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Hemodynamic effects of volume replacement with saline solution and hypertonic hydroxyethyl starch in dogs
Udelsmann, Artur;Bonfim, Matheus Rodrigues;Silva, William Adalberto;Moraes, Ana Cristina de;
Acta Cirurgica Brasileira , 2009, DOI: 10.1590/S0102-86502009000200003
Abstract: purpose: to investigate hemodynamic response to volume replacement with saline solution and hypertonic hydroxyethyl starch in hypovolemic dogs. methods: forty dogs under general anesthesia and hemodynamic monitoring, following measurements at baseline, were bled 20 ml.kg-1 and parameters were measured again after 10 minutes. the animals were randomly divided in two groups and volume replacement was performed with saline solution twice the volume removed or 4 ml.kg-1 of hypertonic hydroxyethyl starch. hemodynamic data were again measured after 5, 15, 30, 45 and 60 minutes. results: with both solutions values returned to satisfactory hemodynamic levels. with saline solution, there was a greater amplitude in variations that tended to decrease progressively. with hypertonic hydroxyethyl starch, the parameters studied returned more rapidly to levels similar to those at baseline and varied less. conclusion: both solutions proved to be efficient at replacing volume in the short period studied, although hypertonic hydroxyethyl starch produced more stable results.
Hypertonic saline resuscitation in sepsis
Charles E Wade
Critical Care , 2002, DOI: 10.1186/cc1546
Abstract: The present discussion focuses on the review by Oliveira and coworkers [1] (presented in this issue), and on the use of hypertonic saline resuscitation in sepsis. Early fluid resuscitation of patients with systemic inflammatory response syndrome reduces the incidence of mortality due to septic shock and sepsis [2]. These favorable results have led to consideration of other fluid modalities. In their review, Oliveira and coworkers consider the use of hypertonic saline solutions in the treatment of patients with severe sepsis.Hypertonic saline has been extensively investigated in animal models with regard to its efficacy in treating hemorrhagic hypotension [3]. Numerous clinical studies of patients with traumatic injuries have been initiated with favorable, but not definitive, results [4]. Limited animal studies have been directed at treatment of septic shock using hypertonic solutions, and clinical studies have been exploratory at best. Hannemann and coworkers [5] studied 21 stable patients with septic shock. Patients were administered 2–4 ml/kg hypertonic saline in hydroxyethyl starch. Following administration there was a small effect on oxygenation by increasing cardiac output and oxygen delivery. There was no control group in this study for comparison. An abstract reported by Oliveira an colleagues [6] described a randomized study of 25 stable patients with sepsis.Administration of 250 ml hypertonic saline in dextran significantly improved cardiac index and pulmonary artery occlusion pressure as compared with administration of an equivalent volume of normal saline. Although favorable, those studies of responses to hypertonic saline solutions in stable patients with sepsis are only descriptive. Furthermore, administration of hypertonic saline solutions during the early stages of septic shock when the patient is not yet hyperdynamic has not been investigated.The major benefit of hypertonic solutions is the rapid expansion of blood volume for a small volume administe
Prehospital resuscitation with hypertonic saline-dextran modulates inflammatory, coagulation and endothelial activation marker profiles in severe traumatic brain injured patients
Shawn G Rhind, Naomi T Crnko, Andrew J Baker, Laurie J Morrison, Pang N Shek, Sandro Scarpelini, Sandro B Rizoli
Journal of Neuroinflammation , 2010, DOI: 10.1186/1742-2094-7-5
Abstract: Using a prospective, randomized controlled trial we investigated the impact of prehospital resuscitation of severe TBI (GCS < 8) patients using 7.5% hypertonic saline in combination with 6% dextran-70 (HSD) vs 0.9% normal saline (NS), on selected cellular and soluble inflammatory/coagulation markers. Serial blood samples were drawn from 65 patients (30 HSD, 35 NS) at the time of hospital admission and at 12, 24, and 48-h post-resuscitation. Flow cytometry was used to analyze leukocyte cell-surface adhesion (CD62L, CD11b) and degranulation (CD63, CD66b) molecules. Circulating concentrations of soluble (s)L- and sE-selectins (sL-, sE-selectins), vascular and intercellular adhesion molecules (sVCAM-1, sICAM-1), pro/antiinflammatory cytokines [tumor necrosis factor (TNF)-α and interleukin (IL-10)], tissue factor (sTF), thrombomodulin (sTM) and D-dimers (D-D) were assessed by enzyme immunoassay. Twenty-five healthy subjects were studied as a control group.TBI provoked marked alterations in a majority of the inflammatory/coagulation markers assessed in all patients. Relative to control, NS patients showed up to a 2-fold higher surface expression of CD62L, CD11b and CD66b on polymorphonuclear neutrophils (PMNs) and monocytes that persisted for 48-h. HSD blunted the expression of these cell-surface activation/adhesion molecules at all time-points to levels approaching control values. Admission concentrations of endothelial-derived sVCAM-1 and sE-selectin were generally reduced in HSD patients. Circulating sL-selectin levels were significantly elevated at 12 and 48, but not 24 h post-resuscitation with HSD. TNF-α and IL-10 levels were elevated above control throughout the study period in all patients, but were reduced in HSD patients. Plasma sTF and D-D levels were also significantly lower in HSD patients, whereas sTM levels remained at control levels.These findings support an important modulatory role of HSD resuscitation in attenuating the upregulation of leukocyte/endothe
Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients – a randomized clinical trial [ISRCTN62699180]
Lilit Harutjunyan, Carsten Holz, Andreas Rieger, Matthias Menzel, Stefan Grond, Jens Soukup
Critical Care , 2005, DOI: 10.1186/cc3767
Abstract: Forty neurosurgical patients at risk of increased ICP were randomized to receive either 7.2% NaCl/HES 200/0.5 or 15% mannitol at a defined infusion rate, which was stopped when ICP was < 15 mmHg.Of the 40 patients, 17 patients received 7.2% NaCl/HES 200/0.5 and 15 received mannitol 15%. In eight patients, ICP did not exceed 20 mmHg so treatment was not necessary. Both drugs decreased ICP below 15 mmHg (p < 0.0001); 7.2% NaCl/HES 200/0.5 within 6.0 (1.2–15.0) min (all results are presented as median (minimum-maximum range)) and mannitol within 8.7 (4.2–19.9) min (p < 0.0002). 7.2% NaCl/HES 200/0.5 caused a greater decrease in ICP than mannitol (57% vs 48%; p < 0.01). The cerebral perfusion pressure was increased from 60 (39–78) mmHg to 72 (54–85) mmHg by infusion with 7.2% NaCl/HES 200/0.5 (p < 0.0001) and from 61 (47–71) mmHg to 70 (50–79) mmHg with mannitol (p < 0.0001). The mean arterial pressure was increased by 3.7% during the infusion of 7.2% NaCl/HES 200/0.5 but was not altered by mannitol. There were no clinically relevant effects on electrolyte concentrations and osmolarity in the blood. The mean effective dose to achieve an ICP below 15 mmHg was 1.4 (0.3–3.1) ml/kg for 7.2% NaCl/HES 200/0.5 and 1.8 (0.45–6.5) ml/kg for mannitol (p < 0.05).7.2% NaCl/HES 200/0.5 is more effective than mannitol 15% in the treatment of increased ICP. A dose of 1.4 ml/kg of 7.2% NaCl/HES 200/0.5 can be recommended as effective and safe. The advantage of 7.2% NaCl/HES 200/0.5 might be explained by local osmotic effects, because there were no clinically relevant differences in hemodynamic clinical chemistry parameters.The development or presence of secondary brain injury in patients with intracranial pathology has been associated with increased morbidity and mortality. An increase in intracranial pressure (ICP) accompanied by a low cerebral perfusion pressure (CPP) should therefore be avoided in these patients. Several clinical studies have demonstrated that outcome is improved by
Small-volume hypertonic saline/pentastarch improves ileal mucosal microcirculation in experimental peritonitis  [cached]
Abdelnasser Assadi,Olivier Desebbe,Thomas Rimmelé,Arnal Florence
Infectious Disease Reports , 2012, DOI: 10.4081/idr.2012.e22
Abstract: We compared the effects of hypertonic saline 7.2% / 6% hydroxyethyl starch (HSS-HES) and isotonic saline 0.9% / 6% hydroxyethyl starch (ISS-HES) on ileal microcirculatory blood flow (MBF) at the initial phase of septic shock. Pigs were anesthetized and mechanically ventilated. Catheters were inserted into right atrium, pulmonary artery, carotid artery, and portal vein for hemodynamic measurements and for blood sampling. Ileal mucosal and muscularis MBF was continuously measured by laser Doppler flowmetry (LDF). Septic shock was obtained 240 min after induction of fecal peritonitis; then animals were randomized to receive 10 mL.kg-1 during 10 min of either HSS-HES or ISS-HES. Systemic and microcirculatory blood flow as well as systemic metabolism were assessed. Fecal peritonitis promoted a hypodynamic septic shock, with significant reduction of mean arterial pressure (MAP) and cardiac index (CI). Ileal mucosal MBF (-34%) and ileal muscularis MBF (-54%) significantly diminished from baseline. Contrary to ISS-HES group, mucosal MBF significantly augmented after HSS-HES (+192% at min 150 post-shock) despite low blood pressure. There was weak correlation with CI (r2= 0.2, P = 0.01) . Muscularis MBF didn’t change. HSS-HES-treated animals had a significantly higher osmolarity and sodium concentration than ISS-HES group. Other variables did not change. Small-volume resuscitation with HSS-HES, but not ISS-HES, improved ileal microcirculatory impairment in experimental peritonitis model of septic shock even when MAP was low. This beneficial microcirculatory effect could be valuable in the management of early severe sepsis.
Safety of acute normovolemic haemodilution with hydroxyethyl starch during intracranial surgery.
Kiran Prasad K,Devaragudi T,Christopher R,Chandramouli B
Neurology India , 2000,
Abstract: The effect of acute normovolemic haemodilution on haemodynamics, serum osmolality and coagulation parameters was studied in 20 patients undergoing intracranial surgical procedures. After induction of anaesthesia, 740+/-153 ml of blood was collected and the same was replaced with an equal volume of 6% hexaethyl starch. Heart rate (HR), blood pressure (BP), central venous pressure (CVP) and end tidal carbon dioxide tension (Et CO2) were monitored for 45 min. Haemoglobin concentration (Hb), haematocrit (Hct), serum osmolality (Osm), bleeding time (BT), prothrombin time (PT) and platelet count were determined before and 45 min after haemodilution. Hb and Hct were significantly lower following haemodilution (13.1+/-1.8 and 10.3+/-1.7 g/dL for Hb and 38.0+/-4.6%. and 30.1+/-4.5% for Hct). There was no significant change in the HR, BP and Et CO2 throughout the study period. CVP increased marginally from 35 to 45 min but was within normal limits. There was no significant change in serum osmolality, bleeding time and prothrombin time following haemodilution. Platelet count decreased following haemodilution but the values were within normal limits. The brain relaxation, as assessed by a semiquantitative scale, was satisfactory in all cases. None of the patients developed intraoperative brain swelling. In conclusion, acute normovolemic haemodilution with hexaethyl starch is tolerated well haemodynamically. It does not cause changes in serum osmolality which can increase brain oedema. It has no adverse effect on intraoperative haemostasis. It is a safe technique to decrease homologous blood transfusion during intracranial surgery.
Hypertonic saline and reduced peroxynitrite formation in experimental pancreatitis
Rios, Ester Correia Sarmento;Moretti, Ana Soares;Velasco, Irineu Tadeu;Souza, Heraldo Possolo de;Abatepaulo, Fatima;Soriano, Francisco;
Clinics , 2011, DOI: 10.1590/S1807-59322011000300019
Abstract: objectives: in this study, we tested the hypothesis that hypertonic saline exerts anti-inflammatory effects by modulating hepatic oxidative stress in pancreatitis. introduction: the incidence of hepatic injury is related to severe pancreatitis, and hypertonic saline reduces pancreatic injury and mortality in pancreatitis. methods: wistar rats were divided into four groups: control (not subjected to treatment), untreated pancreatitis (nt, pancreatitis induced by a retrograde transduodenal infusion of 2.5% sodium taurocholate into the pancreatic duct with no further treatment administered), pancreatitis with normal saline (ns, pancreatitis induced as described above and followed by resuscitation with 0.9% nacl), and pancreatitis with hypertonic saline (hs, pancreatitis induced as described above and followed by resuscitation with 7.5% nacl). at 4, 12, and 24 h after pancreatitis induction, liver levels of inducible nitric oxide synthase (inos), heat-shock protein 70, nitrotyrosine (formation of peroxynitrite), nitrite/nitrate production, lipid peroxidation, and alanine aminotransferase (alt) release were determined. results: twelve hours after pancreatitis induction, animals in the hs group presented significantly lower inos expression (p<0.01 vs. ns), nitrite/nitrate levels (p<0.01 vs. ns), lipid peroxidation (p<0.05 vs. nt), and alt release (p<0.01 vs. ns). twenty-four hours after pancreatitis induction, nitrotyrosine expression was significantly lower in the hs group than in the ns group (p<0.05). discussion: the protective effect of hypertonic saline was related to the establishment of a superoxide-no balance that was unfavorable to nitrotyrosine formation. conclusions: hypertonic saline decreases hepatic oxidative stress and thereby minimizes liver damage in pancreatitis.
Treatment of ganglion using hypertonic saline as sclerosant
D Dogo, AW Hassan, U Babayo
West African Journal of Medicine , 2003,
Abstract: Twenty-nine patients with ganglion of the wrist were treated in this hospital using hypertonic saline as sclerosant. All patients were treated as outpatients. Under aseptic conditions, the ganglia were aspirated using #18 hyperdermic needle. A mixture of 2cc of hypertonic saline and 1cc 1% xylocaine were injected into the empty cavity and crepe bandage applied for 24 – 48 hours. After a follow-up period of 24-36 months, there was only one recurrence which was believed to be accidental injection of the saline outside the empty cavity. This was treated by the same procedure. The most common complication was swelling of the wrist and dorsum of the hand which were seen in 50% of cases. This subsided spontaneously within 72hrs of treatment. Severe pain necessitating ingestion of analgesics (Paracetamol) was reported in 6 patients (20%), which subsided within 48 hours. It is hoped that this new treatment which is cheap and less invasive may be a break through in the treatment of ganglia which hitherto was characterised by high recurrence rate of up to 23%.
The Use of Hypertonic Saline in Management of Hemorrhagic Shock  [PDF]
Mohamed Al Saeed
Egyptian Journal of Hospital Medicine , 2012,
Abstract: Background: The most appropriate solution for volume replacement in hemorrhagic shock is controversial, however, hypertonic saline (HTS) solutions have recently gained widespread acceptance. Aim of the work: to study the use of hypertonic saline with the resuscitation fluids in patients with hemorrhagic shock to evaluate the impact of this solution on the extent of early bacterial translocation and blood pressure. Material and method: Forty patients were involved in this prospective study with class II & III hemorrhagic shock. They were randomized into 2 groups, each of 20 patients. Initial resuscitation in group I was done by using Lactated Ringer's (LR) solution with or without blood according to the patient requirements and in the second group of patients (group II), HTS 7.5% with dose of 4 ml /kg body weight was added to the resuscitation fluids. Regular monitoring of vital signs was done and blood samples were withdrawn 1, 30, and 90 minutes after commencement of the resuscitation and sent for blood culture for both aerobic and anaerobic growths.Results: The mean arterial blood pressure in the group I before resuscitation was found to be about 65mm Hg and the mean was raised to 105 mm Hg after 2 hours of resuscitation with LR ± blood. The mean amount of LR used in this group to resuscitate the patients was found to be 40 ml/kg body weight. In group II, the mean arterial blood pressure was found to be 62 mm Hg and it was efficiently controlled by HTS, LR ± blood and the mean arterial blood pressure 2 hours after commencement of resuscitation was elevated to 124 mm Hg. The mean amount of LR used in this group to resuscitate the patients was found to be 18 ml/kg body weight. The blood cultures were positive in 5% of the patients of group II and in 40% of patients of group I. Escherichia coli were the most commonly isolated organism. Conclusion: hypertonic saline was found to be effective for decreasing the rate of early bacterial translocation to blood and also for more efficient restoring of the mean arterial pressure in patients with hemorrhagic shock.
Comparison of hypertonic saline versus normal saline on cytokine profile during CABG
Mahnaz Mazandarani, Fardin Yousefshahi, Mohammad Abdollahi, Hadi Hamishehkar, Khosro Barkhordari, Mohammad Boroomand, Arash Jalali, Arezoo Ahmadi, Reza Moharari, Mona Bashirzadeh, Mojtaba Mojtahedzadeh
DARU Journal of Pharmaceutical Sciences , 2012, DOI: 10.1186/2008-2231-20-49
Abstract: The present study is a randomized double-blinded clinical trial. 40 patients undergoing CABG were randomized to receive HS 5% or NS before operation. Blood samples were obtained after receiving HS or NS, just before operation, 24 and 48 hours post-operatively. Plasma levels of IL-6 and IL-10 were measured by ELISA.Patients received HS had lower levels of IL-6 and higher level of IL-10 compared with NS group, however these differences were not statistically significant. Results of this study suggest that pre-treatment with small volume hypertonic saline 5% may have beneficial effects on inflammatory response following CABG operation.Infusion of Hypertonic saline (HS) solution increases serum osmolarity and markedly intravascular and interstitial fluid volume expansion, which causes improving hemodynamic status [1]. Fluid resuscitation with various concentrations of HS solutions (1.8% - 7.5%) has been investigated in different types of hypovolemic shock [1]; pre-operative, intra-operative and post-operative fluid therapy [2], burn injury and also septic shock [1]. HS is inexpensive and has no risk of anaphylactoid reactions compared with other artificial plasma volume expanders. There is no risk of transmission of infectious agents compared with human plasma [3]. Rapid correction of intravascular volume is achieved with a small infused volume (4 ml/kg) [1].Recent studies demonstrated immunomodulatory effects of hypertonic saline by blunting neutrophil activation and reducing cytokine production [4,5].Cardiac surgery with cardiopulmonary bypass (CPB) leads to acute changes in the composition and volume of body fluid compartments. CPB dilutes serum proteins, decreases the plasma colloid osmotic pressure and reduces endothelial integrity [6]. This causes fluid shifts from the intravascular to extravascular space and leads to a 33% increase in extravascular fluid space and tissue edema [7]. Complement activation following with systemic inflammatory response syndrome (SIRS
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