviation of operationsbefore the development of physiolog-ical exhaustion. The goal is to inter-rupt the vicious cycle or lethal triadof hypothermia, acidosis and coagu-lopathy by resuscitation, coagulationfactor replacement and rewarmingin the intensive care unit, followedby a return to the operating roomfor definitive therapy. Unfortunately,resuscitation practices and the failuretoachieveearlyhaemostasishavecon-tributed significantly to the incidenceof this ‘bloody’ vicious cycle, fur-ther promulgating the damage con-trolphilosophy.Newerstrategiesthatfocus on improved haemorrhage con-trol, limitation of crystalloids forresuscitation and rapid goal-directedcorrection of coagulopathy shouldreverse this trend toward increaseduse of damage control.Early treatment of injured patientshas traditionally focused on aggres-sive resuscitation with high chloride-containing crystalloid solutions.Resuscitation with crystalloid exac-erbates each element of the lethaltriad. Prehospital and early in-hospital resuscitation has been shownto increase morbidity and mor-tality in patients with penetratingtorso trauma

Role of HES 130/0.4 in resuscitation of patients with major burn injury

SUMMARYTo investigate whether hydroxyethyl starch (HES) 130/0.4 can be used safely in the initial resuscitation (first 48 hours after admission) of burned patients, and more particularly whether its use in the early treatment of burns can reduce crystalloid overload. Burn patients with a total burn surface area over 30% were randomized to two groups receiving either crystalloids (Ringer's lactate) only or HES 130/0.4 (Voluven®, Fresenius Kabi, Bad Homburg, Germany) along with crystalloids for resuscitation. During the first 48 post‐burn hours (PBH), fluid requirements were estimated using the Parkland formula and fluids were administered according to the study protocol. During the study, randomization had to be abandoned due to clinical and ethical reasons. The difference between ‘Fluid required’ and ‘Fluid given’ was recorded as either ‘Fluid saved’ or ‘Fluid excess’. Patients’ body weight and limb circumferences were measured as a guide to quantify the edema. Ten patients in the control group received Ringer's lactate solution only and 22 patients in the HES group received HES 130/0.4 plus Ringer's lactate solution for resuscitation. During the whole study period, mean fluid saving was 15.9% in the control group (n = 3) and 44.7% in the HES group (n = 20) (P = 0.0151). Mean fluid excess was 16.6% in the control group (n = 7) and 12.4% in HES group (n = 2) (P = 0.7120). By the end of 48 PBH, parameters related to tissue edema (mean rise in body weight and circumferences of burned and unburned areas) were significantly more favorable in the HES group (P = 0.0071, P &lt; 0.0001 and P &lt; 0.0001, respectively). Although the other management methods were the same in both groups, nine of 10 patients (90%) in the control group compared with 11 of 22 patients (50%) in the HES group died during their hospitalization (P = 0.0341). HES 130/0.4 appears to be a promising artificial plasma volume expander for burn resuscitation as compared with standard management. Further well‐designed studies with large sample sizes are required to confirm these findings and explore the pharmacodynamic mechanisms involved.

Colloid or crystalloid for resuscitation of major burns?

There is continuing debate over the merits of colloid versus crystalloids for the resuscitation of major burns. This article reviews fluids used in burn resuscitation and discusses potential advantages and disadvantages of colloid and crystalloid.

Circulatory effects of whole blood, packed red cells, albumin, starch, and crystalloids in resuscitation of shock and acute critical illness.

Circulatory deficiencies and the effectiveness of transfusion and fluid therapy may be evaluated by invasive and noninvasive monitoring after high risk surgery, hemorrhage, trauma, and sepsis in the ED, OR, and ICU. Earlier recognition and therapy of circulatory problems in emergency and critically ill patients to achieve optimal goals empirically defined by the survivors' patterns is recommended to improve outcome. WB, Prbc, and colloids markedly and statistically significantly improved pressure, flow, and tissue perfusion and best achieved these goals. Noninvasive monitoring may be used in the ED and OR shortly after admission to identify circulatory deficiencies and to titrate therapy, or they may be used initially as the front-end of subsequent invasive monitoring.

The role of colloids in resuscitation

Colloids have been used for many years in resuscitation yet few studies have thoroughly examined their usefulness. Colloids and a combination of crystalloids and colloids continue to be used without any real scientific basis. Scrutiny of review articles, experimental studies, and clinical investigations reveals conflicting and confusing data. There are too many variables to accurately interpret findings, cross species problems with animal studies, different fluids used making comparisons difficult if not impossible, and confounding variables that include: 1 Health status of the patients 2 Severity/type of injury 3 Complications (especially sepsis) 4 Varying grades of shock 5 Variable time scale of administration of fluids 6 Variable volumes administered 7 Differing methods of determining fluid volume depletion 8 Inconsistent monitoring 9 Differing endpoints 10 Different techniques to measure endpoints 11 Comparison of delayed treatment of traumatic shock with blood loss occurring during surgery of questionable validity. One of the areas that has been studied reasonably well is the allergic effects associated with colloid use and more recently the adverse effects associated with the use of dextrose solutions in patients with head injuries. The continued effort to develop satisfactory resuscitation solutions including the recent development of hypertonic saline solutions (usually in combination with a colloid) highlights the uncertainty that exists in relation to the true role of the colloid and crystalloid agents available. Recent studies question the use of fluids to resuscitate patients with penetrating torso injuries. The aim of this paper is to review what is known about the use of colloids and crystalloids in resuscitation and to recommend guidelines as to which fluid should be used in differing clinical situations.

Colloids vs crystalloids

The choice of colloid or crystalloid solutions for resuscitation of a patient in shock remains controversial. Colloids quickly restore plasma volume along with stabilizing hemodynamics. Almost the entire volume is retained within the vascular space after 1 hour. However, only 8 percent of infused water and less than 25 percent of infused saline are retained in intravascular fluid compartments after 1 hour. When using crystalloids for resuscitation, two to four times as much fluid is required for fluid repletion. The very young or old or persons with cardiac or renal dysfunction may have an increased risk of developing pulmonary edema when crystalloids are administered.

Surgery 1: Trauma

This volume is the first in a series on surgery by Butterworths International Medical Reviews. The editors have selected authorities from both sides of the Atlantic to compose the articles, and six of the 12 chapters have a commentary following the section to contribute depth to the material. Chapter 1 touches on the controversy in the use of colloids<i>v</i>crystalloids in resuscitation and gives in outline form the most imminent measures to be performed. Also mentioned are the indices for measuring severity of injury, which may become widely used. Chapter 2 is a neat review of assessment of multiple injuries including useful comments. Chapter 3 discusses epidemiology of head injuries as well as the outlook for patients with spinal injuries. For the latter, the multidisciplinary approach is approved; for the former, more effective links between neurosurgeons and general surgeons and other specialties are advocated. Chapter 4 reviews thoracic injuries