Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2009
ReviewRelevance of albumin in modern critical care medicine.
The relevance of albumin administration in the critical care setting remains controversial. We know that albumin has numerous important physiological effects and many potentially beneficial effects in critical illness. ⋯ Albumin may be useful in some patients, especially those with hypoalbuminaemia at risk of complications or those with liver insufficiency. Further studies are needed to clarify what precise role albumin has in today's ICU.
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Hypovolaemia is a common cause of circulatory failure in the perioperative period. However, only 50% of critically ill patients respond to volume expansion with an adequate increase in cardiac output. ⋯ The concept of fluid responsiveness has been recognized for more than 20 years, and several studies have shown the superiority of these dynamic variables compared to static filling pressures. However, the usefulness of dynamic variables in critically ill patients is limited by several factors that the clinician needs to know for proper interpretation.
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Best Pract Res Clin Anaesthesiol · Jun 2009
ReviewIsotonic and hypertonic crystalloid solutions in the critically ill.
Disorders of fluid and electrolyte balance in the critically ill are volume-related, compositional, or both. Targeting 'normal' values for plasma volume, osmolality and electrolytes might not be optimal in conditions as diverse as intracranial trauma/haemorrhage, hepatic encephalopathy, abdominal hypertension, or major surgery, because a hyperosmolar state seems to favourably affect tissue (brain and intestinal) oedema formation. ⋯ Crystalloid resuscitation is superior to vasopressors in shock associated with blunt trauma, and is at least not inferior to colloids in septic shock. Traditional rules of thumb indicating the need for three to four times the amount of crystalloids for the plasma volume to be replaced are probably erroneous and might have contributed to association of overly aggressive crystalloid resuscitation with poor outcome.
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Peri-operative fluid therapy continues to be an exercise in empiricism, with nagging questions about efficacy and complications. Pharmacokinetics is used for studying the time dependency of administered drugs. ⋯ This could possibly allow for more rational design of intravenous fluid paradigms to improve clinical fluid therapy. This chapter briefly summarizes currently accepted principles of fluid therapy, discusses the general approach to kinetic analysis of fluid therapy, reviews currently available data defining kinetic responses to fluid therapy, and speculates about future applications of this approach.