• BIOCHEMISTRY
• Chemistry, Clinical
• Diagnostic Techniques and Procedures
• Evidence-Based Practice

• Humans
• Acid-Base Imbalance/diagnosis
• Acid-Base Imbalance/therapy
• Acid-Base Imbalance/blood
• Blood Gas Analysis
• Diagnostic Errors/prevention & control
• Acid-Base Equilibrium

• blood volume
• cardiac load-responsiveness
• centrifugal pump
• veno-arterial extracorporeal life support
• venous drainage

• Humans
• Male
• Extracorporeal Membrane Oxygenation/methods
• Female
• Middle Aged
• Adult
• Echocardiography, Transesophageal/methods
• Aged

• Adult
• Humans
• Creatinine
• Brazil/epidemiology
• Hospital Mortality
• Hospitalization
• Hypotension

• VT ablation
• electroencephalogram (EEG)
• near-infrared spectroscopy (NIRS)
• non invasive neurological monitoring
• percutaneous left ventricular assist device (pLVAD)
• ventricular tachycardia (VT)

• Acetate
• Balanced crystalloids
• Chloride load
• Normal saline

Even though crystalloids are the first choice for fluid resuscitation in hemodynamically unstable patients, their potency as plasma volume expanders in hypovolemia of different etiologies is largely unknown. The objective of the study was to investigate dose–response curves of a crystalloid in hypovolemia induced by either sepsis or hemorrhagic shock.

Rats were randomized to resuscitation with Ringers acetate at a dose 10, 30, 50, 75, or 100 ml/kg at 4 h after induction of sepsis by cecal ligation and puncture (CLP) or 2.5 h after a 30 ml/kg hemorrhage. Plasma volume (¹²⁵I–albumin) was the primary outcome. Plasma volume decreased by about 11.8 (IQR 9.9–14.5) ml/kg relative baseline after CLP and increased dose-dependently by at most 5.8 (IQR 3.3–7.0) ml/kg in the 100 ml/kg group at 15 min after resuscitation. In the hemorrhage group, the plasma volume increased by at most 13.8 (IQR 7.1–15.0) ml/kg in 100 ml/kg group. Blood volumes at baseline, calculated using hematocrit and plasma volumes, were 72.4 (IQR 68.2–79.5) ml/kg in sepsis group and 71.1 (IQR 69.1–74.7) ml/kg in hemorrhage group. At 15 min after resuscitation with a dose of 100 ml/kg blood volumes increased to 54.8 (IQR 52.5–57.7) ml/kg and ; 49.6 (IQR 45.3–56.4) ml/kg, in the sepsis and hemorrhage groups, respectively. Plasma volume expansion as the percentage of dose at 15 min was 5.9 (IQR 2.5–8.8)% and 14.5 (IQR 12.1–20.0)% in the sepsis and hemorrhage groups, respectively. At 60 min, average plasma volume as the percentage of dose had decreased to 2.9 (IQR ([−2.9] − 8.3)% (P = 0.006) in the sepsis group whereas no change was detected in the hemorrhage group. A dose-dependent decrease in the plasma oncotic pressure, which was more marked in sepsis, was detected at 60 min after resuscitation.

We conclude that the efficacy of Ringers acetate as a plasma volume expander is context dependent and that plasma volume expansion is lower than previously realized across a wide range of doses. Ringers acetate decreases plasma oncotic pressure in sepsis, in part, by mechanisms other than dilution.

• Crystalloid
• Dose–response
• Hemorrhage
• Inflammation
• Plasma volume
• Sepsis

• Acid-base balance
• Base replacement
• Fluid therapy
• Metabolic acidosis
• Physiology

• Acid-Base Equilibrium/drug effects
• Acidosis/veterinary
• Animals
• Crystalloid Solutions
• Fluid Therapy/veterinary
• Hydrogen-Ion Concentration
• Infusions, Intravenous/veterinary
• Isotonic Solutions/administration & dosage
• Isotonic Solutions/pharmacology

Fluid administration in critically ill patients may affect acid-base balance. However, the effect of the fluid type used for resuscitation on acid-base balance remains controversial.

We studied the effect of fluid resuscitation of normal saline and the colloids gelatine 4%, hydroxyethyl starch (HES) 6%, and albumin 5% on acid-base balance in 115 clinically hypovolemic critically ill patients during a 90 minute filling pressure-guided fluid challenge by a post-hoc analysis of a prospective randomized clinical trial.

About 1700 mL was infused per patient in the saline and 1500 mL in each of the colloid groups (P<0.001). Overall, fluid loading slightly decreased pH (P<0.001) and there was no intergroup difference. This mildly metabolic acidifying effect was caused by a small increase in chloride concentration and decrease in strong ion difference in the saline- and HES-, and an increase in (uncorrected) anion gap in gelatine- and albumin-loaded patients, independent of lactate concentrations.

In clinically hypovolemic, critically ill patients, fluid resuscitation by only 1500–1700 mL of normal saline, gelatine, HES or albumin, resulted in a small decrease in pH, irrespective of the type of fluid used. Therefore, a progressive metabolic acidosis, even with increased anion gap, should not be erroneously attributed to insufficient fluid resuscitation.

ISRCTN Registry ISRCTN19023197

• Albumins/therapeutic use
• Critical Illness/therapy
• Female
• Fluid Therapy/methods
• Gelatin/therapeutic use
• Humans
• Hydrogen-Ion Concentration
• Hydroxyethyl Starch Derivatives/therapeutic use
• Male
• Middle Aged
• Sodium Chloride/therapeutic use

• B. Braun Melsungen

• Acetate
• Acetate buffered
• Crystalloid
• Infusion therapy
• Lactate buffered
• Normal saline

AIM: To evaluate donation after circulatory death (DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy (HC) and patient/graft survival] and donor risk-conditions.

METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS DonorNet included preoperative systolic and diastolic blood pressure, heart rate, pH, SpO₂, PaO₂, FiO₂, and hemoglobin. Mean arterial blood pressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O₂ content was computed as [hemoglobin (gm/dL) × 1.37 (mL O₂/gm) × SpO₂%) + (0.003 × PaO₂)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mmHg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was (ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.

RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age (33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion (9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin (10.7 ± 2.2 gm/dL vs 12.3 ± 2.1 gm/dL, P = 0.017), lower preoperative arterial oxygen content (14.8 ± 2.8 mL O₂/100 mL blood vs 16.8 ± 3.3 mL O₂/100 mL blood, P = 0.049), greater hypoxia score >2.0 (69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure (92.7 ± 16.2 mmHg vs 83.8 ± 18.5 mmHg, P = 0.10). HC was independently associated with age, multi-pressor/red-cell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure (r² = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2 (7.1/year)], compared to our early experience [era 1 (2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1 (P = 0.03). Era 2 donors had longer times for extubation-to-asystole (14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia (13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia (16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate (73.1% vs 28.6%, P = 0.006).

CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.

• Orthotopic liver transplantation
• Ischemic cholangiopathy
• Hypoxic cholangiopathy
• Donation after circulatory death
• Biliary complications
• Reperfusion injury

• Adolescent
• Adult
• Airway Extubation/adverse effects
• Airway Extubation/mortality
• Biomarkers/metabolism
• Cause of Death
• Child
• Cholestasis/diagnosis
• Cholestasis/etiology
• Cholestasis/mortality
• Cholestasis/surgery
• Donor Selection
• Erythrocyte Transfusion
• Female
• Graft Survival
• Hemoglobins/metabolism
• Humans
• Hypoxia/blood
• Hypoxia/etiology
• Hypoxia/mortality
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Liver Transplantation/mortality
• Male
• Middle Aged
• Oxygen Inhalation Therapy/adverse effects
• Oxygen Inhalation Therapy/mortality
• Reoperation
• Retrospective Studies
• Risk Factors
• Shock/blood
• Shock/mortality
• Shock/physiopathology
• Shock/therapy
• Time Factors
• Tissue Donors
• Treatment Outcome
• Young Adult

• Central venous pressure
• Point-of-care ultrasound
• inferior vena cava collapsibility index
• intravascular volume status assessment
• intravenous fluid bolus

• abl, acute blood loss
• bp, blood pressure
• dm, diabetes mellitus
• dss, dextran sulfate sodium

• Acute Disease
• Animals
• Dextran Sulfate/administration & dosage
• Diabetes Mellitus, Experimental/blood
• Diabetes Mellitus, Experimental/diagnosis
• Female
• Fluid Therapy
• Hemorrhage/physiopathology
• Male
• Mice
• Mice, Inbred C57BL

Microcirculation and macrohemodynamics are severely compromised during septic shock. However, the relationship between these two compartments needs to be further investigated. We hypothesized that early resuscitation restores left ventricular (LV) performance and microcirculatory function but fails to prevent metabolic disorders. We studied the effects of an early resuscitation protocol (ERP) on LV pressure/volume loops-derived parameters, sublingual microcirculation, and metabolic alterations during endotoxic shock.

Twenty-five pigs were randomized into three groups: LPS group: Escherichia coli lipopolysaccharide (LPS); ERP group: LPS + ERP based on volume expansion, dobutamine, and noradrenaline infusion; Sham group. LV pressure/volume-derived parameters, systemic hemodynamics, sublingual microcirculation, and metabolic profile were assessed at baseline and after completing the resuscitation protocol.

LPS significantly decreased LV end-diastolic volume, myocardial contractility, stroke work, and cardiac index (CI). Early resuscitation preserved preload, and myocardial contractility, increased CI and heart rate (p < .05). LPS severely diminished sublingual microvascular flow index (MFI), perfused vascular density (PVD), and the proportion of perfused vessels (PPV), while increased the heterogeneity flow index (HFI) (p < .05). Despite MFI was relatively preserved, MVD, PVD, and HFI were significantly impaired after resuscitation (p < .05). The macro- and microcirculatory changes were associated with increased lactic acidosis and mixed venous O₂ saturation when compared to baseline values (p < .05). The scatter plot between mean arterial pressure (MAP) and MFI showed a biphasic relationship, suggesting that the values were within the limits of microvascular autoregulation when MAP was above 71 ± 6 mm Hg (R² = 0.63).

Early hemodynamic resuscitation was effective to restore macrohemodynamia and myocardial contractility. Despite MAP and MFI were relatively preserved, the persistent microvascular dysfunction could explain metabolic disorders. The relationship between micro- and systemic hemodynamia and their impact on cellular function and metabolism needs to be further studied during endotoxic shock.

The online version of this article (doi:10.1186/s40635-015-0049-y) contains supplementary material, which is available to authorized users.

• CGRP
• Cirrhosis
• Color Doppler ultrasound technique
• ET-1
• Venous hemodynamics

• blood loss
• blood pressure
• cardiac output
• central hypovolemia
• central venous pressure
• stroke volume