Best practice & research. Clinical anaesthesiology
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For decades, the 'third space' was looked upon as an actively consuming compartment. Therefore, perioperative fluid regimens were traditionally based on a generous replacement of this assumed primary loss, in addition to deficits due to insensible perspiration and fasting. The practical consequence was an extremely positive fluid balance in order to maintain blood volume during major surgery. ⋯ Such shifting is related to a destruction of the endothelial glycocalyx, a key structure of the vascular barrier, by traumatic inflammation and iatrogenic hypervolaemia. This explains why patients undergoing major surgical interventions benefit significantly from an infusion regimen which does not substitute but avoids 'third-space shifting'. In summary, eradicating this notion from our minds could be a further key to achieving perioperative fluid optimisation.
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Best Pract Res Clin Anaesthesiol · Jun 2009
ReviewRelevance of albumin in modern critical care medicine.
The relevance of albumin administration in the critical care setting remains controversial. We know that albumin has numerous important physiological effects and many potentially beneficial effects in critical illness. ⋯ Albumin may be useful in some patients, especially those with hypoalbuminaemia at risk of complications or those with liver insufficiency. Further studies are needed to clarify what precise role albumin has in today's ICU.
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Hypovolaemia is a common cause of circulatory failure in the perioperative period. However, only 50% of critically ill patients respond to volume expansion with an adequate increase in cardiac output. ⋯ The concept of fluid responsiveness has been recognized for more than 20 years, and several studies have shown the superiority of these dynamic variables compared to static filling pressures. However, the usefulness of dynamic variables in critically ill patients is limited by several factors that the clinician needs to know for proper interpretation.
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Best Pract Res Clin Anaesthesiol · Jun 2009
ReviewRelevance of non-albumin colloids in intensive care medicine.
Current guidelines on initial haemodynamic stabilization in shock states suggest infusion of either natural or artificial colloids or crystalloids. However, as the volume of distribution is much larger for crystalloids than for colloids, resuscitation with crystalloids alone requires more fluid and results in more oedema, and may thus be inferior to combination therapy with colloids. This chapter describes the currently available synthetic colloid solutions [i.e., dextran, gelatin and hydroxyethyl starch (HES)] in detail, and critically discusses their specific effects including potential adverse effects. ⋯ When considering the efficacy and risk/benefit profile of synthetic colloids, modern tetrastarches appear to be most suitable for intensive care medicine, given their high volume effect, low anaphylactic potential and predictable pharmacokinetics. However, the impact of tetrastarch solutions on mortality and renal function in septic patients has not been fully determined, and further comparison with crystalloids in prospective, randomized studies is required. Such studies are currently ongoing and their results should be awaited before drawing final conclusions on the HES preparations.