The Experts below are selected from a list of 279 Experts worldwide ranked by ideXlab platform
Konrad Reinhart - One of the best experts on this subject based on the ideXlab platform.
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contra hydroxyethyl starch solutions are unsafe in critically ill patients
Intensive Care Medicine, 2009Co-Authors: Christiane S. Hartog, Konrad ReinhartAbstract:To describe the risk–benefit profile of hydroxyethyl starch (HES). Narrative review. (1) Efficacy: no single clinical study or systemic review has shown that administration of any HES solution confers a clinically relevant benefit compared to Crystalloids in critically ill patients or surgical patients in need of volume replacement. Contrary to beliefs expecting a ratio of 4:1 or more for Crystalloid to colloid volume need, recent studies of goal-directed resuscitation observed much lower ratios of between 1 and 1.6. (2) Safety: HES administration is associated with coagulopathy, nephrotoxicity, pruritus and increased long-term mortality. Clinical studies claiming that modern HES 130/0.4 is safe have serious methodological drawbacks and do not adequately address the safety concerns. Given the complete lack of superiority in clinical utility studies and the wide spectrum of severe side effects, the use of HES in the ICU should be stopped. The belief that four times as much Crystalloid as colloid fluid volume is needed for successful resuscitation is being seriously questioned.
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Isotonic and hypertonic Crystalloid solutions in the critically ill
Best practice & research. Clinical anaesthesiology, 2009Co-Authors: Michael Bauer, Andreas Kortgen, Christiane S. Hartog, Niels Riedemann, Konrad ReinhartAbstract:Disorders of fluid and electrolyte balance in the critically ill are volume-related, compositional, or both. Targeting 'normal' values for plasma volume, osmolality and electrolytes might not be optimal in conditions as diverse as intracranial trauma/haemorrhage, hepatic encephalopathy, abdominal hypertension, or major surgery, because a hyperosmolar state seems to favourably affect tissue (brain and intestinal) oedema formation. However, adequately powered studies regarding the impact of hypertonic saline on outcome are lacking. Isotonic Crystalloids are the cornerstone of resuscitation and must be balanced against natural or artificial colloids and vasopressors. Crystalloid resuscitation is superior to vasopressors in shock associated with blunt trauma, and is at least not inferior to colloids in septic shock. Traditional rules of thumb indicating the need for three to four times the amount of Crystalloids for the plasma volume to be replaced are probably erroneous and might have contributed to association of overly aggressive Crystalloid resuscitation with poor outcome.
Matthew W. Semler - One of the best experts on this subject based on the ideXlab platform.
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Balanced Crystalloid Solutions.
American journal of respiratory and critical care medicine, 2019Co-Authors: Matthew W. Semler, John A. KellumAbstract:Intravenous fluid therapy is the most common intervention received by acutely ill patients. Historically, saline (0.9% sodium chloride) has been the most frequently administered intravenous fluid, especially in North America. Balanced Crystalloid solutions (e.g., lactated Ringer's, Plasma-Lyte) are an increasingly used alternative to saline. Balanced Crystalloids have a sodium, potassium, and chloride content closer to that of extracellular fluid and, when given intravenously, have fewer adverse effects on acid-base balance. Preclinical research has demonstrated that saline may cause hyperchloremic metabolic acidosis, inflammation, hypotension, acute kidney injury, and death. Studies of patients and healthy human volunteers suggest that even relatively small volumes of saline may exert physiological effects. Randomized trials in the operating room have demonstrated that using balanced Crystalloids rather than saline prevents the development of hyperchloremic metabolic acidosis and may reduce the need for vasopressors. Observational studies among critically ill adults have associated receipt of balanced Crystalloids with lower rates of complications, including acute kidney injury and death. Most recently, large randomized trials among critically ill adults have examined whether balanced Crystalloids result in less death or severe renal dysfunction than saline. Although some of these trials are still ongoing, a growing body of evidence raises fundamental concerns regarding saline as the primary intravenous Crystalloid for critically ill adults and highlights fundamental unanswered questions for future research about fluid therapy in critical illness.
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Balanced Crystalloids versus Saline in Noncritically Ill Adults.
The New England journal of medicine, 2018Co-Authors: Wesley H Self, Matthew W. Semler, Jonathan P Wanderer, Li Wang, Daniel W Byrne, Sean P Collins, Corey M Slovis, Christopher J Lindsell, Jesse M Ehrenfeld, Edward D SiewAbstract:Comparative clinical effects of balanced Crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). We conducted a single-center, pragmatic, multiple-crossover trial comparing balanced Crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among adults who were treated with intravenous Crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of Crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced Crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. A total of 13,347 patients were enrolled, with a median Crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned Crystalloid. The number of hospital-free days did not differ between the balanced-Crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced Crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced Crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01). Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced Crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT-ED ClinicalTrials.gov number, NCT02614040 .).
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Saline Is Not the First Choice for Crystalloid Resuscitation Fluids.
Critical care medicine, 2016Co-Authors: Matthew W. Semler, Todd W. RiceAbstract:Fluid resuscitation with Crystalloid solutions is among the most common interventions for hospitalized patients. Currently, providers choose between two classes of available Crystalloid solutions: 0.9% sodium chloride (saline) and “balanced” Crystalloids (such as lactated Ringer solution [ Baxter, D
Loren G. Yamamoto - One of the best experts on this subject based on the ideXlab platform.
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Terminology used to describe volume expanding resuscitation fluid
Resuscitation, 2006Co-Authors: Wendy C. Matsuno, Loren G. YamamotoAbstract:Many published reports state that the type of resuscitation fluid to be used for volume expansion should be "isotonic Crystalloid" or "isotonic fluid". Generally, this terminology refers to normal saline (NS) and lactated Ringer's (LR) solution. This terminology is suboptimal technically since not all "isotonic" Crystalloids are sufficient volume expanders. A total of 48 reference books from the areas of general pediatrics, pediatric emergency medicine, emergency medicine, pediatric critical care, pediatric surgery, general surgery, internal medicine, family medicine, adult critical care, obstetrics and gynecology, endocrinology, and life support course manuals were reviewed. The description of fluids for hypovolemic shock, trauma, and diabetic ketoacidosis resuscitation was accurate in 46% of the time.
Glenn M. Chertow - One of the best experts on this subject based on the ideXlab platform.
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Crystalloids versus colloids for resuscitation in shock.
Current opinion in nephrology and hypertension, 2000Co-Authors: Sushrut S. Waikar, Glenn M. ChertowAbstract:The optimal composition of fluid for volume resuscitation in critically ill patients has been the subject of controversy for decades. Clinicians are faced with several options, including Crystalloid solutions of varying tonicity, several colloid preparations (albumin and others), and blood products. Some of these solutions may be differentially distributed between the intra- and extravascular, and intra- and extracellular compartments, accounting for a variety of physiological effects. Two recently published meta-analyses concluded that colloids afford no survival benefit in critically ill patients compared with Crystalloids. Albumin infusion may be of more value in patients with cirrhosis, or in those at high risk of acute renal failure. Additional randomized trials will be needed to establish the optimal composition and volume of colloid or Crystalloid solutions for resuscitation in shock.
Karthik Raghunathan - One of the best experts on this subject based on the ideXlab platform.
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Crystalloids in critical illness
Oxford Medicine Online, 2016Co-Authors: Karthik Raghunathan, Andrew ShawAbstract:‘Crystalloid’ refers to solutions of crystalline substances that can pass through a semipermeable membrane and are distributed widely in body fluid compartments. The conventional Starling model predicts transvascular exchange based on the net balance of opposing hydrostatic and oncotic forces. Based on this model, colloids might be considered superior resuscitative fluids. However, observations of fluid behaviour during critical illness are not consistent with such predictions. Large randomized controlled studies have consistently found that colloids offer no survival advantage relative to Crystalloids in critically-ill patients. A revised Starling model describes a central role for the endothelial glycocalyx in determining fluid disposition. This model supports Crystalloid utilization in most critical care settings where the endothelial surface layer is disrupted and lower capillary pressures (hypovolaemia) make volume expansion with Crystalloids effective, since transvascular filtration decreases, intravascular retention increases and clearance is significantly reduced. There are important negative consequences of both inadequate and excessive Crystalloid resuscitation. Precise dosing may be titrated based on functional measures of preload responsiveness like pulse pressure variation or responses to manoeuvres such as passive leg raising. Crystalloids have variable electrolyte concentrations, volumes of distribution, and, consequently variable effects on plasma pH. Choosing balanced Crystalloid solutions for resuscitation may be potentially advantageous versus ‘normal’ (isotonic, 0.9%) saline solutions. When used as the primary fluid for resuscitation, saline solutions may have adverse effects in critically-ill patients secondary to a reduction in the strong ion difference and hyperchloraemic, metabolic acidosis. Significant negative effects on immune and renal function may result as well.
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What is the ideal Crystalloid
Current opinion in critical care, 2015Co-Authors: Karthik Raghunathan, Patrick Nailer, Ryan KonoskeAbstract:Purpose of review We discuss the importance of the composition of intravenous Crystalloid solutions. On the basis of current physiologic principles, evidence from basic science and clinical experiments, recent observational studies, and clinical trials, we conclude that the 'ideal Crystalloid' depends on clinical context. We make recommendations on solutions that may be used during critical illness, major surgery, and certain clinical situations. Recent findings The routine use of solutions with a supraphysiologic chloride content and a low strong ion difference (SID), such as isotonic saline solution, may be associated with adverse outcomes, especially among critically ill patients. On the contrary, solutions with a physiologic chloride content and a 'balanced' electrolyte composition (SID closer to plasma) may improve the likelihood of survival. The distribution of different types of Crystalloids across traditional 'body compartments' is a function of osmolality of the fluid infused relative to plasma, integrity of the glycocalyx, and the hemodynamic/'volume' state of the patient. During critical illness, the routine administration of colloids may offer no clinical benefits compared with the use of Crystalloids. Summary Crystalloids, like other types of intravenous fluids, are drugs with important effects on clinical outcomes that may be mediated by osmolality, chloride content, and SID.
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association between the choice of iv Crystalloid and in hospital mortality among critically ill adults with sepsis
Critical Care Medicine, 2014Co-Authors: Karthik Raghunathan, Andrew D. Shaw, Brian Nathanson, Til Sturmer, Alan M Brookhart, Mihaela S Stefan, Soko Setoguchi, Chris Beadles, Peter K LindenauerAbstract:Objective:Isotonic saline is the most commonly used Crystalloid in the ICU, but recent evidence suggests that balanced fluids like Lactated Ringer’s solution may be preferable. We examined the association between choice of Crystalloids and in-hospital mortality during the resuscitation of critically
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Fluid Management in Cardiac Surgery: Colloid or Crystalloid?
Anesthesiology clinics, 2013Co-Authors: Andrew D. Shaw, Karthik RaghunathanAbstract:The Crystalloid-colloid debate has raged for decades, with the publication of many meta-analyses, yet no consensus. There are important differences between colloids and Crystalloids, and these differences have direct relevance for cardiac surgical patients. Rather than asking Crystalloid or colloid, we believe better questions to ask are (1) High or low chloride content? and (2) Synthetic or natural colloid? In this paper we review the published literature regarding fluid therapy in cardiac surgery and explain the background to these two important and unanswered questions.