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.
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.
SourceAvailable from: Namkje Vellinga[Show abstract] [Hide abstract]
ABSTRACT: Objectives: Microcirculatory alterations are associated with adverse outcome in subsets of critically ill patients. The prevalence and significance of microcirculatory alterations in the general intensive care unit (ICU) population are unknown. We studied the prevalence of microcirculatory alterations in a heterogeneous ICU population and its predictive value in an integrative model of macro- and microcirculatory variables. Design: Multicenter observational point prevalence study. Setting: The Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP) study was conducted in 36 ICUs worldwide. Patients: A heterogeneous ICU population consisting of 501 patients. Interventions: none. Measurements and main results: Demographic, hemodynamic and laboratory data were collected in all ICU patients ≥18 years. Sublingual Sidestream Dark Field imaging was performed to determine the prevalence of an abnormal capillary microvascular flow index (MFI < 2.6) and its additional value in predicting hospital mortality. In 501 patients with a median APACHE II score of 15 [10-21], a SOFA score of 5 [2-8] and a hospital mortality of 28.4%, 17% exhibited an abnormal capillary MFI. Tachycardia (heart rate >90 bpm) (odds ratio (OR) 2.71, 95%-confidence interval (CI) 1.67-4.39, P<0.001), mean arterial pressure (OR 0.979, 95%-CI 0.963-0.996, P=0.013), vasopressor use (OR 1.84, 95%-CI 1.11-3.07, P=0.019) and lactate level >1.5 mEq/L (OR 2.15, 95%-CI 1.28-3.62, P=0.004) were independent risk factors for hospital mortality, but not abnormal MFI. In reference to MFI, a significant interaction was observed with tachycardia. In tachycardic patients, the presence of an abnormal MFI was an independent, additive predictor for in-hospital mortality (OR 3.24, 95%-CI 1.30-8.06, P=0.011). This was not true for non-tachycardic patients, nor for the total group of patients. Conclusions: In a heterogeneous ICU population, an abnormal MFI was present in 17% of patients. This was not associated with mortality. However, in patients with tachycardia, an abnormal MFI was independently associated with an increased risk of hospital death.Critical Care Medicine 08/2014; 2014(1). DOI:10.1097/CCM.0000000000000553 · 6.15 Impact Factor
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ABSTRACT: To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines. © Veterinary Emergency and Critical Care Society 2015.01/2015; 25(1):20-47. DOI:10.1111/vec.12283
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ABSTRACT: Improvement of mucosal barrier function and reduction of bacterial translocation are important in the management of sepsis. The mechanisms that underlie the protective effects of colloids on the intestinal mucosal barrier are unclear. The study aims to investigate the effect of fluid resuscitation with hydroxyethyl starch (HES) 130/0.4 against intestinal mucosal barrier dysfunction in a rabbit model of sepsis. Thirty healthy rabbits were randomly and equally divided into a sham-operated control, a sepsis model, or a sepsis + HES treatment group. The sepsis model and sepsis + HES treatment groups were subjected to a modified colon ascendens stent peritonitis (CASP) procedure to induce sepsis. Four hours after the CASP procedure, fluid resuscitation was performed with 6% HES 130/0.4. Arterial and superior mesenteric vein blood samples were collected 4 and 8 h after the CASP procedure for blood gas analysis and measuring tumor necrosis factor-α, interleukin-10, and D-lactate levels. The rabbits were euthanized 8 h after CASP, and sections of the small intestine were stained to evaluate histopathological changes. Respiratory rate and blood pressure were stable during the resuscitation period. Fluid resuscitation with 6% HES 130/0.4 alleviated pathological changes in the abdominal cavity, improved blood gas parameters and inflammatory mediator levels, decreased plasma D-lactate levels, and reduced intestinal mucosal injury compared with the non-treated sepsis model. Fluid resuscitation with 6% HES 130/0.4 protects against intestinal mucosal barrier dysfunction in rabbits with sepsis, possibly via mechanisms associated with improving intestinal oxygen metabolism and reducing the release of inflammatory mediators.Indian Journal of Pharmacology 01/2015; 47(1):49-54. DOI:10.4103/0253-7613.150333 · 0.68 Impact Factor