Plasma Volume Expansion Research Articles

IMPROVING HEALTH INFORMATION OF PREGNANT MOTHERS WITH THE ISLAMIC FAMILY APPROACH THROUGH THE RECOGNITION OF ANEMIA SIGNS

The most direct cause of maternal death is bleeding. Bleeding is divided into two categories, namely antepartum bleeding (vaginal bleeding at 28 weeks of gestation or more) and postpartum hemorrhage (bleeding that occurs within the first 24 hours after delivery). Bleeding occurs due to lack of supervision and examination during pregnancy, including prevention of anemia. Mothers who suffer from anemia in pregnancy will be very susceptible to infection and bleeding, even if the bleeding is only a little. Experience has shown that maternal death due to bleeding is more common in women who suffer from anemia. Anemia often occurs due to iron deficiency because pregnant women have a twofold increase in iron requirements due to an increase in blood volume without expansion of plasma volume, to meet the needs of the mother (prevent blood loss during childbirth) and fetal growth. Anemia is a condition where the hemoglobin level (>11(gr/L)2), hematocrit (>0.33gr/L), and red blood cell count are below normal values. Anemia in pregnancy is the biggest public health problem that occurs worldwide, especially in developing countries, in low socio-economic groups, and has a very large influence on the quality of human resources. Anemia in pregnancy is called "Potential Danger to Mother and Child" (potentially harmful to mother and child), which contributes to the increasing prevalence of maternal mortality and morbidity. As for infants, it can increase the risk of infant morbidity and mortality, as well as increase the incidence of LBW. Given this, the problem of anemia should be a serious concern for all relevant parties, especially in health services on the front lines. So it is necessary to provide information about anemia signs, namely by providing information and giving Fe tablets, prayers for the good of the mother and fetus, stress management and consumption of green vegetables. Physical and psychological changes are sometimes quite disturbing daily life. Some pregnant women have difficulty regulating emotions because of the changes that occur. Especially the changes in the first trimester of pregnancy. Family support for pregnant women is very important and has many benefits. Not only from husbands, but also from parents, in-laws, sisters, brothers, relatives, or even close friends.

Effects of aldosterone on the human placenta: Insights from placental perfusion studies

IntroductionIn pregnancy, aldosterone is linked to maternal plasma volume expansion, improved fetal and placental growth/angiogenesis and reduced maternal blood pressure. Aldosterone levels are low in women with pre-eclampsia. Given the placental growth properties of aldosterone in pregnancy, we hypothesised that increased aldosterone improves placental function ex vivo. We applied aldosterone in the dual human placenta perfusion model and analysed specific regulatory markers. MethodsA single cotyledon was perfused using a trimodal perfusion setup consisting of a control phase (CP; basic perfusion medium (BPM) alone) and two consecutive experimental phases (EP1/EP2; BPM supplemented with 1.5 x 10−9M and 1.5 x 10−7M aldosterone, respectively). CP and EP1/EP2 were conducted in closed circuits lasting 2 h each. Quality/time control perfusions using BPM alone were performed for 360 min to distinguish time-dependent effects from aldosterone-related effects. Perfusates were assessed for control parameters (pH/pO2/pCO2/glucose/lactate/creatinine/antipyrine). Maternal perfusates were analysed for placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), interleukin-10 (IL-10) and tumour necrosis factor-alpha (TNF-α) using ELISAs. mRNA expression of abovementioned factors was measured by qPCR in post-perfusion tissue. ResultsData from quality/time control perfusions indicated that TNF-α and IL-10 release continuously increased over time. Contrary, in the trimodal perfusion setup the application of aldosterone decreased TNF-α secretion (P < 0.05, EP1/EP2 vs CP, 120 min) and increased PlGF release (P < 0.05, EP1 vs CP, 90/120 min) into the maternal perfusates. mRNA expression followed similar trends, but did not reach significance. DiscussionOur ex vivo placental perfusion data suggest that increasing aldosterone promotes anti-inflammatory and pro-angiogenic factors, which could positively contribute to healthy pregnancy outcomes.

A narrative review of Hyporeninemic hypertension-an indicator for monogenic forms of hypertension.

While the role of the renin-angiotensin-aldosterone system (RAAS) in the development of hypertension is well known, the significance and contribution of low renin hypertension is often overlooked. RAAS stimulation results in more tubular absorption of sodium and water along the nephron, contributing to a higher circulating vascular volume. In addition, members of the RAAS system, such as angiotensin II, have direct effects on vascular vasoconstriction, the heart, aldosterone synthesis in the adrenal glands, the sympathetic nervous system, and the central nervous system. This has resulted in a line of antihypertensive therapeutics targeting RAAS with angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and renin inhibitors, which prevent conversion of angiotensinogen to angiotensin. While general practitioners and nephrologists are well aware of the causes and the long-term consequences of elevated renin and aldosterone levels, the opposite situation with low renin and/or low aldosterone levels is frequently underappreciated. The objective of this review is to provide insight to the less common forms of hyporeninemic hypertension. We searched the PubMed online library for keywords related to hyporeninemic hypertension and focused on the pediatric population. For pathophysiology we focused on literature of the last 5 years. The low renin and aldosterone levels may be indicators of inherited (especially when associated with hypokalemia), monogenic forms of hypertension stimulating excessive tubular sodium and water absorption which subsequently results in plasma volume expansion and hypertension. These forms of hypertension require frequently specific forms of therapy. This underlines the importance of the practitioner to be familiar with these rare diseases. In this review article, we outline the different forms of hypertension characterized by low renin/low aldosterone and low renin/high aldosterone levels, how to diagnose these forms of hypertension, and how to treat them.

Impact of sodium citrate ingestion during recovery after strenuous exercise in the heat on heart rate variability: A randomized, crossover study

Changes in hydration status influence plasma volume (PV) which is associated with post‐exercise parasympathetic reactivation. The present study hypothesized that, after dehydrating cycling exercise in the heat (DE), stimulation of PV expansion with sodium citrate (CIT) supplementation would promote heart rate variability (HRV) recovery in endurance‐trained men. Twelve participants lost 4% of body mass during DE. During subsequent 16‐h recovery, participants consumed water ad libitum (CIT =5.5‐L, PLC =5.1‐L) and ate prescribed food supplemented with CIT or placebo in a randomized, double‐blind, crossover manner. Relative changes in PV were assessed across DE and 16‐h recovery. HRV was analyzed before and 16 h after DE in three conditions for altogether four 5‐min periods: supine in a thermoneutral environment, supine in the heat (32°C, 46% relative humidity; 2 periods), and standing in the heat. A larger expansion of PV across 16‐h recovery occurred in CIT compared to placebo trial (p < 0.0001). However, no between‐trial differences appeared in HRV parameters (lnRMSSD, lnSDNN, lnLF/HF) in any 5‐min period analyzed before or 16 h after DE (in all cases p > 0.05). Increases in HR (p < 0.001) and lnLF/HF (p = 0.005) and decreases in lnRMSSD (p < 0.001) and lnSDNN (p < 0.001) occurred following DE in both trials. Larger PV expansion induced by CIT supplementation after DE does not improve recovery of HRV at rest and has no influence on HRV responsiveness in endurance‐trained men.

Heat Acclimation with or without Normobaric Hypoxia Exposure Leads to Similar Improvements in Endurance Performance in the Heat.

Background: Combining the key adaptation of plasma volume (PV) expansion with synergistic physiological effects of other acclimation interventions to maximise endurance performance in the heat has potential. The current study investigated the effects of heat acclimation alone (H), combined with normobaric hypoxia exposure (H+NH), on endurance athletic performance. Methods: Well-trained participants completed a heat-stress trial (30 °C, 80% relative humidity (RH), 20.8% fraction of inspired oxygen (FiO2)) of a 75 min steady-state cycling (fixed workload) and a subsequent 15 min cycling time trial for distance before and after intervention. Participants completed 12 consecutive indoor training days with either heat acclimation (H; 60 min·day−1, 30 °C, 80% RH; 20.8% FiO2) or heat acclimation and overnight hypoxic environment (H+NH; ~12 h, 60% RH; 16% FiO2 simulating altitude of ~2500 m). Control (CON) group trained outdoors with average maximum daily temperature of 16.5 °C and 60% RH. Results: Both H and H+NH significantly improved time trial cycling distance by ~5.5% compared to CON, with no difference between environmental exposures. PV increased (+3.8%) and decreased (−4.1%) following H and H+NH, respectively, whereas haemoglobin concentration decreased (−2%) and increased (+3%) in H and H+NH, respectively. Conclusion: Our results show that despite contrasting physiological adaptations to different environmental acclimation protocols, heat acclimation with or without hypoxic exposure demonstrated similar improvements in short-duration exercise performance in a hot environment.

Obesity and heart failure with preserved ejection fraction: pathophysiology and clinical significance

Obesity is a risk factor for heart failure and cardiovascular disease. Of particular note, over 80% of patients with heart failure with a preserved ejection fraction (HFpEF) are overweight or obese. In this study, we aimed to review the association between obesity and HFpEF. Obese patients with HFpEF exhibit a distinct phenotype. In addition to impaired left ventricular (LV) diastolic function and high filling pressures, obese patients with HFpEF possess other factors that cause elevated LV filling pressure, such as a greater dependence on plasma volume expansion, aggravated pericardial restraint, and increased ventricular interaction. Obesity can contribute to HFpEF through hemodynamic, neurohormonal, inflammatory, and mechanical mechanisms. An increased amount of body fat can induce plasma volume expansion, resulting in chamber remodeling, pericardial restraint, and ultimately elevations in LV filling pressure. Obesity can mediate the activation of sympathetic nervous system signaling and the renin-angiotensin-aldosterone system. These unique pathophysiological characteristics of individuals with both obesity and HFpEF suggest that obesity with HFpEF can be considered a specific phenotype. Future research is expected to clarify effective treatment modalities for obesity-related HFpEF.

The Common Phenotype Of Polycythemia And Hypervolemia In Hospitalized Heart Failure Patients

<h3>Background</h3> : Heart failure patients have wide variations in intravascular volumes which form the basis for disease initiation and progression and contribute to confusion in treatment strategies. Blood volume analysis (BVA) is a bedside blood test that measures with 98% accuracy intravascular volumes of a HF patient, including plasma and red blood cell volume (RBCV). Extremes in excess of red blood cell volume (polycythemia (P)) in HF patients have been associated with poorer outcomes including mortality. A not uncommon BVA phenotype is that of secondary P, with or without hypervolemia(P/Hypervol). We sought to further clarify the clinical correlates and outcomes associated with this phenotype in a mixed LVEF cohort of hospitalized HF patients and whether this phenotype would be detectable utilizing pHct or Hgb measures. <h3>Methods/Results</h3> : In a cohort of 245 consecutively admitted HF patients (142 men/103 women) with mixed EFs who underwent BVA guided care, 25 patients (10.2%) had P/Hypervol and 3 patients (1.2%) had P with normal or low total blood volume. The presence of this phenotype was equal in patients with HFrEF and HFpEF (52%/48%). P/Hypervol was observed less frequently in patients over 75 (p=0.03), and among patients with BMI>35 (p=0.07). Despite P, the peripheral Hct (pHct) was either normal (57.1%), or >10% below normal (39.3%), indicating that in a majority of patients excess red cells were accompanied by an excess of plasma and that pHct would not indicate P. The BVA-provided RBCV showed that in 93% of patients with P that diuresis alone would not be able to achieve euvolemia without extreme hemoconcentration. Patients with P or P/Hypervol were treated with therapeutic phlebotomy or sent for hematology consults to achieve euvolemia. In terms of outcomes at 30 days post-discharge, 12% of the phenotype were readmitted, similar to those with other phenotypes; no deaths occurred in the P/Hypervol phenotype within 30 days or 365 days. 30-day readmissions did occur (56%) in the phenotype similar to other phenotypes (62.3%). <h3>Conclusions</h3> : The P/Hypervol phenotype is common and worrisome for several reasons. Neither the pHct, the BMI or age is sufficient to identify this phenotype. The plasma and red blood cell volume (RBCV) expansion may hasten disease progression accounting for underrepresentation of older patients in this cohort. Further, the discrepancy in the pHct might lead clinicians to suspect that the patient has a dilutionally low pHct, when, in fact, they have an increased RBCV and a diuretic strategy alone will only hemoconcentrate the patient, increasing viscosity and risk of thrombotic events while not achieving euvolemia. BVA-guided assessment demonstrated the specificity to identify this phenotype. and raise the value of therapeutic phlebotomy to optimize volume and RBCV; this cohort merits improved BVA-guided evaluation to better discern the impact of this phenotype on HF outcomes.

Deviations From the Ideal Plasma Volume and Isolated Tricuspid Valve Surgery-Paving the Way for New Risk Stratification Parameters.

BackgroundCongestion and plasma volume expansion are important features of heart failure, whose prognostic significance has been investigated in a range of surgical and non-surgical settings. The aim of this study was to evaluate the value of the estimated plasma volume status (ePVS) in patients undergoing isolated tricuspid valve surgery.MethodsThis study included patients who underwent isolated tricuspid valve surgery at the Vienna General Hospital (Austria) between July 2008 and November 2018. The PVS cut-off was calculated using ROC analysis and Youden's Index.ResultsEighty eight patients (median age: 58 [IQR: 35-70] years; 44.3% male; 75.6% NYHA III/IV; median EuroSCORE II 2.65 [IQR: 1.70-5.10]; 33.0% endocarditis-related regurgitation; 60.2% isolated repair; 39.8% isolated replacement) were included in this study. Patients who died within 1 year following surgery had significantly higher baseline ePVS values than survivors (median ePVS 5.29 [IQR: −1.55-13.55] vs. −3.68 [IQR: −10.92-4.22]; p = 0.005). During a median actuarial follow-up of 3.02 (IQR: 0.36-6.80) years, patients with a preoperative ePVS ≥ −4.17 had a significantly increased mortality (log-rank p = 0.006).ConclusionsePVS is an easily obtainable risk parameter for patients undergoing isolated tricuspid valve surgery capable of predicting mid- and long-term outcomes after isolated tricuspid valve surgery.

A crossover control study of three methods of heat acclimation on the magnitude and kinetics of adaptation.

What is the central question to the study? Are primary indices of heat adaptation (e.g., expansion of plasma volume and reduction in resting core temperature) differentially affected by the three major modes of short-term heat acclimation, that is, exercise in the heat, hot water immersion and sauna? What it the main finding and its importance? The three modes elicited typical adaptations expected with short-term heat acclimation, but these were not significantly different between modes. This comparison has not previously been made and highlights that individuals can expect similar adaptation to heat regardless of the mode used. Heat acclimation (HA) can improve heat tolerance and cardiovascular health. The mode of HA potentially impacts the magnitude and time course of adaptations, but almost no comparative data exist. We therefore investigated adaptive responses to three common modes of HA, particularly with respect to plasma volume. Within a crossover repeated-measures design, 13 physically active participants (five female) undertook four, 5-day HA regimes (60min/day) in randomised order, separated by ≥4weeks. Rectal temperature (Tre ) was clamped at neutrality via 36.6°C (thermoneutral) water immersion (TWI; i.e., control condition), or raised by 1.5°C via heat stress in 40°C water, sauna (55°C, 52% relative humidity), or exercise in humid heat (40°C, 52% relative humidity; ExH). Adaptation magnitude was assessed as the pooled response across days 4-6, while kinetics was assessed via the 6-day time series. Plasma volume expansion was similar in all heated conditions but only higher than TWI in exercise in the heat (ExH) (by 4%, P=0.036). Approximately two-thirds of the expansion was attained within the initial 24h and was moderately related to that present on day 6, regardless of HA mode (r=0.560-0.887). Expansion was mediated by conservation of both sodium and albumin content, with little evidence for these having differential roles between modes (P=0.706 and 0.320, respectively). Resting Tre decreased by 0.1-0.3°C in all heated conditions, and systolic blood pressure decreased by 4mmHg, but not differentially between conditions (P≥0.137). In conclusion, HA mode did not substantially affect the magnitude or rate of adaptation in key resting markers of short-term HA.

The Hyperhydration Potential of Sodium Bicarbonate and Sodium Citrate.

Buffering agents have not been comprehensively profiled in terms of their capacity to influence water retention prior to exercise. The purpose of this investigation was to profile the fluid retention characteristics of sodium bicarbonate (BIC) and sodium citrate (CIT) to determine the efficacy of these buffering mediums as hyperhydrating agents. Nineteen volunteers (13 males and six females; age = 28.3 ± 4.9years) completed three trials (randomized and cross-over design). For each trial, a baseline measurement of body mass, capillary blood, and urine was collected prior to ingestion of their respective condition (control condition [CON] = 25ml/kg artificially sweetened water; BIC condition = CON + 7.5g/L of sodium in the form of BIC; CIT condition = CON + 7.5g/L of sodium in the form of CIT). The fluid loads were consumed in four equal aliquots (0, 20, 40 and 60min; fluid intake was 1.972 ± 361ml [CON]; 1.977 ± 360ml [BIC]; 1.953 ± 352ml [CIT]). Samples were recorded at 20 (body mass and urine) and 60min (blood) intervals for 180min. Blood buffering capacity (HCO3-) was elevated (p < .001) in both BIC (32.1 ± 2.2mmol/L) and CIT (28.9 ± 3.8mmol/L) at 180min compared with CON (25.1 ± 1.8mmol/L). Plasma volume expansion was greater (p < .001) in both BIC (8.1 ± 1.3%) and CIT (5.9 ± 1.8%) compared with CON (-1.1 ± 1.4%); whereas, total urine production was lower in BIC and CIT at 180min (BIC vs. CON, mean difference of 370 ± 85ml; p < .001; CIT vs. CON, mean difference of 239 ± 102ml; p = .05). There were no increases observed in body mass (p = .9). Under resting conditions, these data suggest BIC and CIT induce a greater plasma hypervolemic response as compared with water alone.

Oxidized alkyl phospholipids stimulate sodium transport in proximal tubules via a nongenomic PPARγ-dependent pathway

Oxidized phospholipids have been shown to exhibit pleiotropic effects in numerous biological contexts. For example, 1-O-hexadecyl-2-azelaoyl-sn-glycero-3-phosphocholine (azPC), an oxidized phospholipid formed from alkyl phosphatidylcholines, is a peroxisome proliferator–activated receptor gamma (PPARγ) nuclear receptor agonist. Although it has been reported that PPARγ agonists including thiazolidinediones can induce plasma volume expansion by enhancing renal sodium and water retention, the role of azPC in renal transport functions is unknown. In the present study, we investigated the effect of azPC on renal proximal tubule (PT) transport using isolated PTs and kidney cortex tissues and also investigated the effect of azPC on renal sodium handling in vivo. We showed using a microperfusion technique that azPC rapidly stimulated Na+/HCO3− cotransporter 1 (NBCe1) and luminal Na+/H+ exchanger (NHE) activities in a dose-dependent manner at submicromolar concentrations in isolated PTs from rats and humans. The rapid effects (within a few minutes) suggest that azPC activates NBCe1 and NHE via nongenomic signaling. The stimulatory effects were completely blocked by specific PPARγ antagonist GW9662, ERK kinase inhibitor PD98059, and CD36 inhibitor sulfosuccinimidyl oleate. Treatment with an siRNA against PPAR gamma completely blocked the stimulation of both NBCe1 and NHE by azPC. Moreover, azPC induced ERK phosphorylation in rat and human kidney cortex tissues, which were completely suppressed by GW9662 and PD98059 treatments. These results suggest that azPC stimulates renal PT sodium-coupled bicarbonate transport via a CD36/PPARγ/mitogen-activated protein/ERK kinase/ERK pathway. We conclude that the stimulatory effects of azPC on PT transport may be partially involved in volume expansion.

Role of Albumin in Spontaneous Bacterial Peritonitis: Indications, Side-Effects and Outcome

The most prevalent bacterial infection in cirrhotic patients is spontaneous bacterial peritonitis. Hospitalized patients with cirrhosis and ascites have an incidence that ranges between 10% and 30%, making it one of their primary complications. Since it may lead to kidney failure, hepatic encephalopathy, gastrointestinal bleeding, hypervolemic hyponatremia, the development of acute or chronic liver failure, systemic sepsis, so the outcomes in patients with spontaneous bacterial peritonitis are poor. Early antibiotic treatment is essential for bacterial spontaneous peritonitis. It is advised to utilize albumin in addition to antibiotics for some high-risk patients who have spontaneous bacterial peritonitis. The purpose of this research is to review the available information about the role of albumin in spontaneous bacterial peritonitis: indications, side-effects and outcome. Albumin is a plasma volume expander and is responsible for decreasing inflammatory response mediators such nitric oxide and the proinflammatory cytokines tumour necrosis factor-alpha and interleukin-6 because of this property it has a beneficial role in spontaneous bacterial peritonitis. Intravenous albumin administration has also been demonstrated to enhance systemic hemodynamic and renal function among spontaneous bacterial peritonitis patients. This effect is mediated by both an increase in cardiac function and a decrease in arterial vasodilatation Albumin along with the antibiotics is safe and effective in management of spontaneous bacterial peritonitis. It reduces the risk of renal complications and mortality. Although further research for standardizing the dosage and duration of albumin is needed.

IMPACT OF REFRACTORY ASCITES ON THE SURVIVAL OF PATIENTS WITH CIRRHOSIS

Refractory ascites is an infrequent complication in patients with cirrhosis; it is considered in those who do not respond to diuretics or who have adverse effects with diuretics. Treatment is large-volume paracentesis, followed by plasma volume expansion to prevent paracentesis-induced circulatory dysfunction (PICD) to avoid deterioration in renal function and hyponatremia. Intermittent paracentesis could increase morbidity and mortality in these patients. Perhaps the classic prognostic scales, such as MELD, undervalue this factor that is not usually considered for prioritizing transplantation. The objective of this study is to assess the survival of patients with cirrhosis with refractory ascites. Observational, retrospective, descriptive and analytical study. Patients with cirrhosis and refractory ascites were included, who were subjected to intermittent paracentesis on several occasions from February 2019 to June 2021. Descriptive statistics were performed with central tendency and dispersion measures, baseline and final MELD were calculated, and mortality was evaluated. Eleven patients were included, six men (54.5%) and five women (45.5%), aged 54 ± eight years. The patients had a range of paracentesis performed from 3 to 30 occasions (median five interventions), with a follow-up of 1 to 40 months (median of 8 months). The etiology of cirrhosis was alcoholic 63.6%, MALFD 9.1%, and 27.3% other causes. The total amount of fluid drained per patient was 37 to 439 L, 90% of the patients classified as Child-Pugh grade C, and 10% B. The median of the initial MELD was 15 (range = 13), and the median of the final MELD was 22 (range=17). There was no significant difference according to the Wilcoxon test p = 0.317. The renal function between the first and the last paracentesis decreased mildly by 24% and from 36% to 45% severely. Overall mortality was six patients (54.5%). The causes of death were spontaneous bacterial peritonitis (SBP) 9%, ACLF (Acute on Cronic Liver Failure) 27%, infarction 9%, and sepsis 9%. Median survival was 18 months (range 13-23) Patients with refractory ascites have very high mortality (59%); Despite the amount of fluid drained, up to 439L in one patient (for example), it did not seriously affect kidney function overall. We found no statistically significant difference between the initial and final MELD values (Figure 1). However, the MELD score does not make them candidates for liver transplantation; therefore, refractory ascites should be considered with an additional score to enter them on the transplant list. Refractory ascites is uncommon, but it has high mortality; the MELD scale may not accurately predict the possibility of death, so they should be entered with an additional score to consider them candidates for liver transplantation. The authors declare that there is no conflict of interest

Calculated blood loss overestimates diagnosis of postpartum hemorrhage in patients with hypertensive disorders of pregnancy

There is no gold standard for quantifying peripartum blood loss. Calculated blood loss (CBL), which estimates blood loss using body weight and hematocrit change after delivery, was recently used to assess the benefit of tranexamic acid for prevention of postpartum hemorrhage (PPH). Since CBL estimates are influenced by plasma volume expansion after delivery, we hypothesize that CBL is less accurate in patients with hypertensive disorders of pregnancy (HDP).

Gelatin and the risk of acute kidney injury after cardiac surgery.

Gelatin has been used as a plasma volume expander because of its ability to preserve intravascular volume more effectively than crystalloids. However, gelatin may have detrimental effects on kidney function and increase the risk of acute kidney injury (AKI). We investigated by retrospective analysis of prospectively collected data whether the administration of 4% succinyl gelatin is associated with an increased risk of AKI after cardiac surgery. We compared two propensity score-matched groups of 1,187 patients (crystalloid group and gelatin group). The incidence of AKI was similar in both groups (gelatin 21% and crystalloid 20%) (p=0.414). The incidence of moderate AKI (8% vs. 6%) was higher in the gelatin group, but there was no difference in mild or severe AKI. Postoperative serum creatine on the first (70 vs. 70μmol L-1 , p=0.689) or fourth (71 vs. 70, p=0.313) postoperative day was similar between groups and there was no difference in the need for new renal replacement therapy (p=0.999). Patients in the gelatin group received less crystalloids (2080ml vs. 4130ml, p=0.001) and total fluids (3760ml vs. 4180ml, p=0.001), their fluid balance was less positive (p=0.001) and they required less vasoactive and inotropic medication (p=0.001). Gelatin was not associated with increased mortality compared to the crystalloid group. Gelatin was not associated with AKI after cardiac surgery.

Plasma Volume Expansion and Fluid Kinetics of 20% Albumin During General Anesthesia and Surgery Lasting for More Than 5 Hours.

Intraoperative administration of crystalloid for plasma volume expansion may be reduced by use of hyperoncotic albumin. However, the degree of plasma volume expansion with administration of 20% albumin is poorly quantitated. We estimated the amount of volume expansion attributable to 20% albumin administration in patients undergoing surgery for more than 5 hours. Twenty percent albumin was delivered at 3 mL/kg by intravenous infusion during 30 minutes to 15 patients (mean ± standard deviation [SD] age; 46 ± 15 years) undergoing surgery. Blood samples and urine were collected for 5 hours. Mass balance calculations and volume kinetics were used to estimate plasma volume expansion and capillary leakage of albumin and fluid. Administration of 20% albumin was associated with an increase in plasma volume amounting to 1.7 times the infused volume. After correction for hemorrhage, the median (and 25th to 75th percentiles) intravascular half-life for the administered albumin mass was 20.4 (14.2-34.7) hours. The plasma volume decreased with a half-life of 21.7 (16.1-26.8) hours. Urinary excretion was 3 times greater than the infused volume of albumin, but kinetic analysis suggested that other flows of fluid to and from the plasma occurred more slowly than previously found in volunteers. Hemodynamic support with norepinephrine increased urinary excretion and contracted the plasma volume. Albumin (20%) increased the plasma volume by 1.7 times the infused volume. Our results do not support that the transcapillary leakage of albumin is accelerated by anesthesia and surgery.

Predictive value of plasma volume status for contrast-induced nephropathy in patients with heart failure undergoing PCI.

AimsContrast‐induced nephropathy remains a common complication of coronary procedure and increases poor outcomes, especially in patients with heart failure. Plasma volume expansion relates to worsening prognosis of heart failure. We hypothesized that calculated plasma volume status (PVS) might provide predictive utility for contrast‐induced nephropathy in patients with heart failure undergoing elective percutaneous coronary intervention (PCI).Methods and resultsWe enrolled 441 patients with heart failure undergoing elective PCI from 2012 to 2018. Pre‐procedural estimated PVS by the Duarte's formula (Duarte‐ePVS) and Kaplan–Hakim formula (KH‐ePVS) were calculated for all patients. CIN was defined as an absolute serum creatinine (SCr) increase ≥0.5 mg/dL or a relative increase ≥25% compared with the baseline value within 48 h of contrast medium exposure. We assessed the association between PVS and CIN in patients with heart failure undergoing elective PCI. In 441 patients, 28 (6.3%) patients developed CIN. The median Duarte‐ePVS was 4.44 (3.87, 5.13) and the median KH‐ePVS was −0.03 (−0.09, 0.05). The best cutoff values for Duarte‐ePVS and KH‐ePVS to predict CIN were 4.64 (with 78.6% sensitivity and 61.7% specificity) and 0.04 (with 64.5% sensitivity and 75.5% specificity), respectively. After adjusting for potential confounding variables, KH‐ePVS > 0.04 [odds ratio (OR) 2.685, 95% confidence interval (CI) 1.012–7.123, P = 0.047] remained significantly associated with CIN whereas Duarte‐ePVS was not.ConclusionsPre‐procedural KH‐ePVS is an independent risk factor for CIN in patients with heart failure undergoing elective PCI. The best cutoff point of KH‐ePVS for predicting CIN was 0.04.

Prognostic value of simple risk index and plasma volume status in patients with acute decompensated heart failure

Abstract Background Increased heart rate (HR) and low systolic blood pressure (SBP) are associated with adverse clinical outcomes in patients admitted for acute decompensated heart failure (ADHF), and simple risk index (SRI) based on easily assessed clinical characteristics (age, HR, and SBP) provides prognostic information. On the other hand, plasma volume (PV) expansion plays an essential role in heart failure, and PV status is has been reported to be associated with adverse outcomes in ADHF patients. However, there is no information available on the value of the combination of SRI and PV status in patients admitted for ADHF. Methods and results We studied 301 patients admitted for ADHF. At the admission, SRI was calculated as (HR x [age/10]2)/SBP. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). During a follow-up period of 4.3±3.2 yrs, 95 patients had all-cause death (ACD) and 68 patients had cardiovascular death (CVD). At multivariate Cox analysis, SRI and PV status were significantly associated with ACD and CVD, independently of the prior history of heart failure hospitalization and serum creatinine and sodium levels, after the adjustment with serum albumin level and anemia. Patients with both greater SRI (≥35.1 by ROC analysis; AUC 0.599 [0.524–0.674]) and greater PV status (≥8.1% by ROC analysis; AUC 0.625 [0.550–0.700]) had a significantly higher risk of ACD and CVD than those with either or none of them (ACD: 49% vs 27% vs 24%, p&amp;lt;0.0001, CVD: 39% vs 18% vs 15%, p&amp;lt;0.0001,respectively). Conclusion The combination of SRI and PV status might be useful for stratifying patients at risk for the total mortality and cardiovascular death in patients with ADHF. Funding Acknowledgement Type of funding sources: None.

1588 A Rare Case of Arteriovenous Malformation Following TMJ Arthroscopy: A Case Report and Review of The Literature

Abstract Patients undergo temporo-mandibular joint (TMJ) arthroscopy as part of the diagnosis and management of chronic pain in the TMJ. Known complications of the procedure include bleeding within the joint spaces, lacerations of the external auditory canal and local nerve damage. We present the case of a 25-year-old woman who developed an arteriovenous fistula in the right pre-auricular region secondary to TMJ arthroscopic examination. She had presented with ongoing TMJ pain necessitating further investigation with arthroscopy. Following her procedure her TMJ symptoms improved, however she developed right pre-auricular swelling of gradual onset, right-sided headaches, and pulsatile tinnitus. Due to her pregnancy of around 16 weeks this was originally linked to expansion in plasma volume and hyperdynamic circulation; however, this was later diagnosed as an extremely rare, post-operative complication of TMJ arthroscopy. Her examination revealed a pre-auricular pulsatile swelling measuring approximately 1.5 cm. Blood tests including ESR and CRP were within normal limits excluding temporal arteritis. An ultrasound scan revealed an AV fistula of the right superficial temporal artery; Her MRI confirmed single vessel supply. Following discussion in the vascular anomalies MDT, she underwent embolisation with PHIL and surgical excision via a preauricular approach. The procedure was successful, and the patient made a full recovery. The literature reports very few cases of iatrogenic arterio-venous fistulas resulting from TMJ arthroscopic surgery. Our case emphasises the importance of a multidisciplinary approach in combining embolisation with surgical excision resulting in the successful management of a rare post-operative complication.

Distribution of crystalloid fluid infused during onset of anesthesia-induced hypotension: a retrospective population kinetic analysis

BackgroundInduction of anesthesia causes a drop in arterial pressure that might change the kinetics of infused crystalloid fluid. The aim of this report is to provide a mathematical view of how fluid distributes in this setting.MethodsData were retrieved from three studies where 76 patients (mean age 63 years, mean body weight 66 kg) had received approximately 1.1 L of Ringer’s solution over 60 min by intravenous infusion before and during induction of spinal, epidural, or general anesthesia. A population kinetic model was used to analyze the fluid distribution and its relationship to individual-specific factors. Frequent measurements of blood hemoglobin and the urinary excretion served as dependent variables.ResultsBefore anesthesia induction, distribution to the extravascular space was threefold faster than elimination by urinary excretion. Both distribution and elimination of infused fluid were retarded in an exponential fashion due to the anesthesia-induced decrease in the mean arterial pressure (MAP). A decrease in MAP from 110 to 60 mmHg reduced the rate of distribution by 75% and the rate of elimination by 90%. These adaptations cause most of the infused fluid to remain in the bloodstream. Age, gender, type of anesthesia, and the use of ephedrine had no statistically significant effect on plasma volume expansion, apart from their possible influence on MAP.ConclusionThe decrease in MAP that accompanies anesthesia induction depresses the blood hemoglobin concentration by inhibiting both the distribution and elimination of infused crystalloid fluid. The report provides mathematical information about the degree of these changes.