No Differences in Renal Function between Balanced 6% Hydroxyethyl Starch (130/0.4) and 5% Albumin for Volume Replacement Therapy in Patients Undergoing Cystectomy: a Randomized Controlled Trial

BACKGROUND The use of artificial colloids has declined in critical care, whereas they are still used in perioperative medicine. Little is known about the nephrotoxic potential in noncritically ill patients during routine surgery. The objective of this trial was to evaluate the influences of albumin 5% and balanced hydroxyethyl starch 6% (130/0.4) on renal function and kidney injury. METHODS One hundred urologic patients undergoing elective cystectomy were randomly assigned for this prospective, single-blinded, controlled study with two parallel groups to receive either albumin 5% or balanced hydroxyethyl starch 6% (130/0.4) as the only perioperative colloid. The primary endpoint was the ratio of serum cystatin C between the last visit at day 90 and the first preoperative visit. Secondary endpoints were estimated glomerular filtration rate and serum neutrophil gelatinase-associated lipocalin until the third postoperative day and risk, injury, failure, loss, and end-stage renal disease criteria at postoperative days 3 and 90. RESULTS The median cystatin C ratio was 1.11 (interquartile range, 1.01 to 1.23) in the albumin and 1.08 (interquartile range, 1.00 to 1.20) in the hydroxyethyl starch group (median difference = 0.03; 95% CI, -0.09 to 0.08; P = 0.165). Also, there were no significant differences concerning serum cystatin C concentrations; estimated glomerular filtration rate; risk, injury, failure, loss, and end-stage renal disease criteria; and neutrophil gelatinase-associated lipocalin. Infusion requirements, transfusion rates, and perioperative hemodynamics were similar in both groups. CONCLUSIONS With respect to renal function and kidney injury, this study indicates that albumin 5% and balanced hydroxyethyl starch 6% have comparable safety profiles in noncritically ill patients undergoing major surgery

Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options

Mast cell activation disease comprises disorders characterized by accumulation of genetically altered mast cells and/or abnormal release of these cells' mediators, affecting functions in potentially every organ system, often without causing abnormalities in routine laboratory or radiologic testing. In most cases of mast cell activation disease, diagnosis is possible by relatively non-invasive investigation. Effective therapy often consists simply of antihistamines and mast cell membrane-stabilising compounds supplemented with medications targeted at specific symptoms and complications. Mast cell activation disease is now appreciated to likely be considerably prevalent and thus should be considered routinely in the differential diagnosis of patients with chronic multisystem polymorbidity or patients in whom a definitively diagnosed major illness does not well account for the entirety of the patient's presentation

Key characteristics impacting survival of COVID-19 extracorporeal membrane oxygenation

Background Severe COVID-19 induced acute respiratory distress syndrome (ARDS) often requires extracorporeal membrane oxygenation (ECMO). Recent German health insurance data revealed low ICU survival rates. Patient characteristics and experience of the ECMO center may determine intensive care unit (ICU) survival. The current study aimed to identify factors affecting ICU survival of COVID-19 ECMO patients. Methods 673 COVID-19 ARDS ECMO patients treated in 26 centers between January 1st 2020 and March 22nd 2021 were included. Data on clinical characteristics, adjunct therapies, complications, and outcome were documented. Block wise logistic regression analysis was applied to identify variables associated with ICU-survival. Results Most patients were between 50 and 70 years of age. PaO2/FiO2 ratio prior to ECMO was 72 mmHg (IQR: 58–99). ICU survival was 31.4%. Survival was significantly lower during the 2nd wave of the COVID-19 pandemic. A subgroup of 284 (42%) patients fulfilling modified EOLIA criteria had a higher survival (38%) (p = 0.0014, OR 0.64 (CI 0.41–0.99)). Survival differed between low, intermediate, and high-volume centers with 20%, 30%, and 38%, respectively (p = 0.0024). Treatment in high volume centers resulted in an odds ratio of 0.55 (CI 0.28–1.02) compared to low volume centers. Additional factors associated with survival were younger age, shorter time between intubation and ECMO initiation, BMI > 35 (compared to < 25), absence of renal replacement therapy or major bleeding/thromboembolic events. Conclusions Structural and patient-related factors, including age, comorbidities and ECMO case volume, determined the survival of COVID-19 ECMO. These factors combined with a more liberal ECMO indication during the 2nd wave may explain the reasonably overall low survival rate. Careful selection of patients and treatment in high volume ECMO centers was associated with higher odds of ICU survival

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Hypervolemia increases release of atrial natriuretic peptide and shedding of the endothelial glycocalyx

Acute normovolemic hemodilution (ANH) and volume loading (VL) are standard blood-sparing procedures. However, VL is associated with hypervolemia, which may cause tissue edema, cardiopulmonary complications and a prolonged hospital stay. The body reacts to hypervolemia with release of atrial natriuretic peptide (ANP) from the heart. ANP has been shown to deteriorate the endothelial glycocalyx, a vital part of the vascular permeability barrier. The aim of the present study was to evaluate and compare ANP release and damage to the glycocalyx during ANH and VL

Effekte einer 6-tägigen Höhenexposition auf die Gefäßbarriere Vorläufige Ergebnisse der DLR EFA-Studie

Einleitung: Ein schneller Aufstieg in große Höhe führt in den ersten 2-5 Tagen zur akuten Höhenkrankheit (AHK), deren Mechanismen nur unzureichend verstanden sind. In Tierund klinischen Studien kam es durch Hypoxie und Inflammation zum Zusammenbruch der Gefäßbarriere bestehend aus einer endothelialen Mikroschicht aus Proteoglykanen (Glycocalyx). Daraus folgte eine erhöhte Gefäßpermeabilität mit Ödembildung und Proteinurie. Die Glycocalyx erholte sich in einer dieser Studien innerhalb von 5 Tagen und zeigte damit eine vergleichbare zeitliche Dynamik wie die AHK. Im Rahmen der AHK ist das Verhalten der endothelialen Glycocalyx allerdings bisher nicht erforscht worden. Hypothesen: Eine 6-tägige Höhenexposition führt zu Hypoxämie, Albuminurie, Bildung peripherer Ödeme und einer Erhöhung der Blutkonzentration der (endothelialen) Glycocalyxfragmente Syndecan-1, Heparansulfat, und Hyaluronan und des Inflammationsmarkers CRP im Vergleich zu den Ausgangswerten in Meereshöhe. Methodik: Aktiver, zweitägiger Aufstieg von 9 gesunden Probanden (4�) zur Capanna Regina Margherita (4554 m, Monte Rosa Massiv, Italien) mit anschließendem 6-tägigem Aufenthalt. Tägliche Messung der peripheren Sauerstoffsättigung und Quantifizierung der akuten Höhenkrankheit mittels Lake Louise Fragebogen (LLS), tägliche 24hUrinsammlung zur quantitativen Bestimmung der Albuminausscheidung und tägliche Blutabnahmen zur späteren Analyse der genannten Glycocalyxfragmente und des CRP. Ergebnisse: Die Höhenexposition führte im Probandenkollektiv nach 48 h zu einer maximalen Hypoxämie mit einer peripheren Sättigung von 76 ±4% und zur Höhenkrankheit (max. 5,5 ±1,8 Punkte im LLS nach der ersten Nacht in 4554 m). Alle Probanden zeigten klinisch periphere Ödeme. Am 5. Tag in der Höhe war das Albumin im Urin signifikant gegenüber dem Ausgangswert in 70 Meter über Meereshöhe erhöht. Syndecan-1, Heparansulfat und Hyaluronan waren in der Höhe signifikant gegenüber den Ausgangswerten erhöht. Schlussfolgerungen: Die in dieser Höhenstudie gefundenen peripheren Ödeme in Kombination mit der erhöhten Albuminausscheidung im Urin, sprechen für eine Erhöhung der Durchlässigkeit der Gefäßbarriere. Die erhöhte Konzentration an Glycocalyx-Bestandteilen im Blut in der Höhe deutet auf eine Fragmentierung der endothelialen Glycocalyx als Pathomechanismus hin. Die bekannten Trigger der Glycocalyx-Fragmentierung, Hypoxämie und eine systemische Inflammationsreaktion, könnten in diesem Fall eine Rolle gespielt haben. Förderung: Die Studie wurde durch programmatische Mittel des DLR Instituts für Luft- und Raumfahrtmedizin und durch Fördermittel der Deutschen Gesellschaft für Berg- und Expeditionsmedizin (BExMed) finanziert