Comparison of 6% hydroxyethyl starch 130/0.4 and saline solution for resuscitation of the microcirculation during the early goal-directed therapy of septic patients

Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Azcuénaga 870, Buenos Aires C1115AAB, Argentina.
Journal of critical care (Impact Factor: 2.19). 12/2010; 25(4):659.e1-8. DOI: 10.1016/j.jcrc.2010.04.007
Source: PubMed

ABSTRACT The aim of this study was to show that 6% hydroxyethyl starch (HES) 130/0.4 achieves a better resuscitation of the microcirculation than normal saline solution (SS), during early goal-directed therapy (EGDT) in septic patients.
Patients with severe sepsis were randomized for EGDT with 6% HES 130/0.4 (n = 9) or SS (n = 11). Sublingual microcirculation was evaluated by sidestream dark field imaging 24 hours after the beginning of EGDT.
On admission, there were no differences in Sequential Organ Failure Assessment score, mean arterial pressure, lactate, or central venous oxygen saturation. After 24 hours, no difference arose in those parameters. Sublingual capillary density was similar in both groups (21 ± 8 versus 20 ± 3 vessels/mm(2)); but capillary microvascular flow index, percent of perfused capillaries, and perfused capillary density were higher in 6% HES 130/0.4 (2.5 ± 0.5 versus 1.6 ± 0.7, 84 ± 15 versus 53 ± 26%, and 19 ± 6 versus 11 ± 5 vessels/mm(2), respectively, P < .005).
Fluid resuscitation with 6% HES 130/0.4 may have advantages over SS to improve sublingual microcirculation. A greater number of patients would be necessary to confirm these findings.

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    • "respectively). ICU mortality was lower in the starch group when analyzing only randomized controlled trials, however this result was due to the inclusion of the studies by Dubin et al [9], and Lv et al [13], that were both of low quality (RR, 0.42 [95% CI, 0.24- 0.73]) [13] [14] (Fig. E2). AKI was higher in the group of HES in all subgroup analyses with the exception in studies where the colloid infusion on the first day was less than 1500 mL (RR, 1.20 [95% CI, 0.98-1.47]). "
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    ABSTRACT: Fluid resuscitation is a key intervention in sepsis, but the type of fluids used varies widely. The aim of this meta-analysis is to determine whether resuscitation with hydroxyethyl starches (HES) compared with crystalloids affects outcomes in patients with sepsis. Search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials up to February 2013. Studies that compared resuscitation with HES versus crystalloids in septic patients, and reported incidence of acute kidney injury (AKI), renal replacement therapy (RRT), transfusion of red blood cell (RBC) or fresh frozen plasma and/or mortality. Three investigators independently extracted data into uniform risk ratio measures. The Grading of Recommendations Assessment, Development and Evaluation framework was used to determine the quality of the evidence. Ten trials (4624 patients) were included. An increased incidence of AKI (risk ratio [RR], 1.24 [95% Confidence Interval {CI}, 1.13-1.36], and need of RRT (RR, 1.36 [95% CI, 1.17-1.57]) was found in patients who received resuscitation with HES. Resuscitation with HES was also associated with increased transfusion of RBC (RR, 1.14 [95% CI, 1.01-1.93]), but not fresh frozen plasma (RR, 1.47 [95% CI, 0.97-2.24]). Furthermore, while intensive care unit mortality (RR, 0.74 [95% CI, 0.43-1.26]), and 28-day mortality (RR, 1.11 [95% CI, 0.96-1.28]) was not different, resuscitation with HES was associated with higher 90-day mortality (RR, 1.14 [95% CI, 1.04-1.26]). Fluid resuscitation practice with HES as in the meta-analyzed studies is associated with increased an increase in AKI incidence, need of RRT, RBC transfusion, and 90-day mortality in patients with sepsis. Therefore, we favor the use of crystalloids over HES for resuscitation in patients with sepsis.
    Journal of critical care 10/2013; 29(1). DOI:10.1016/j.jcrc.2013.09.031 · 2.19 Impact Factor
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    • "In healthy volunteers, PPVs (small vessels) well above 90% are described, whereas in septic patients, a capillary PPV of 78% (23%) is described [11] [42] [43]. In septic shock, norepinephrine dose >0.1 microgram/kg/min and a lactate >2 mmol/L were associated with a significantly lower PVD (12 [8] [9] [10] [11] [12] [13] [14] [15] versus 14 [11] [12] [13] [14] [15] [16] [17] n/mm 2 for norepinephrine dose >0.1 microgram/kg/min and 10 [8] [9] [10] [11] [12] [13] versus 14 [11] [12] [13] [14] [15] [16] [17] n/mm 2 for lactate >2 mmol/L), as well as a significantly lower PPV (80 [70–91] versus 100 [90] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100]% for norepinephrine dose >0.1 microgram/kg/min and 82 [71–99] versus 93 [84–100]% for lactate >2 mmol/L) [44]. In uncomplicated major abdominal surgery, preoperative PPV (small vessels) was 89% (83–95) versus 79% (73–92) in patients who developed complications postoperatively [4]. "
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    ABSTRACT: Objective. Sublingual microcirculatory alterations are associated with an adverse prognosis in several critical illness subgroups. Up to now, single-center studies have reported on sublingual microcirculatory alterations in ICU patient subgroups, but an extensive evaluation of the prevalence of these alterations is lacking. We present the study design of an international multicenter observational study to investigate the prevalence of microcirculatory alterations in critically ill: the Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP). Methods. 36 ICU's worldwide have participated in this study aiming for inclusion of over 500 evaluable patients. To enable communication and data collection, a website, an Open Clinica 3.0 database, and image uploading software have been designed. A one-session assessment of the sublingual microcirculation using Sidestream Dark Field imaging and data collection on patient characteristics has been performed in every ICU patient >18 years, regardless of underlying disease. Statistical analysis will provide insight in the prevalence and severity of sublingual alterations, its relation to systemic hemodynamic variables, disease, therapy, and outcome. Conclusion. This study will be the largest microcirculation study ever performed. It is expected that this study will also establish a basis for future studies related to the microcirculation in critically ill.
    Critical care research and practice 05/2012; 2012:121752. DOI:10.1155/2012/121752
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    • "Then Arnold et al. reported that a determination of MFI during bedside video acquisition (MFI point of care ) gave a good agreement with the MFI by quadrants [12]. Finally, Dubin et al. used the mean value of the MFI determined in each individual vessel (MFI vessel by vessel ) [1] [8] [9]. This analysis is time consuming but tightly correlated with the actual red blood cell (RBC) velocity measured with a software both in experimental and clinical conditions [1] [13] [14]. "
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    ABSTRACT: The microvascular flow index (MFI) is commonly used to semiquantitatively characterize the velocity of microcirculatory perfusion as absent (0), intermittent (1), sluggish (2), or normal (3). There are three approaches to compute MFI: (1) the average of the predominant flow in each of the four quadrants (MFI(by quadrants)), (2) the direct assessment during the bedside video acquisition (MFI(point of care)), and (3) the mean value of the MFIs determined in each individual vessel (MFI(vessel by vessel)). We hypothesized that the agreement between the MFIs is poor and that the MFI(vessel by vessel) better reflects the microvascular perfusion. For this purpose, we analyzed 100 videos from septic patients. In 25 of them, red blood cell (RBC) velocity was also measured. There were wide 95% limits of agreement between MFI(by quadrants) and MFI(point of care) (1.46), between MFI(by quadrants) and MFI(vessel by vessel) (2.85), and between MFI(by point of care) and MFI(vessel by vessel) (2.56). The MFIs significantly correlated with the RBC velocity and with the fraction of perfused small vessels, but MFI(vessel by vessel) showed the best R(2). Although the different methods for the calculation of MFI reflect microvascular perfusion, they are not interchangeable and MFI(vessel by vessel) might be better.
    Critical care research and practice 04/2012; 2012:102483. DOI:10.1155/2012/102483
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