Effect of fluid resuscitation with balanced solutions on platelets: In vitro simulation of 20% volume substitution

   Background: Fluid resuscitation in massive bleeding may cause coagulation disorders by dilution of platelets and clotting factors or by the impact on their function. The aim of this study was to investigate the effects of balanced crystalloid and colloid solutions on platelets in vitro using complex assessment of coagulation. Methods: The study group was comprised of 32 American Society of Anesthesiologists physical status class I male volunteers, aged 21–35 (29 ± 4) years, weighting 59–103 (81.2 ± 9.8) kg. Whole blood samples were diluted at a 4:1 ratio with the following fluids: balanced crystalloid (Plasmalyte®), 6% hydroxyethyl starch 130/0.4 (Volulyte®) and succinylated gelatin (Geloplasma®). Coagulation was as­sessed using standard morphology, rotational thromboelastometry and aggregometry. Results: Dilution with all fluids caused statistically significant drop in the number of platelets (p < 0.01) but the effect did not differ between solutions (p > 0.05 for all). Other platelet parameters, such as platelet distribution width, mean platelet volume and platelet-large cell ratio were not affected by the solutions. Hemodilution had no effect on platelet function (p = 0.1). Decreased platelet component of clot strength was found for all three fluids (p < 0.05), although the effect for colloids was more pronounced. Conclusions: The effect of balanced crystalloids and colloids on platelet aggregation was insignificant, even after 20% volume substitution with the resuscitation fluids.

Prolonged ventilation post cardiac surgery - tips and pitfalls of the prediction game

<p>Abstract</p> <p>Background</p> <p>Few available models aim to identify patients at risk of prolonged ventilation after cardiac surgery. We compared prediction models developed in ICU in two adjacent periods of time, when significant changes were observed both in population characteristics and the perioperative management.</p> <p>Methods</p> <p>We performed a retrospective review of two cohorts of patients in our department in two subsequent time periods (July 2007 - December 2008, n = 2165; January 2009 - July 2010, n = 2192). The study was approved by the Institutional Ethics Committee and the individual patient consent was not required. Patients were divided with regard to ventilation time of more or less than 48 hours. Preoperative and procedure-related variables for prolonged ventilation were identified and multivariate logistic regression analysis was performed separately for each cohort.</p> <p>Results</p> <p>Most recent patients were older, with more co-morbidities, more frequently undergoing off-pump surgery. At the beginning of 2009 we also changed the technique of postoperative ventilation. Percentage of patients with prolonged ventilation decreased from 5.7% to 2.4% (p < 0.0001).Preoperative and procedure-related variables for prolonged ventilation were identified. Prediction models for prolonged ventilation were different for each cohort. Most recent significant predictors were: aortic aneurysm surgery (OR 12.9), emergency surgery (OR 5.3), combined procedures (OR 5.1), valve procedures (OR 3.2), preoperative renal dysfunction (OR 2.9) and preoperative stroke or TIA (OR 2.8).</p> <p>Conclusions</p> <p>Prediction models for postoperative ventilation should be regularly updated, particularly when major changes are noted in patients' demographics and surgical or anaesthetic technique.</p

Ferritin and transferrin saturation cannot be used to diagnose iron-deficiency anemia in critically ill patients

Abstract Introduction: Iron-deficiency anaemia (IDA) is the most common anaemia globally. The frequency of IDA among critically ill patients is not known. The aim of our study was to analyse performance of standard iron metabolism parameters in diagnosis of IDA in the critically ill. Material and methods: We performed a retrospective analysis of consecutive anaemic patients admitted to the intensive care unit. Based on various cut-off values for ferritin and/or transferrin saturation (TfS), we determined the incidence of IDA. Results: The population consisted of 27 (53%) men and 24 (47%) women. The median haemoglobin concentration was well 96 [interquartile range (IQR 87–109)] g/L. The studied population had markedly increased concentration of C-reactive protein [119 (IQR 44–196) mg/L], ferritin [686 (385–1114) µg/L], whereas iron concentration and TfS were below reference value. Depending on cut-off value chosen, IDA could be diagnosed in between 7.8 (ferritin &lt; 100 µg/L +TfS &lt; 20%) and 56.9 % (TfS &lt; 20%) of patients. Conclusions: Ferritin and transferrin saturation cannot be used for precise diagnosis of IDA caused by absolute or functional iron deficiency in the critically ill

Preservation of boilers and turbines with the surface active substance octadecylamine (ODA)

______________________________________________________________________ Basic requirements Based on the feed-in priority of electricity from renewable energy sources, conventional fossil fuel power plants are faced with new challenges. In times of sinking electricity prices on the one hand and rising fuel costs on the other, the economic running of highly efficient gas and steam turbine power plants is becoming increasingly more difficult. The results are frequent and often lengthy shutdowns. Coal-fired power plants must cope with flexible load requirements and longer run-times in low and part load operation. In contrast, higher reserve capacities, which are often needed quickly, must be made available. For these reasons, preservation procedures play an increasingly important role. Because of different methods, the operator must decide to what extent and with which technology the system should be protected during downtime. Not only does the cost of the preservation play a role, the method should also provide good protection with simple handling and a flexible management system. It must also be taken into account that beside the boiler, the steam and water-driven components, including the turbines, are subject to corrosion during shutdowns as well. Thus, these systems of the plant remain unprotected when the preservation method used entails keeping the boiler water warm with nitrogen flushing. Apart from the classical preservation procedures, preservation with film-forming amines presents an interesting alternative. The preservation procedure using the active substance octadecylamine (ODA) is presented on the following pages. Although a wet-chemical method, the preservation effect remains intact and stable, even after draining or partial draining. This technology of preservation is explained using a practical example. Preservation with octadecylamine Development The use of ODA for the preservation of power plant systems has a long tradition. As early as the 1970s, several publications and patents described the effect and method of preservation with ODA. [1], [2], [3] At that time, the active substance was used in its pure form. As ODA is a water-insoluble solid, the use of the pure substance makes high technical demands on the dosing stations. The active substance has to be melted on site at the facilities and kept in the liquid state for dosing. This poses serious problems. Only by using the stable and watersoluble emulsion developed by REICON, could these problems be overcome. Due to the unavailability of a permanently stable ODA emulsion in Russia, preservation with pure ODA is still carried out at nuclear facilities (e.g. Kola) and conventional power plants to this day. [4, 5] Properties of the active substance octadecylamine ODA is a long-chain, aliphatic amine with the chemical formula C18H37NH2. Due to its volatility and a distribution coefficient similar to that of ammonia, a good distribution in the water and steam cycle is ensured. The active substance has the following characteristics

Cultural adaptation and validation of the Organizational Culture Assessment Instrument for a sample of brazilian nursing professionals

Este estudo teve por objetivo traduzir, adaptar culturalmente e validar o Organizational Culture Assessment Instrument - OCAI para uma amostra de trabalhadores de enfermagem brasileiros. Trata-se de um estudo observacional do tipo transversal com amostragem não probabilística. O processo de adaptação cultural seguiu as etapas: tradução, síntese e consenso das traduções, avaliação da versão traduzida por Comitê de Juízes, retrotradução, análise semântica e pré-teste. A tradução foi realizada por dois tradutores e a síntese das traduções por um terceiro tradutor. Estas versões foram analisadas por um Comitê de Juízes, gerando uma versão consensual que foi retrotraduzida e enviada para os autores do instrumento original, os quais a aprovaram. A análise semântica e o pré-teste foram realizadas por 30 profissionais de enfermagem e, após a realização das alterações sugeridas, foi gerada a versão adaptada para o contexto brasileiro do OCAI em uma amostra de trabalhadores de enfermagem (OCAI-Nurs). Em relação à avaliação das propriedades psicométricas, foram estimadas: a sensibilidade psicométrica dos itens; a validade de construto fatorial, por meio da Análise Fatorial Confirmatória e do método da máxima verossimilhança, utilizando-se os índices de qualidade de ajustamento ?2/gl, GFI, CFI e RMSEA; a validade de construto convergente, estimada pela Variância Extraída Média; a invariância fatorial, avaliada pela análise multigrupos (teste da diferença de qui-quadrado em amostras independentes); e a confiabilidade do instrumento, avaliada por meio da consistência interna dos fatores (alfa de Cronbach e confiabilidade composta). O processo de validação foi realizado com 277 profissionais de enfermagem de quatro hospitais do interior do Estado de São Paulo. Observou-se predominância de mulheres (82,3%); a média de idade foi de 36,25 anos; o tempo médio de atuação nos hospitais foi de seis anos e de atuação profissional de 12 anos. Os resultados obtidos na adaptação cultural mostraram que o OCAI-Nurs é compreensível, fácil de ser respondido e adequado para a amostra de profissionais de enfermagem brasileiros. No processo de validação, os resultados mostraram que a sensibilidade psicométrica dos itens foi considerada adequada; a validade de construto fatorial apresentou propriedades psicométricas insatisfatórias nos itens CD1A, GC3B, CD1Bf, EE5Bf, CD1C, GC3D, LO2D e LO2Df e, portanto, foram excluídos; a validade de construto convergente apresentou limitação em todos os perfis, exceto no Perfil de Controle (presente); houve invariância estrita dos modelos fatoriais para todos os perfis, exceto no perfil Colaboração (futuro) e Competitivo (presente); quanto à confiabilidade, o OCAI-Nurs apresentou ? adequado no perfil Competitivo no presente e CC adequada nos perfis de Controle e Competitivo no presente. Deste modo, o OCAI-Nurs obteve índices de ajustamento bons, indicando que o instrumento é adequado para a amostra estudada, porém, mostrou pesos fatoriais baixos e confiabilidade comprometida, os quais podem ser justificados pelas diferenças entre os valores que caracterizam a cultura dos hospitais e da enfermagem e aqueles que determinam os perfis culturais do OCAI. Por este motivo, sugerese a realização de estudos futuros na tentativa de se obter uma estrutura fatorial mais estável do OCAI-Nurs e o desenvolvimento de instrumentos que sejam capazes de captar as especificidades do trabalho em saúde e de enfermagemThis study aimed to translate, culturally adapt and validate the Organizational Culture Assessment Instrument - OCAI for a sample of Brazilian nursing workers. This is an observational cross-sectional study with non-probabilistic sampling. The process of cultural adaptation followed the steps: translation, synthesis and consensus of translations, evaluation of the version translated by Committee of Judges, back-translation, semantic analysis and pre-test. The translation was done by two translators and the synthesis of the translations by a third translator. These versions were analyzed by a Committee of Judges, generating a consensual version that was backtranslated and sent to the authors of the original instrument, which approved it. Semantic analysis and pre-test were performed by 30 nursing professionals and, after the proposed changes were made, the adapted version to the Brazilian context of OCAI in a sample of nursing workers (OCAINurs) was generated. In relation to the evaluation of the psychometric properties, the psychometric sensitivity of the items were estimated; the factorial construct validity, using the Confirmatory Factor Analysis and the maximum likelihood method, using the quality indexes of adjustment ?2/gl, GFI, CFI and RMSEA; the convergent construct validity, estimated by Average Extraction Variance; factorial invariance, assessed by multi-group analysis (chi-square test in independent samples); and the reliability of the instrument, evaluated through the internal consistency of the factors (Cronbach\'s alpha and composite reliability). The validation process was performed with 277 nursing professionals from four hospitals in the interior of the State of São Paulo. A predominance of women (82.3%) was observed; the mean age was 36.25 years; the average time of operation in the hospitals was six years and of professional performance was 12 years. The results obtained in the cultural adaptation showed that OCAI-Nurs is understandable, easy to answer and suitable for the sample of Brazilian nursing professionals. In the validation process, the results showed that the psychometric sensitivity of the items was considered adequate; the factorial construct validity showed unsatisfactory psychometric properties in items CD1A, GC3B, CD1Bf, EE5Bf, CD1C, GC3D, LO2D and LO2Df and, therefore, were excluded; the convergent construct validity presented limitation in all the profiles, except in the Control Profile (present); there was a strict invariance of the factorial models for all profiles, except in the Collaborate (future) and Compete profile (present); as to reliability, OCAI-Nurs presented adequate ? in the Competitive profile in the present and adequate CC in the Control and Compete profiles in the present. Thus, the OCAI-Nurs obtained good adjustment indexes, indicating that the instrument is adequate for the studied sample, but showed low factorial weights and compromised reliability, which can be justified by the differences between the values that characterize the hospitals and nursing culture and those who determine the cultural profiles of OCAI. For this reason, it is suggested to carry out future studies in an attempt to obtain a factorial structure of OCAI-Nurs more stable and the development of instruments that are able to capture the specificities of work in health and nursin

The Impact of Red Blood Cell Transfusion on Blood Lactate in Non-Bleeding Critically Ill Patients&mdash;A Retrospective Cohort Study

Anemia should preferably be managed without red blood cell transfusion (RBCT); instead, therapy should be focused on causes of anemia along with efforts to minimize blood loss. Lactate could potentially be used as a physiologic RBCT trigger, although there are some limitations to its interpretation. The aim of our study was to analyze the impact of RBCT on blood lactate with consideration of factors known to increase its concentration and to assess the usefulness of blood lactate as a potential physiologic RBCT trigger. We performed a retrospective analysis of all RBCT episodes in non-bleeding critically ill patients. We retrieved demographic data, data on RBCT itself (duration, type of RBC, volume of RBC, age of RBC), laboratory parameters (lactate, hemoglobin, glucose, total bilirubin), and factors potentially increasing lactate. We analyzed 77 RBCTs with elevated pre-RBCT lactate. The median age of patients was 66 (IQR 57&ndash;73) years and the distribution of sexes was even. The named factors potentially influencing lactate had no impact on its concentration. The median pre-post RBCT lactate was 2.44 (IQR 2.08&ndash;3.27) and 2.13 (IQR 1.75&ndash;2.88) mmol/L, respectively (p &lt; 0.01); the median decrease was 0.41 (IQR 0.07&ndash;0.92) mmol/L. We conclude that RBCT did not normalize mildly elevated lactate. Common causes of elevated lactate probably had no impact on its concentration. Therefore lactate may have a limited role as a physiologic RBCT trigger in non-bleeding severely anemic critically ill patients

Management Strategies in Septic Coagulopathy: A Review of the Current Literature

One of the &lsquo;organs&rsquo; that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized