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Mean arterial pressure and central venous pressure (estimates and standard errors based on mixed effects models). Difference between slopes of curves at 0 hours, p = 0.20/0.12, and difference between curvatures p = 0.34/0.25 (MAP/CVP).
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Fluids are often given liberally after the return of spontaneous circulation. However, the optimal fluid regimen in survivors of cardiac arrest is unknown. Recent studies indicate an increased fluid requirement in post-cardiac arrest patients. During hypothermia, animal studies report extravasation in several organs, including the brain. We investi...
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Context 1
... dropped significantly in both groups (Fig. 3). The cardiac index (CI) was 2.2 l/min/m 2 (0.2) on admission to the MICU. At 24 hours, before rewarming, the CI was higher in both groups and significantly higher in the con- trol group (Fig. 4). MAP and CVP did not differ signifi- cantly between groups (Fig. 5). There were no differences in dose and type of vasopressors between the groups. All patients needed vasopressors, primarily dopamine in accordance with the MICU ...Citations
... Pathophysiologic conditions, such as shock, low cardiac output, and sepsis-like syndromes, additionally influence the requirement for volume administration [4]. Moreover, increased capillary leakage is known to contribute to a higher demand for fluids [5]. Several sepsis studies demonstrated the negative impact of excessive volume administration on the outcome of these patients [6][7][8][9][10][11]. ...
(1) Background: Fluid resuscitation is a necessary part of therapeutic measures to maintain sufficient hemodynamics in extracorporeal membrane oxygenation (ECMO) circulation. In a post-hoc analysis, we aimed to investigate the impact of increased volume therapy in veno-arterial ECMO circulation on renal function and organ edema in a large animal model. (2) Methods: ECMO therapy was performed in 12 female pigs (Deutsche Landrasse × Pietrain) for 10 h with subsequent euthanasia. Applicable volume, in regard to the necessary maintenance of hemodynamics, was divided into moderate and extensive volume therapy (MVT/EVT) due to the double quantity of calculated physiologic urine output for the planned study period. Respiratory and hemodynamic data were measured continuously. Additionally, renal function and organ edema were assessed by blood and tissue samples. (3) Results: Four pigs received MVT, and eight pigs received EVT. After 10 h of ECMO circulation, no major differences were seen between the groups in regard to hemodynamic and respiratory data. The relative change in creatinine after 10 h of ECMO support was significantly higher in EVT (1.3 ± 0.3 MVT vs. 1.8 ± 0.5 EVT; p = 0.033). No major differences were evident for lung, heart, liver, and kidney samples in regard to organ edema in comparison of EVT and MVT. Bowel tissue showed a higher percentage of edema in EVT compared to MVT (77 ± 2% MVT vs. 80 ± 3% EVT; p = 0.049). (4) Conclusions: The presented data suggest potential deterioration of renal function and intestinal mucosa function by an increase in tissue edema due to volume overload in ECMO therapy.
... In the Cochrane library, a systematic review was performed to analyze the effects of HES on kidney function [23]. This review is from studies referring partially [38,44,45,[49][50][51][52][53][54] or entirely [43,55,56] to unpublished data or data from abstracts only [57]. Certain studies included in the research are from published data only [40,41,46,47,[58][59][60][61][62][63][64][65][66][67][68] and one of them contains no data on renal function [43]. ...
Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusion: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.
... In the Cochrane library, a systematic review was performed to analyze the effects of HES on kidney function. 23 This review is from studies referring partially 38,44,45,[48][49][50][51][52][53] or entirely 43,54,55 to unpublished data or data from abstracts only 56 . Certain studies included in the research are from published data only 40,41,46,47,[57][58][59][60][61][62][63][64][65][66][67] and one of them contains no data on renal function 43 . ...
Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship; the AKI-inducing property of 6% HES 130/0.4 or 0.42 could not be accounted as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusion: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Further conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.
... When circulation dependent on ECMO completely, blood flow is directly dependent on the vascular factors that determine venous return, e.g. vascular closing conditions, pressure vascular volume and the elastance and resistive properties of vessels [7].In addition, CS and postresuscitation syndrome patients may experience systemic capillary leakage due to damage to endothelial cells, often presenting as sepsis-like syndrome, therefore may develop systemic capillary leakage, which can induce intravascular hypovolemia [8][9][10].V-A ECMO itself is also a cause of inflammation, which can lead to severe vascular paralysis due to extensive blood exposure to non-endothelial substances [11,12].To date, there are few reviews of hemodynamic management during V-A ECMO in CS patient. Hemodynamic management in patient with CS during V-A ECMO is summarized in this review. ...
Background
The use of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for cardiorespiratory support is increasing. However, few criteria for hemodynamic management have been described yet in V-A ECMO patients.
Method
We performed a review of hemodynamic management during V-A ECMO in CS patient based the literature published. We discuss how to optimize hemodynamic management.
Results
Patients on V-A ECMO require special hemodynamic management. It is crucial to maintain an adequate tissue oxygen supply and demand balance. Hemodynamic optimization is essential to support LV decompression and improve end-organ function and should be initiated immediately after initiating V-A ECMO support, during which more positive fluid balance is associated with worse outcomes.
Conclusion
The hemodynamic management of CS patients with V-A ECMO are complex and involves various aspect. Clinicians who care for patients on VA ECMO should combined use many availability indicators to guide hemodynamic management.
... In contrast to septic patients, where large clinical trials are available, prospective trials on fluid resuscitation (and endothelial dysfunction) in cardiac arrest are limited. In a small randomized trial (n = 24) Heradstveit et al. showed that infusion of hypertonic saline and hydroxyethyl starch significantly reduced the total fluid volume, improved fluid balance and increased serum osmolality compared to a standard crystalloid fluid regimen, but failed to show an impact on magnetic resonance imaging diagnosed brain oedema formation, which was, however, largely absent in their population (42). More recently, in a randomized placebo-controlled trial, iloprost, a prostacyclin analog aiming to improve endothelial function and reduce ischemia-reperfusion injury, failed to show beneficial effects in post-cardiac arrest patients (43). ...
Background: The post-cardiac arrest (CA) phase is characterized by high fluid requirements, endothelial activation and increased vascular permeability. Erythrocytes are large cells and may not leave circulation despite massive capillary leak. We hypothesized that dynamic changes in hemoglobin concentrations may reflect the degree of vascular permeability and may be associated with neurologic function after CA.
Methods: We included patients ≥18 years, who suffered a non-traumatic CA between 2013 and 2018 from the prospective Vienna Clinical Cardiac Arrest Registry. Patients without return of spontaneous circulation (ROSC), with extracorporeal life support, with any form of bleeding, undergoing surgery, receiving transfusions, without targeted temperature management or with incomplete datasets for multivariable analysis were excluded. The primary outcome was neurologic function at day 30 assessed by the Cerebral Performance Category scale. Differences of hemoglobin concentrations at admission and 12 h after ROSC were calculated and associations with neurologic function were investigated by uni- and multivariable logistic regression.
Results: Two hundred and seventy-five patients were eligible for analysis of which 143 (52%) had poor neurologic function. For every g/dl increase in hemoglobin from admission to 12 h the odds of poor neurologic function increased by 26% (crude OR 1.26, 1.07–1.49, p = 0.006). The effect remained unchanged after adjustment for fluid balance and traditional prognostication markers (adjusted OR 1.27, 1.05–1.54, p = 0.014).
Conclusion: Increasing hemoglobin levels in spite of a positive fluid balance may serve as a surrogate parameter of vascular permeability and are associated with poor neurologic function in the early post-cardiac arrest period.
... Patients with CA typically encounter circulatory collapse and subsequently undergo a systemic in ammatory response, including pathologic vasodilation, increased capillary leakage, and low albumin levels. Large-volume uid and other drugs are often administered to maintain intravascular volume and improve cardiac output, especially during the early stage during and after ECPR [22][23]. As mentioned above, liberal uid resuscitation is actually not recommended in critically ill patients with sepsis. ...
Background: Large amounts of fluid administration are often needed during the extracorporeal cardiopulmonary resuscitation (ECPR) course. Finally, fluid overload is often present.
Methods: Adult patients on ECPR admitted to our center from May 2015 to December 2020 were included. Net fluid balance for consecutive 4 days after ECPR was recorded. The primary outcome was to intensive care unit(ICU) survival . We used multivariable logistic regression to assess the association between fluid status and clinical outcome.
Results: A total of 72 patients were enrolled and divided into two groups: the survivor group and the non-survivor group. The overall rate of ICU survival was 44.4%. Daily fluid balance(DFB) in the survivor group was lower than that in the non-survivor group at day 4 (-11.47[-19.74,8.7] vs -5.08[-12.94,13.9]ml/kg, P=0.046), as was CFB over the first 4 days (-36.03[-51.45,19.03] vs -7.22[-32.79,21.02] ml/kg, P=0.009). Both continuous renal replacement therapy(CRRT) and CFB from days 1-4 were significantly correlated with ICU survival(OR=14.617[95%CI:1.344,48.847], P=0.028; OR=1.261[95%CI1.091,1.375], P=0.003, respectively). CFB from day 1-4 was determined to have a roughly linear association with the log odds of ICU survival.
Conclusions: Early negative fluid balance maybe associated with ICU survival in patients receiving ECPR.
... However, the use of hyperosmolar therapy in treating cerebral edema due to CA requires further investigations. Heradstveit et al. [17] conducted a comparative study of 19 CA survivors using 7.2% hypertonic saline with 6% poly starch solution (HH) therapy or standard uid therapy (Ringer's acetate and normal saline) for 24 h after ROSC. The authors reported that the effects of both forms of uid therapy on brain edema were similar, as magnetic resonance imaging (MRI) showed no differentiation between the two therapies. ...
Background: This study aimed to compare the day-specific association of blood–brain barrier (BBB) disruption with neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors treated with target temperature management (TTM).
Methods: This retrospective single-center study included 68 OHCA survivors, who underwent TTM between April 2018 and December 2019. The albumin quotient (QA) was calculated as [albuminCSF] / [albuminserum] immediately (day 1), and at 24 h (day 2), 48 h (day 3), and 72 h (day 4) after return of spontaneous circulation (ROSC). The degree of BBB disruption was weighted using the following scoring system: 0.07 ≥ QA (normal), 0.01 ≥ QA > 0.007 (mild), 0.02 ≥ QA > 0.01 (moderate), and QA > 0.02 (severe). This system gave it 0 (normal), 1 (mild), 4 (moderate), and 9 (severe) points. Poor neurological outcome was determined at six months after ROSC and was defined as cerebral performance categories 3–5.
Results: We enrolled 68 patients (males, 48; 71%); 37 (54%) of them had a poor neurological outcome. The distributions of this outcome at six months in patients with moderate and severe BBB disruption versus the other groups were 19/22 (80%) vs. 18/46 (50%) on day 1, 31/37 (79%) vs. 6/31 (32%) on day 2, 32/37 (81%) vs. 5/31 (30%) on day 3, and 32/39 (85%) vs. 5/29 (30%) on day 4 (P < 0.001). Using ROC analyses, the optimal cutoff values of QA levels for prediction of neurological outcomes were determined as: day 1, > 0.009 (sensitivity 56.8%, specificity 87.1%); day 2, > 0.012 (sensitivity 81.1%, specificity 87.1%); day 3, > 0.013 (sensitivity 83.8%, specificity 87.1%); day 4, > 0.013 (sensitivity 86.5%, specificity 87.1%); sum of all time points, > 0.039 (sensitivity 89.5%, specificity 79.4%); and scoring system, > 9 (sensitivity 91.9%, specificity 87.1%).
Conclusions: Our results suggested that QA is a useful tool for predicting neurological outcomes in OHCA survivors treated with TTM. However, the prediction of poor neurological outcome using QA showed low sensitivity at 100% specificity. Thus, it could be used as part of a multimodal approach than as a single prognostic prediction tool.
... Post-cardiac arrest syndrome is characterized by a severe systemic inflammatory response, which is associated with impaired hemodynamics (27) and increased mortality (28). Elevated markers of systemic inflammation such as interleukin 6 drive vascular permeability and leakage (29), a key characteristic of patients with systemic inflammation (30), and are predictors of high mortality and poor neurological outcome (31,32). ...
Systemic inflammation is a key characteristic of sepsis but also also in non-infectious conditions such as post-cardiac arrest syndrome. Cytokine adsorption and extracorporeal membrane oxygenation are emerging therapies applied in these critically ill patients, but the experience with their concurrent use is limited. We evaluated cytokine adsorption in critically ill patients requiring support with either veno-venous (vv) or veno-arterial (va) extracorporeal membrane oxygenation (ECMO) support and hypothesized that adsorber incorporation into the ECMO circuit was technically feasible and not associated with imminent risk. We analyzed data from the first six cases of a prospective single-center registry of patients undergoing veno-venous (vv) or veno-arterial (va) ECMO therapy. While in most published cases cytokine adsorbers were inserted into a hemofiltration circuit, we directly incorporated the adsorber into the ECMO circuit without interruption of continuous ECMO support. We observed no relevant side effects attributable to cytokine adsorption. Thirty-day mortality was 83% (predicted mortality 87%), indicating that the decision for adding cytokine adsorption may have been considered as an ultima ratio decision in severe cases with poor prognosis. Vasopressor or inotrope use, lactate level, and fluid balance did not change significantly when comparing pre- vs. post-cytokine adsorption values. Interestingly, the real-time course of the mentioned three surrogate parameters remained unaltered in all but two cases, regardless of cytokine removal. Beneficial effects of cytokine adsorption are plausible in two va-ECMO-treated patient, where increasing lactate began to drop after initiation of cytokine adsorption. Taken together, these data suggest that incorporation of cytokine adsorption into the management of critically ill patients requiring continued ECMO support is feasible and easy to handle. Whether cytokine removal improves clinical outcome in ECMO-treated patients should now be investigated in randomized controlled trials.
... Patients frequently require large-volume fluid resuscitation during the initial phases of ECMO treatment in order to maintain a sufficient amount of vascular blood drainage for extracorporeal blood flow [5][6][7]. This need for liberal fluid infusion during ECMO treatment is further exacerbated by the fact that most patients undergoing ECMO treatment are in an intravascular hypovolemic state aggravated by systemic capillary leakage [8,9]. In addition to the inevitable large-volume fluid resuscitation, administration of blood products for bleeding events accompanying ECMO implantation and reduced urine volume caused by concomitant acute kidney injury (AKI) also play a part in the aggravation of fluid overload in patients undergoing ECMO [10][11][12][13][14]. Furthermore, excessive positive fluid balance during intensive care unit (ICU) stay is reported to affect outcome, and a positive fluid balance was found to increase the risk of mortality in patients with septic shock [15][16][17]. ...
... This response induces pathologic vasodilation and fluid loss to the interstitial compartment, resulting in reduced vascular volume. In addition, major conditions associated with patients undergoing ECMO, such as shock and low cardiac output as well as increased capillary leakage related to sepsis-like syndrome, are factors that contribute [8,32,33]. This insufficient intravascular volume can lead to extracorporeal flow failure, which results in more frequent ECMO circuit changes and decreased total ECMO delivery time [6,34]. ...
Background
Extracorporeal membrane oxygenation (ECMO) is a cardiorespiratory support technique for patients with circulatory or pulmonary failure. Frequently, large-volume fluid resuscitation is needed to ensure sufficient extracorporeal blood flow in patients initiating ECMO. However, excessive overhydration is known to increase mortality in critically ill patients. Therefore, in order to define a tolerant volume range in patients undergoing ECMO treatment, the association between cumulative fluid balance (CFB) and outcome was evaluated in patients undergoing ECMO.
Methods
This retrospective multicenter cohort study was conducted with 723 patients who underwent ECMO in three tertiary care hospitals between 2005 and 2016. CFB was calculated as total fluid input minus total fluid output during the first 3 days from ECMO initiation. The patients were divided into groups that initiated ECMO owing to cardiovascular disease (CVD)-related or non-cardiovascular disease (non-CVD)-related causes. The primary endpoint was mortality within 90 days after ECMO commencement.
Results
Totals of 406 and 317 patients were included in the CVD and non-CVD groups, respectively. In the CVD group, the mean age was 58.4 ± 17.7 years, and 68.2% were male. The mean age was 55.7 ± 15.7 years, and 65.3% were male in the non-CVD group. The median CFB values were 64.7 and 53.5 ml/kg in the CVD and non-CVD groups, respectively. Multivariable analysis using Cox proportional hazards models revealed a significantly increased risk of 90-day mortality in patients with higher CFB values in both the CVD and non-CVD groups. However, the risks were elevated only in the two CFB quartile groups with the largest CFB amounts. Cubic spline models showed that mortality risk began to increase significantly when CFB was 82.3 ml/kg in the CVD group. In patients with respiratory diseases, the mortality risk increase was significant for those with CFB levels above 189.6 ml/kg.
Conclusions
Mortality risk did not increase until a certain level of fluid overload was reached in patients undergoing ECMO. Adequate fluid resuscitation is critical to improving outcomes in these patients.
Electronic supplementary material
The online version of this article (10.1186/s13054-018-2211-x) contains supplementary material, which is available to authorized users.
... Fourteen studies (n = 9629) recorded data on target thresholds, such as CVP or MAP, used to estimate the sufficiency of crystalloids or colloids. Crystalloids were sufficient in achieving target thresholds in 11/14 (79%) studies overall [19,20,[28][29][30][31][32][33][34][35][36]. In comparison, colloids were sufficient at raising CVP to the target threshold of 8-12 mm Hg in all 14 studies (100%). ...
Purpose:
Guidelines recommend crystalloids for fluid resuscitation in sepsis/shock and switching to albumin in cases where crystalloids are insufficient. We evaluated hemodynamic response to crystalloids/colloids in critically ill adults.
Materials and methods:
The primary research question was: "Are crystalloids sufficient for volume replacement in severe indications (intensive care unit [ICU]/critical illness)?" Randomized, controlled trials (RCTs) were identified using PubMed and EMBASE, and screened against predefined inclusion/exclusion criteria. Meta-analyses were performed on extracted data.
Results:
Fifty-five RCTs (N = 27,036 patients) were eligible. Central venous pressure was significantly lower with crystalloids than with albumin, hydroxyethyl starch (HES), or gelatin (all p < .001). Mean arterial pressure was significantly lower with crystalloids vs. albumin (mean difference [MD]: -3.5 mm Hg; p = .03) or gelatin (MD: -9.2 mm Hg; p = .02). Significantly higher volumes of crystalloids were administered vs. HES (MD: +1775 mL); volume administered was numerically higher vs. albumin (MD: +1985 mL). Compared with the albumin group, cardiac index was significantly lower in the crystalloid group (MD: -0.6 L/min/m2, p < .001). All mortality and 90-day mortality were significantly lower for crystalloids compared with HES (relative risk 0.91; p = .009 and 0.9; p = .005, respectively).
Conclusions:
Crystalloids were less efficient than colloids at stabilizing resuscitation endpoints; guidance on when to switch is urgently required.
