Current opinion in critical care
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Fluid resuscitation is a common intervention in acute medical practice. The optimum fluid for resuscitation remains hotly debated and it is likely to vary from one clinical situation to another. Human albumin solutions have been available since the 1940s, but their use varies greatly around the world. This review examines the current evidence for and against the use of albumin as a resuscitation fluid. ⋯ Fluid resuscitation with albumin is well tolerated and produces similar results to resuscitation with saline. Albumin should be avoided in patients with traumatic brain injury; possible benefits in adults with severe sepsis remain to be confirmed.
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This review explores the contemporary definition of the term 'balanced crystalloid' and outlines optimal design features and their underlying rationale. ⋯ The case for balanced crystalloids is growing but unproven. A large randomized controlled trial of balanced crystalloids versus 0.9% sodium chloride is the next step.
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Using perioperative goal-directed therapy (GDT) or peroperative hemodynamic optimization significantly reduces postoperative complications and risk of death in patients undergoing noncardiac major surgeries. In this review, we discuss the main changes in the field of perioperative optimization over the last few years. ⋯ GDT is safe and more likely to tailor the amount of fluids given to the amount of fluids actually needed. This approach includes assessment of fluid responsiveness and, if necessary, the use of inotropes; moreover, this approach can be coupled with a restrictive strategy for maintenance fluids. These strategies have been increasingly incorporated into protocols for perioperative hemodynamic optimization in high-risk patients undergoing major surgery, resulting in more appropriate use of fluids, vasopressors, and inotropes.
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This review summarizes the current evidence base for commonly transfused blood components with a particular focus on the nonacutely bleeding patient. ⋯ As all blood components have some level of risk, the general approach to transfusion should be one of minimization. For the nonacutely bleeding critically ill patient, a RBC transfusion trigger of 70 g/l is clinically acceptable. For patients at potentially higher risk of adverse effects related to anemia such as those with septic shock, severe and/or acute ischemic heart disease, or brain injury, a higher threshold (80-90 g/l) may be considered. There is insufficient evidence to recommend specific thresholds for transfusion of frozen plasma or platelets in the critically ill.
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To review recent studies and information on the relationship between fluid administration and kidney function in critically ill patients. ⋯ Clinicians need to weigh the balance between adequate resuscitation of cardiac output and avoidance of fluid overload. Protocolized resuscitation to hemodynamic goals may help achieve these conflicting goals at least in the early phases of critical illness. In critically ill patients with, or at risk of, AKI, clinicians should avoid starch and, possibly, saline solutions.