Total Infusion Volume Research Articles

Low rate of infusional toxicity after expanded cord blood transplantation

Background aimsUmbilical cord blood (CB) is used with increasing frequency to restore hematopoiesis in patients with bone marrow transplant who lack a suitable human leukocyte antigen–matched donor. CB transplantation is limited by low cell doses and delays in neutrophil and platelet engraftment. CB progenitors expanded ex vivo before transplantation provide more rapid hematopoietic and immune reconstitution as well as less engraftment failure compared with unmanipulated CB. However, the safety of infusing double and ex vivo–expanded CB has not been systematically examined. MethodsWe reviewed the immediate adverse events (AE) associated with the infusion of CB occurring within 24 hours in 137 patients enrolled in clinical CB transplant trials at the MD Anderson Cancer Center from February 2004 to May 2010. All patients received an unmanipulated CB unit followed by infusion of a second unmanipulated CB unit or a second CB unit expanded ex vivo with the use of cytokines in a liquid culture system or in mesenchymal stromal cell co-cultures. ResultsA total of three grade 2 and two grade 3 infusion reactions occurred within 24 hours of CB transplantation. This resulted in an AE rate of 3.7%. The majority of AEs manifested as signs of hypertension. No association with patient age, sex, disease status, premedication, ABO compatibility or total infusion volume was observed. In summary, the incidence of infusion-related toxicities in patients who receive unmanipulated and ex vivo–expanded double CB transplantation is low. ConclusionsWe conclude that the infusion of unmanipulated followed by expanded CB products is a safe procedure associated with a low probability of inducing severe reactions.

Seven years of patient-controlled epidural analgesia in a Swedish hospital: a prospective survey.

Epidural analgesia for postoperative pain relief needs to be monitored regularly in order to evaluate benefits and avoid potential hazards. To evaluate efficacy and safety profile of a ward-based regimen for postoperative epidural analgesia combining patient-controlled epidural analgesia (PCEA) and continuous epidural infusion (CEI). We conducted a prospective survey in all patients who received postoperative epidural analgesia between March 2004 and February 2011. We analysed 4663 patients undergoing elective and acute surgery. University hospital in Sweden. The median level of catheter insertion ranged from T8 in high abdominal surgery to T11 in gynaecological surgery. Mean infusion rate was 5.4 ± 1.6 ml h and was adjusted for age. Mean duration was 3.3 ± 2.1 days. Eighty-seven percent of the patients rated satisfaction 8 to 10 out of 10 on a post-treatment scale. Reasons for termination were elective in 77.1%, due to inadequate pain relief in 11.4%, due to suspected infection in 0.7% and due to other causes in 10.9%. Of the latter, dislodgement of the catheter (4.0%) and leakage from the puncture site (1.4%) dominated. Catheter reinsertion was performed in 5.3% of the patients, and in 5.0%, the treatment was converted into an intravenous (i.v.) morphine patient-controlled analgesia regimen. The incidence of motor blockade was 1.7%, sedation 2.1%, nausea 12.8% and pruritus 18.8%. Bolus doses accounted for 16% of the total infusion volume. No epidural haematoma was seen. One epidural abscess requiring antibiotic treatment occurred. Our prospective survey indicates that PCEA in combination with CEI is effective and relatively well tolerated. The incidence of side effects is generally low and severe adverse events very rare.

Six Percent Hydroxyethyl Starch 130/0.4 (Voluven®) versus 5% Human Serum Albumin for Volume Replacement Therapy during Elective Open-heart Surgery in Pediatric Patients

Although 5% albumin (human serum albumin [HSA]) is widely used in cardiac surgery children, synthetic colloids may provide a valuable alternative. This study compared 6% hydroxyethyl starch (HES) 130/0.4 with HSA for volume replacement in this population. The study was a two-center, randomized, controlled, parallel-group, double-blind trial performed in children aged 2-12 yr undergoing elective surgery for congenital heart disease under extracorporeal circulation. The primary objective was to demonstrate equivalence between HES and HSA with regard to the total volume of colloid infusion for intraoperative volume replacement including priming of the extracorporeal circuitery. In the per-protocol population, mean volume of colloid required until end of surgery was (mean ± SD) 36.6 ± 11.8 ml/kg body weight in the HES group (N = 29) and 37.0 ± 11.9 ml/kg body weight in the HSA group (N = 26; ratio of means HES/HSA = 0.98 [95% CI, 0.84-1.16]). Intraoperative fluid balance was less positive in the HES group (P = 0.047). No difference was found regarding hemodynamics, the use of vasoactive and inotropic drugs. Blood loss, erythrocytes transfusion, and renal function were not different between groups. The incidence of adverse events up to postoperative day 28 did not differ between the groups. In pediatric cardiac surgery, HES showed equivalence to HSA with regard to volume replacement therapy in children aged from 2 to 12 yr. Although there was no suggestion of an imbalance of safety measures between HES and HSA, the study was not powered to provide any firm conclusions about safety of tetrastarch in this population.

A new model for the study of secondary intra-abdominal hypertension in rats

BackgroundTo build a new and appropriate model of secondary intra-abdominal hypertension (IAH) in rats. MethodsA total of 32 female Sprague–Dawley rats were randomized into four groups. Group I: the rats were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg for 1 h and portal hypertension was induced by partial ligation of the portal vein 1 h later; Group II: after inducing portal hypertension, hemorrhagic shock of MAP of 40 mm Hg was induced and maintained for 1 h; Group III: after inducing portal hypertension, hemorrhagic shock of MAP of 40 mm Hg was induced and maintained for 2 h; Group IV: after inducing portal hypertension, hemorrhagic shock of MAP of 40 mm Hg was induced and maintained for 2 h, and a specially designed abdominal restraint device was used. After these procedures, respectively, the collected blood was reinfused and lactated Ringer solution was continuously infused until the secondary IAH model was established. ResultsNo models were built in Groups I, II, and III. One rat died in Group IV after portal vein ligation, and all the remaining rats successfully developed IAH; the success rate was 87.5%. During the resuscitation period, the average time was 5.26 ± 0.59 h and the average total infusion volume was 665.5 ± 86.04 mL/kg. ConclusionA rat model of secondary IAH was successfully established by resuscitation after a combination of inducing portal hypertension, hemorrhaging to a MAP of 40 mm Hg for 2 h, and using an abdominal restraint device. All these criteria mimic key etiological factors for the development of secondary IAH.

English

CONTEXT: Preloading of crystalloid is a traditional practice to prevent spinal anaesthesia induced hypotension. But coloading seems to be more physiological and rational approach as effect was achieved during the time of spinal anaesthesia. AIMS: To compare crystalloid preload and coload for the prevention of spinal block induced hypotension in lower limb surgeries. Secondary outcomes included no. of dose of mephenteramine & atropine, bradycardia, nausea, vomiting, total volume of infusion, blood loss & urine output. SETTINGS AND DESIGN: Tertiary level, teaching hospital. Prospective, randomized study. MATERIALS AND METHODS: Total sixty patients of either sex, aged 20 to 60 years, scheduled for lower limb surgery under spinal anaesthesia were randomized into preload and coload group, 30 patients in each group. In preload group, 20 ml/kg of Ringer lactate was preloaded 20 minutes before commencement of spinal anaesthesia. In group Coload, 20 ml/kg of Ringer lactate was coloaded in 20 minutes just after lumbar puncture. STATISTICAL ANALYSIS USED: Quantitative data were compared with student's t test and qualitative data with chi-square or fisher exact test. P 0.05). Mean baseline value and trends at various time intervals of heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure were comparable in both groups. Total incidence of hypotension in group Preload and group Coload were 13.33% and 10% respectively (p=0.463). Total incidence of bradycardia in group Preload and group Coload were 6.67% and 10% respectively (p=0.394). No. of dose of atropine to treat bradycardia was 2 out of 30 patients (6.67%) and 3 out of 30 patients (10%) for group P and C respectively (p=0.394). No. of dose of mephenteramine to treat hypotension was 4 out of 30 patients (13.33%) for each group (p=1). Incidence of nausea was 6.67% for group Preload and 10% for group Coload (p=0.394). Incidence of vomiting was 3.33% for group Preload and 6.67 % for group Coload (p=0.278). Total volume used for preloading was about 1474 ± 206 ml and for coloading was 1386 ± 176 ml (p=0.0805). Urine output in preloading and coloading groups was 223 ± 100 and 173 ± 89 ml respectively (p=0.0453). CONCLUSIONS: Coloading with 20 ml/kg of Ringer's lactate was as effective as preloading of same amount 20 minute before lumber puncture to prevent spinal induced hypotension.

Evaluation of safety and efficacy of a 20% Subcutaneous Immunoglobulin (Hizentra™), after a dose equivalent switch from intravenous or subcutaneous replacement therapy in a cohort of primary immunodeficient patients

Methods A cohort study of 57 PID patients was reviewed 3 months post-transition to the 20% Subcutaneous Immunoglobulin (HizentraTM), in order to evaluate clinical outcomes and adverse events related to a dose-equivalent switch from 10% liquid solution intravenous (Privigen and Gamunex) or 16% subcutaneous replacement therapy (Vivaglobin) to weekly infusion of HizentraTM, Descriptive analyses were performed in relations to IgG levels, total infusion volume and infusion time.

EXAMINATION OF THE USEFULNESS OF NON-INVASIVE STROKE VOLUME VARIATION MONITORING FOR ADJUSTING FLUID SUPPLEMENTATION DURING LAPAROSCOPIC ADRENALECTOMY IN PATIENTS WITH PHEOCHROMOCYTOMA

The measurement of stroke volume variation (SVV) using the FloTrac™ system (Edwards Lifescience, USA) is useful to estimate cardiac preload. We evaluated the benefits of SVV monitoring for adjusting fluid supplementation during laparoscopic adrenalectomy under anesthesia in patients with pheochromocytoma. Among 10 patients who underwent laparoscopic adrenalectomy for pheochromocytoma in our institution from June 2004 to December 2009, SVV was not monitored in 5 patients (group I) and in the other 5 patients (group II), SVV monitoring was performed. Subject age, height and body weight, total volume of fluid supplemented, blood loss, urine output and net fluid in-out balance during the procedure were retrospectively assessed. In those with SVV monitoring, infusion volume was adjusted for SVV less than 13%. There were significant differences in the patient age and body weight between the two groups (group I: 64.2 years old and 55.1 kg; group II: 43.6 years old and 71.7 kg). Both total infusion volume and urine output were significantly higher in group I compared with group II (5,610 vs. 2,400 ml and 1,125 vs. 750 ml, respectively). Total blood loss was similar between the two groups. Values of the net fluid balance divided by the body weight and total anesthesia period (hr) were significantly lower in group II compared with group I (I; +13.2 in group I and +6.2 in group II, ml/kg/hr). These data suggest that SVV monitoring is helpful to estimate the optimal volume for fluid supplementation and could prevent excessive fluid infusion during surgical procedures.

Comparison of extubation times between protocolized versus automated weaning systems after major surgery

Background. Prolonged mechanical ventilation is associated with adverse clinical outcomes for critically ill patients. Objective. To assess the the extubation times of protocolised versus automated weaning systems in patients after major surgery in intensive care unit. Design. Retrospective analysis.Measurements and results. We analyzed 70 patients with major abdominal or pelvic surgery. Patients that were used Draeger Evita2 Dura for weaning process named as the C (control) group (n=35) and patients that were used Draeger Evita2 XL Smartcare/PS named as the SC group (n=35). A physician evaluate the patient every 5 or 10 minutes in group C. Gender, age, weight, operation time, operation type, the total volume of intravenous infusion, bleeding, total dose of propofol, fentanyl citrate, rocuronium during surgery and extubation time were all recorded. All side effects included reintubation, bleeding, stroke, death, postoperative myocardial infarction were all recorded. The partial oxygen pressure (Pa02) and partial carbondioxide pressure (PaC02) were recorded before and after extubation.Results. Demographic data and operative data were similar between groups (p>0.05). The extubation time was similar between groups (SC group versus C group: 191,14±79,1 min versus 188,29±51,47 min, p=0,534. There was significant decrease in arterial PO2 and increase in arterial PCO2 after extubation in all groups. No side effects were observed. Conclusion. In conclusion, although we found no differences between SmartCare and control groups, the evaluating of the patient increased the workload in the control group. We think that SmartCare decreased the workload. Thus, it can be recommended for weaning process of patients after major surgery in intensive care unit.

Feasibility study of postoperative management based on ERAS of patients with gastrectomy.

127 Background: Although the usefulness of the postoperative management based on Enhanced Recovery After Surgery (ERAS) program of patents with colectomy is shown, there are a few papers concerning ERAS program for gastric cancer patients. The aim of the present study was to examined whether a new postoperative management based on ERAS was feasible for pts with gastrectomy. Methods: From September 2009 to April 2010, we have adopted the new clinical pathway (CP) based on ERAS and oral rehydration therapy (ORT) for 30 consecutive gastric cancer patients who underwent curative gastrectomy. These pts began a oral rehydration solution (ORS) on the first postoperative day, and after the volume of ORS got 1,000 ml, we stopped intravenous transfusion. The incidence of adverse events, postoperative pt's activity score, which pt's daily activity was evaluated with, and total infusion volume of these pts were compared with 30 pts with the previous CP that were enrolled as a control group. Results: There were no significant differences in the clinical and operative factors between the two groups. The post operative patient's activity score of ERAS group was significantly higher up to 7th postoperative day (POD). Total infusion volume was significantly little besides, in most cases, infusion therapy was substituted for ORT with OS-1 within 2 POD. There was no difference in the hospitalized days, and the incidence of adverse events were statistically no significance between two groups. Conclusions: Our CP based on ERAS and ORT is feasible for patients with gastrectomy. No significant financial relationships to disclose.

Guidelines for automated manual infusion: a practical way of prescribing postdilution on-line hemodiafiltration

Post-dilution on-line hemodiafiltration (OL-HDF) is the most efficient infusion mode to obtain maximum clearances of uremic toxins, with a recommended manual infusion flow (Qi) of 25% of the blood flow with the main limitation that causes alarms by hemoconcentration throughout the session. Recent technical advances allow automatic prescription of Qi if hematocrit and total protein (TP) values are specified. As these analytical results are not possible to obtain in each dialysis session, a practical way to prescribe Qi is to make an automatic prescription adjusting the hematocrit and total protein values at the beginning of the session to obtain the manual prescription required and we will call it automatic-manual prescription. The aim of this study was to compare manual Qi with automatic-manual Qi in postdilution OL-HDF. 30 patients (16 men and 14 women), 59.9 +/- 15 years old, in hemodialysis program for 50.1 +/- 67 months were included. Every patient underwent four OL-HDF sessions, two with manual Qi (4008-S and 5008 monitors) and two with automatic-manual Qi (A-M), one with the same Qi and one with manual Qi +20 (A-M+20). The same usual dialysis parameters were maintained: helixone dialyzer, dialysis time of 266 +/- 39 minutes, blood flow of 420 +/- 36. Recirculation, Kt and intradialysis alarms were measured at each session. No significant differences in the fistula recirculation or dialysis dose measured using Kt. Total infusion volume was 24.9 +/- 4 (4008 S), 23.4 +/- 4 L (5008) with manual Qi, 23.6 +/- 4 L (A-M) Qi (NS) and 25.8 +/- 5 L (A-M+20). Only 14% of patients had no incidents. The number of alarms was significantly higher with manual prescription 55 alarms with 4008 and 40 with 5008 vs. AM (11) p < 0.01) and A-M+20 (16 alarms) We concluded that automatic-manual Qi is a practical way for post-dilutional OL-HDF prescription where the same efficiency and total reinfusion volume with an important reduction of intradialysis alarms are obtained, allowing to rise Qi by 20% without increasing intradialysis alarms.

Complete free flap loss due to extensive hemodilution

Free tissue transfer in reconstruction of lower extremity wounds is well established. Controversy surrounds type and regimen of intravenous fluid application during microsurgery. Hemodilution is supposed to influence haemostatic process. We performed an analysis of 48 patients treated with a free latissimus dorsi muscle flap to the lower leg for posttraumatic soft-tissue coverage. Postoperative latissimus dorsi muscle flap perfusion was controlled by clinical monitoring. Intraoperative infusion management was evaluated retrospectively. In 4 of 48 included patients, a complete loss of free latissimus dorsi muscle flap was registered. Concomitant increased saline infusion was detected (4,534 ml versus. 6,125 ml; P = 0.048). Similar findings for relation of total infusion volume to body weight were seen (44 ml/kg versus 69 ml/kg; P = 0.01). No significant colloid infusion was detected. We demonstrate the clinical relevance of extensive intraoperative hyperhydration, which can provoke a complete free flap loss.

Safety of HES 130/0.4 (Voluven®) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery

Patients with impaired renal function are at risk of developing renal dysfunction after abdominal aortic surgery. This study investigated the safety profile of a recent medium-molecular-weight hydroxyethyl starch (HES) preparation with a low molar substitution (HES 130/0.4) in this sensitive patient group. Sixty-five patients were randomly allocated to receive either 6% hydroxyethyl starch (Voluven); n = 32) or 3% gelatin (Plasmion); n = 33) for perioperative volume substitution. At baseline, renal function was impaired in all study patients as indicated by a measured creatinine clearance < 80 mL min(-1). The main renal safety parameter was the peak increase in serum creatinine up to day 6 after surgery. Both treatment groups were compared for non-inferiority (pre-defined non-inferiority range hydroxyethyl starch < gelatin + 17.68 micromol L(-1) or 0.2 mg dL(-1). Other renal safety parameters included minimum postoperative creatinine clearance, incidence of oliguria and adverse events of the renal system. Baseline characteristics, surgical procedures and the mean total infusion volume were comparable. Non-inferiority of hydroxyethyl starch vs. gelatin could be shown by means of the appropriate non-parametric one-sided 95% CI for the difference hydroxyethyl starch-gelatin [-infinity, 11 micromol L(-1)]. Oliguria was encountered in three patients of the hydroxyethyl starch and four of the gelatin treatment group. One patient receiving gelatin required dialysis secondary to surgical complications. Two patients of each treatment group died. As we found no drug-related adverse effects of hydroxyethyl starch on renal function, we conclude that the choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.

Pre-incisional epidural ropivacaine, sufentanil, clonidine, and (S)+-ketamine does not provide pre-emptive analgesia in patients undergoing major pancreatic surgery

The concept of pre-emptive analgesia remains controversial. This prospective, randomized, and double-blind study compared epidural administration of ropivacaine 2 mg ml(-1), sufentanil 0.5 microg ml(-1), clonidine 3 microg ml(-1), and S(+)-ketamine 0.25 mg ml(-1) (study solution) given before incision with the same combination started at the end of the operation. After testing the stability of the solution using high performance liquid chromatography (HPLC) and examining 12 patients for possible side-effects in comparison with the epidural infusion of ropivacaine 2 mg ml(-1) and sufentanil 0.5 microg ml(-1), 30 patients undergoing major pancreatic surgery were recruited into the study. Before induction of anaesthesia, an epidural catheter was inserted (TH6-8). Patients in Group 1 received a bolus of 8 ml followed by a continuous infusion (8 ml h(-1)) of the study solution before induction of anaesthesia. In Group 2, patients received the same volume of saline before operation, the study solution was started at the end of surgery. After operation, the infusion was maintained for at least 96 h using a patient-controlled epidural analgesia (PCEA) pump in both groups. Patients were evaluated up to the seventh postoperative day for pain and side-effects. Visual analogue scale (VAS) values at rest were as follows: G1 vs G2: 24 h, 19 (sd 23) vs 6 (13); 48 h, 4 (10) vs 11 (21); and 72 h, 12 (22) vs 13 (21). VAS values during coughing and mobilization were also comparable. Total volume of epidural infusion was 904 (114) ml in G1 vs 892 (154) ml in G2. The incidence of side-effects (nausea, vomiting, and motor block) was low and not different between the groups. Pre-incisional epidural analgesic infusion did not provide pre-emptive analgesia compared with administration started at the end of surgery, but both groups had low pain scores.

Fluid resuscitation of trauma patients: how fast is the optimal rate?

The Advanced Trauma Life Support guidelines recommend an initial rapid infusion of fluid (1-2 L) in trauma and hemorrhage victims as a diagnostic procedure to aid treatment decisions. Although patient response to initial fluid resuscitation is the key to determining therapeutic strategies, the appropriate rate of infusion is not clearly defined. Ninety-nine adult (age >16 years) blunt trauma victims with hypotension were enrolled. Patients were classified into 3 groups according to hemodynamic state after initial fluid resuscitation and requirement of surgical intervention. Total volume and rate of infusion differed significantly between the groups ( P < .05). Patients requiring fluid administration at higher rate were all hemodynamically unstable and required immediate surgical intervention. Moreover, rate of infusion was the best predictor of the patients who required immediate surgical intervention. Moderate fluid infusion rate should be considered to allow identification of the patient's response to initial fluid resuscitation.

Anesthesiologic Provision of Osteosynthesis of the Neck of the Femur in Geriatric Patients

The purpose of the study was to evaluate the clinical efficiency of femoral 3 in 1 block using the solution of a local anesthetic in combination with an opioid versus central regional (spinal) anesthesia during operation involving osteosynthesis of the neck of the femur with cannulated screws in geriatric patients. Osteosynthesis of the neck of the femur with cannulated screws proposed by the Osteosynthesis Association (OA) was performed in 90 patients (33 males and 57 females) aged 65 to 90 (71.0±5.026) years. Two procedures were used for the anesthe-siological provision of the operation. The osteosynthesis was made in 65 patients under central regional (spinal) anesthesia (Group 1) and in 25 patients under femoral 3 in 1 block employing the solution of a local anesthetic in combination with an opioid (Group 2). Both groups were matched by age, gender, anthropometric data, and the pattern of concomitant diseases. Analysis of the findings revealed that in 40% of cases, operations made under spinal anesthesia (Group 1) used adrenomimetics: ephedrine, 0.2—0.4 mg/kg, or dopamine, 3—5 ^g^kg/min; the total infusion volume was 2254±162 ml. Colloid agents (polyglucin, 6% infucol, or 6% refortan solutions) were given to 23 (36%) of the 65 patients. The reduction in mean blood pressure was 26.3% of the baseline. Group 2 did not require the use of colloidal and/or adrenomimetics. The mean intraoperative infusion volume was 1146±109.3 ml. During surgery, hemodynamics remained stable in all the patients. All Group 1 patients operated on under spinal anesthesia experienced postoperative pain whose relief required the use of nonsteroidal anti-inflammatory drugs (ketorol, ketonal, baralgin) and opioids (promedole, omnopon), 44% of cases requiring multiple administration of narcotic analgesics within the first and second postoperative days. Analysis of the postoperative period indicated a good analgesia in the patients operated on under femoral 3 in 1 block with local anesthetic solution in combination with an opioid. At a rest, all Group 2 patients did not observe no painful sensations at the site of surgery. Thus, femoral 3 in 1 block with 40 ml of 0.25% marcaine and 10 mg of morphine hydrochloride is an effective and safe anesthesiological support in geriatric patients during operations involving the osteosynthesis with OA cannulated screws. Perineutal administration of 10 mg of morphine hydrochloride provides a good postoperative analgesia, which is an important factor in preventing cardiorespiratory complications in patients to be surgically treated.

Risk factors for intraoperative hypotension in traumatic intracranial hematoma.

Patients suffering from traumatic intracranial hemorrhage (TICH) may experience an episode of catastrophic intraoperative hypotension (IHT), after decompression of the brain. The aim of this study was to investigate the risk factors for IHT during emergency craniotomy A total of 67 patients, who underwent emergency craniotomy due to TICH, were divided into two groups: IHT ( n=31 ) or without IHT ( n=36 ). Data concerning (1) age; (2) gender; (3) mechanism of injury; (4) Glasgow Coma Scale (GCS) on admission; (5) abnormality of the pupils (anisocoria or mydriasis); (6) mean arterial blood pressure; (7) heart rate; (8) time elapsed before craniotomy from injury; (9) initial brain CT scans; (10) duration of craniotomy; and (11) total infusion or urine volume until craniotomy were collected prospectively as IHT risk factors. Low GCS score (<5), tachycardia (heart rate >112min(-1)) and hypertension (mean blood pressure >131mmHg) before emergency craniotomy were strongly ( P<0.05 ) associated with IHT. Delayed surgery (>173min until craniotomy) also had a significant ( P<0.005 ) effect on IHT. The risk factors for IHT were considered as a low GCS score on admission, tachycardia, hypertension before emergency craniotomy and delayed surgery. These results suggested the patients with IHT had a high sympathetic tone before emergency craniotomy A sudden reduction in sympathetic tone after surgical decompression of the brain might cause IHT. We concluded that an important factor in the occurrence of IHT was not only the injury severity, but also the balance between sympathetic and parasympathetic activity before decompression surgery.

A multicenter pilot prospective study comparing Celsior and University of Wisconsin preserving solutions for use in liver transplantation

Primary dysfunction (PDF) still occurs after orthotopic liver transplantation (OLT). Celsior solution (CS) might offer some advantages over the conventional University of Wisconsin (UW) solution for organ preservation, but to date, this has not been prospectively evaluated in the context of OLT. In this prospective, randomized, multicenter, pilot study, 215 potential liver donors were enrolled and randomized. In 42 cases, the livers were unsuitable for transplantation; therefore, 173 randomized livers ultimately were implanted after perfusion and cold preservation with CS (n = 83) or UW solution (n = 90). In accord with the indications of the CS manufacturing company, total CS infusion volume was 90 mL/kg, greater than that of UW solution (60 mL/kg). The main aim of the study is to compare the prevalence of PDF between the two groups. Donor and recipient variables were similar in the two groups. Episodes of PDF were numerically lower in the CS (2.4%) than UW group (7.8%), but the difference was not statistically significant. There was a trend toward a lesser need for early re-OLT (<30 days) in the CS group (P = .0507), but again, no statistically significant difference emerged. Overall and time-differentiated postoperative deaths also were similar. One-year actuarial patient (UW, 89% v CS, 87%) and graft (UW, 83% v CS, 85%) survival rates were similar. In conclusion, CS was similar to UW solution as a preservation solution in the clinical setting of OLT at the infusion volumes described, although some theoretical advantages of CS composition suggest that CS might prove a valid alternative to UW preservation solution in multiorgan harvesting, including the liver. A study on a larger patient basis is needed. (Liver Transpl 2003;9:814-821.)

Effects of Lactose in Saline Infusion on Electrolyte Alterations in Trypanosoma vivax-Infected Cattle.

Alteration of serum electrolytes (Na+, K+, Cl-, and HCO3-) was studied in Zebu cattle experimentally infected with 11.0×106 Trypanosoma vivax. Another group of similarly infected cattle was intravenously infused with lactose in normal saline, at a dose rate of 0.5g/kg body weight as a function of the animal blood volumes of about 6-7% their body weights. Serum Na+ and Cl- concentrations showed significant (p<0.05) increases following decreasing parasitemia on days 6, 7, and 8 post infection (p.i.), whereas the greatest drops, resulting in hyponatremia and hypochloremia, occurred at the period when parasites were very scant in the blood. The Na+ and Cl- returned to normalcy between days 10 and 13p.i., coinciding with the second parasitemic wave. K+ values showed a nonsignificant decline following the decline of parasitemia, and rose to normal values thereafter, around the second wave of parasitemia. The HCO3- values were lowest when the parasites became numerous in the blood on day 3p.i., with a significant (p<0.05) decrease at peak parasitemia on day 5p.i. Subsequently, HCO3- concentrations increased when parasites became low in number in the peripheral circulation; thereafter, interrupted but significant (p<0.05) increases in HCO3- values occurred as the disease progressed. With the i.v. infusion of lactose in normal saline when the disease had been established, evidenced by peak parasitemia and declining packed cell volume (PCV), serum Na+ and Cl- remained normal as observed in the first uninfected uninfused group. The variations of K+ and HCO3- showed a similar pattern during the infusion. The values of all four electrolytes were relatively reduced immediately after and during the course of the infusion. The anion gaps were 20-22mM/liter for the uninfected group; 22-25mM/liter on days 3-5p.i. and 16-19mM/liter on days 6-13p.i, for the infected, uninfused group. Whereas infusion into the infected group produced an anion gap of 15-25mM/liter. The choice of saline as a solvent for lactose and the total infusion volume had no detrimental effect on the host's electrolytes and acid-base status; rather, the infusion ameliorated the aberrations in electrolytes associated with T. vivax in cattle.

Transvascular fluid distribution of hyperoncotic Dextran solution.

The purpose of this study was to confirm the changes in extra-aand intravascular fluid distribution during an i.v. influsion of hyperoncotic Dextran solution. Twenty-three mongrel dogs with normal capillary integrities were divided into four groups. The R1 and R2 groups received i.v. infusion of Ringer lactate (RL) with a rate of 10 and 30 ml·kg-1·h-1, the D group 6% Dextran 70 solution (DEX) of 10 ml·kg-1·h-1. and the RD group DEX of 10 plus RL of 20 ml·kg-1·h-1. The distribution of infused fluid was assessed with the changes in circulating blood volume (CBV), extravascular fluid volume (EVW), and thoracic duct lymph volume (QL). In the R1 and R2 groups, EVW increased by 63% and 51%, respectively, of total infusion volume (tInf), while CBV increased by only 10% and 13% of tnf. In the D and RD groups, CBV increased by 103% and 51% of tInf. However, EVW decreased by 21% and increased by 32% of tInf, respectively. In the latter groups, the plasma volume filtered out into the extravascular compartment was less than in the corresponding former group by 52% and 6% of tInf, respectively and the restoration ratio of EVW by lymph was about 3 to 1.8 times greater. One-fourth to one-third of the plasma expanding effect of 6% Dextran 70 solution was ascribed to direct fluid drawing from the extravascular space, and the rest was due to both the decrease in plasma filtration into extravascular space and the increase in lymphatic restoration of EVW.

Does Retrograde Administration of Blood Cardioplegia Improve Myocardial Protection During First Operation for Coronary Artery Bypass Grafting?

The objective of this study was to evaluate the value of retrograde blood cardioplegia in coronary artery bypass grafting. In 1994 and 1995, 224 patients undergoing first-time isolated coronary artery bypass grafting were randomized to antegrade (112 patients, group 1) or retrograde (112 patients, group 2) administration of blood cardioplegia. In group 1, 76 patients were given warm cardioplegia (at 33 degrees C) and 36 had cold cardioplegia (< 20 degrees C), whereas in group 2 cardioplegia was warm in 77 patients and cold in 35. The two randomization groups had similar demographic and angiographic characteristics. The number of grafted coronary arteries averaged 2.9 +/- 0.7 in group 1 and 2.8 +/- 0.7 in group 2. Total duration of cardiopulmonary bypass (78 +/- 23 and 75 +/- 21 minutes) and of aortic cross-clamping (47 +/- 16 and 46 +/- 16 minutes), total volume of infusion of the crystalloid component of cardioplegia (988 +/- 297 and 1016 +/- 595 mL), and total duration of infusion of cardioplegia (23 +/- 10 and 22 +/- 11 minutes) were similar (p > 0.05). There was no death in group 1 and one in group 2 as a result of a pulmonary embolus, for a global early mortality of 0.45%. The numbers of perioperative myocardial infarction (5 versus 3), congestive heart failure (4 versus 5), postoperative hemorrhage (4 versus 4), and stroke (1 versus 2) were also similar (p > 0.05). Release curves of total creatine kinase, creatine kinase-MB by serum activity and mass concentration, and troponin T were not significantly different (p > 0.05) between the two groups. For the 216 patients without perioperative myocardial infarction, peak enzyme release of creatine kinase-MB at 24 hours averaged 23 +/- 22 and 20 +/- 18 IU/L, and that of troponin T averaged 1.1 +/- 1.1 and 1.3 +/- 1.5 micrograms/L at 6 hours for the antegrade and the retrograde groups, respectively (p > 0.05). Our results indicate no evidence that the retrograde method of cardioplegic infusion improves myocardial protection during first operation for isolated coronary revascularization compared with the usual antegrade route.