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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EDuring a session on fluid administration in the operating room, presenters discussed the use of different monitoring approaches and devices, the use of colloids and crystalloids in intensive care unit, as well as the risks of normal saline solution.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ERisks \u0026amp; Complications\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EAnesthesiology Equipment\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ERisks \u0026amp; Complications\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EAnesthesiology Equipment\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EStarting off the session on fluid administration in the operating room, Andrew Leibowitz, MD, Icahn School of Medicine at Mount Sinai, New York, New York, USA, presented an overview entitled \u201cMonitoring and Optimizing Intravascular Volume.\u201d His review addressed current knowledge of fluid administration and a summary of data on the use of different monitoring approaches and devices.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ETo balance the risks of giving too much or too little fluid, it is important to carefully consider the comorbidities and status of the patient (eg, a healthy patient may respond differently than one who is elderly and critically ill) as well as the risks and benefits of hyper\u2013 and hypovolemia. Additionally, it is important to realize that almost 50% of patients who are hypotensive in the operating room do not experience increases in cardiac output or blood pressure following fluid administration.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003ETo achieve the correct level of hydration, it is important to find ways to determine when fluids are beneficial. For example, common indicators (eg, blood pressure) are not effective, and increased lactate levels do not necessarily indicate hypoperfusion (many other possible reasons exist).\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EWhile central venous pressure can be measured, it does not correlate with blood volume, and there is no cutoff that determines whether patients are likely to respond to fluid administration [Marik PE et al. \u003Cem\u003EChest.\u003C\/em\u003E 2008]. Even in healthy volunteers, change in central venous pressure is not correlated with blood volume [Kumar A. \u003Cem\u003ECrit Care Med.\u003C\/em\u003E 2004]. Additionally, cardiac output is not a reliable measure, because it is variable and not correlated with outcomes. There is no evidence that it is beneficial to increase cardiac output (which can cause adverse effects through increasing heart rate); one reason that pulmonary artery catheters have not improved outcomes is that they do not provide relevant information.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003ESeveral devices have been developed to show cardiac output derived from pulmonary artery catheters. These devices give imprecise measurements (eg, the true cardiac output could be \u0026gt; 30% above or below the measurement shown by the device), and they have been tested on average patients rather than those who are critically ill.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003ETo know when it is beneficial to provide fluid volume, Dr Leibowitz recommends examining arterial pressure changes. A systolic pressure change \u0026gt; 13% suggests that a patient will respond favorably to a fluid challenge, causing an increase in blood pressure, while patients with changes \u0026lt; 9% are not likely to respond. Patients in the middle range fall into a gray zone in which clinical judgment is needed. The limitations of this approach are that it can be used only if a patient is on mechanical ventilation, has a tidal volume greater than 8 mL\/kg, and has a sinus rhythm.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EVarious devices have been developed, including PiCCO\u003Csub\u003E2\u003C\/sub\u003E, LiDCO Plus, LiDCO Rapid, and Flotrac\/Vigileo, and they have limitations\u2014for instance, these devices do not show output that is within 30% of the patient\u0027s real output (considered an important criterion for acceptability). In summary, Dr Leibowitz encouraged clinicians to be skeptical and to use arterial pressure changes to make decisions about fluids, realizing that the utility of other approaches (including new devices) is unclear.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EFollowing Dr Leibowitz\u0027 s introductory talk, John E. Ellis, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA, gave a presentation on the use of colloids and crystalloids in intensive care unit (ICU) and operating room environments.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003ETrials and meta\u2013analyses have been conducted to compare fluids [Myburgh JA, Mythen MG. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013]. In the ICU, albumin and saline result in similar survival probabilities [Finfer S et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2004]. Colloid and crystalloid are associated with similar outcomes in critically ill patients with hypovolemic shock [Annane D et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2013]. However, some possible adverse events have been reported. Albumin may be associated with worse outcomes in patients with traumatic brain injury. Additionally, hydroxyethyl starch may be associated with complications involving coagulation and acute kidney injury [Zarychanski R et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2013]. According to Dr Ellis, hydroxyethyl starch is not frequently used now, except for goal\u2013directed fluid therapy [Gan TJ et al. \u003Cem\u003EAnesthesiology\u003C\/em\u003E. 2002].\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EIn making decisions about fluids, it is important to consider the glycocalyx [Chapell D, Jacob M. \u003Cem\u003EBest Pract Res Clin Anaesthesiol.\u003C\/em\u003E 2014]. The glycocalyx affects the pressure in the interstitial space, is involved in transport, forms a barrier, and acts as a sensor. When it is damaged (eg, by ischemia), leakage can occur. Prophylactic hyper\u2013volemia can damage the glycocalyx and increase risks. If intravascular hypovolemia is the only issue, meaning that the glycocalyx is intact, then isoncotic albumin and hydroxyethyl starch are more effective.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EIn summary, Dr Ellis mentioned that albumin should not be used with traumatic brain injury and that hydroxyethyl starch should not be used in sepsis or when there is a risk of acute kidney injury. However, the safety of many of these fluids has not been definitively established, and it is not clear whether crystalloid or colloid is better in general. Fluid recommendations may differ in the operating room, because more fluid could help ambulatory patients recover with fewer side effects, while having fewer of the negative consequences affecting high\u2013risk patients in the ICU.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EContinuing the discussion of fluid choices, Michael H. Wall, MD, University of Minnesota, Minneapolis, Minnesota, USA, gave a presentation entitled \u201cAre Synthetic Colloids Safe?\u201d After summarizing the types of colloids and how they are named, he described ways that their structures affect their metabolism (eg, larger ones are metabolized while smaller ones are rapidly excreted) [Westphal M et al. \u003Cem\u003EAnesthesiology\u003C\/em\u003E. 2009]. In addition to differing in structure, synthetic colloids differ in source (waxy maize vs potatoes) and in solvents.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EA range of safety concerns has been voiced. Colloids may influence coagulation and platelet function and may affect renal function, among other issues. Additionally, there is a lack of data on their effects on elderly individuals, children, and patients with renal disease.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EWhile the results have been mixed, studies have not shown clinical benefits for one colloid, hydroxyethyl starch, and some have suggested substantial risks (especially to kidneys) [Gillies MA et al. \u003Cem\u003EBr J Anaesth.\u003C\/em\u003E 2014; Serpa Neto A et al. \u003Cem\u003EJ Crit Care.\u003C\/em\u003E 2014]. Dr Wall opined that, based on the current evidence, synthetic colloids are not safe for us.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003ESteven G. Venticinque, MD, University of Texas Health Science Center, San Antonio, Texas, USA, concluded the session with his presentation \u201cChoosing the Correct Colloid,\u201d which focused on risks of normal saline solution.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EDr Venticinque began by providing some history and explaining the Stewart approach to acid\u2013base chemistry to explain why normal saline can cause hyperchloremic acidosis. He then summarized multiple studies showing that normal saline can cause negative effects that are not caused by balanced solutions (eg, lactated Ringer\u0027s solution). He suggested that a more balanced solution could be developed with an organic anion that can be metabolized but lacks excess ions, such as calcium, magnesium, and potassium.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003ESaline is often considered important for patients with elevated potassium and renal failure, brain injury and elevated intracranial pressure, and blood transfusion compatibility issues. However, there is evidence that even these patients are not helped by saline solutions when compared with balanced solutions [Roquilly A et al. \u003Cem\u003ECritical Care.\u003C\/em\u003E 2013; Levac B et al. \u003Cem\u003ECan J Anaesth.\u003C\/em\u003E 2010; Albert K et al. \u003Cem\u003ECan J Anaesth.\u003C\/em\u003E 2009; Hadimioglu N et al. \u003Cem\u003EAnesth Analg.\u003C\/em\u003E 2008; Khajavi MR et al. \u003Cem\u003ERen Fail.\u003C\/em\u003E 2008; Cruz RJ Jr et al. \u003Cem\u003EAnesth Analg.\u003C\/em\u003E 2006; Cull DL et al. \u003Cem\u003ESurg Gynecol Obstet.\u003C\/em\u003E 1991]. One major problem with using saline is that it is confounds interpretation of blood gases when they are used as an index of resuscitation. Recent British consensus guidelines state that balanced solutions should be used in place of saline for adult patients receiving intravenous therapy, except for the specific case of hypochloremia [Soni N. \u003Cem\u003EAnaesthesia\u003C\/em\u003E. 2009].\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EIn conclusion, Dr Venticinque cautioned that normal saline can cause non\u2013anion gap acidosis and hyper\u2013chloremia and can potentially act as a confounding factor during resuscitation. For these reasons, he thinks that it may be harmful in many situations in which it is currently being used.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/40\/19.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzon01\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}