M.F.M. James

Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma)

BACKGROUND The role of fluids in trauma resuscitation is controversial. We compared resuscitation with 0.9% saline vs hydroxyethyl starch, HES 130/0.4, in severe trauma with respect to resuscitation, fluid volume, gastrointestinal recovery, renal function, and blood product requirements. METHODS Randomized, controlled, double-blind study of severely injured patients requiring >3 litres of fluid resuscitation. Blunt and penetrating trauma were randomized separately. Patients were followed up for 30 days. RESULTS A total of 115 patients were randomized; of which, 109 were studied. For patients with penetrating trauma (n=67), the mean (sd) fluid requirements were 5.1 (2.7) litres in the HES group and 7.4 (4.3) litres in the saline group (P<0.001). In blunt trauma (n=42), there was no difference in study fluid requirements, but the HES group required significantly more blood products [packed red blood cell volumes 2943 (1628) vs 1473 (1071) ml, P=0.005] and was more severely injured than the saline group (median injury severity score 29.5 vs 18; P=0.01). Haemodynamic data were similar, but, in the penetrating group, plasma lactate concentrations were lower over the first 4 h (P=0.029) and on day 1 with HES than with saline [2.1 (1.4) vs 3.2 (2.2) mmol litre⁻¹; P=0.017]. There was no difference between any groups in time to recovery of bowel function or mortality. In penetrating trauma, renal injury occurred more frequently in the saline group than the HES group (16% vs 0%; P=0.018). In penetrating trauma, maximum sequential organ function scores were lower with HES than with saline (median 2.4 vs 4.5, P=0.012). No differences were seen in safety measures in the blunt trauma patients. CONCLUSIONS In penetrating trauma, HES provided significantly better lactate clearance and less renal injury than saline. No firm conclusions could be drawn for blunt trauma. STUDY REGISTRATION ISRCTN 42061860.

An audit of anaesthetic record keeping

Summary An audit of anaesthetic records was performed to determine the rate of completion and adequacy of such records. Less than one third of all records was complete and legible. In one quarter of all anaesthetics, no record of any kind was made. The remaining 45% were all incomplete or illegible in some or all respects. It is concluded that the standard of record-keeping in this random sample falls far short of the minimum acceptable standard.

The intubating laryngeal mask produces less heart rate response to intubation than conventional laryngoscopy

We compared heart rate and blood pressure changes to intubation produced by conventional laryngoscopic-guided intubation to those produced by blind intubation through the intubating laryngeal mask (ILM) in normotensive adults with normal airways. Forty paralysed, anaesthetised adults undergoing elective surgery were randomly assigned to one of two groups: 1. Blind intubation through the ILM using a straight silicone tracheal tube manufactured for specific use with the ILM; 2. Intubation with a size 3 macintosh laryngoscope using a polyvinyl chloride tube. Intubation success rate, number of intubation attempts, time to intubation were recorded. Heart rate and non-invasive blood pressure preinduction, preintubation and at one minute intervals after intubation until ten minutes post intubation were recorded. The intubation success rate was 90%(68% first attempt)for the ILM group and 100%(all first attempt) for the laryngoscopic group. Time to successful intubation was longer (50 vs 22s) and more intubation attempts were required in the ILM group (p<0.0001). Changes from pre-intubation values showed a significantly lower heart rate response in the ILM group at 4 to 10 minutes post intubation (p<0.05). The ILM may have a role in managing the intubation response in patients where an increase in heart rate is associated with an increased risk, such as in patients with ischaemic heart disease.

The anion study: effect of different crystalloid solutions on acid base balance, physiology, and survival in a rodent model of acute isovolaemic haemodilution

Background: Commercially available crystalloid solutions used for volume replacement do not exactly match the balance of electrolytes found in plasma. Large volume administration may lead to electrolyte imbalance and potential harm. We hypothesised that haemodilution using solutions containing different anions would result in diverse biochemical effects, particularly on acid‐base status, and different outcomes. Methods: Anaesthetised, fluid‐resuscitated, male Wistar rats underwent isovolaemic haemodilution by removal of 10% blood volume every 15 min, followed by replacement with one of three crystalloid solutions based on acetate, lactate, or chloride. Fluids were administered in a protocolised manner to achieve euvolaemia based on echocardiography‐derived left ventrical volumetric measures. Removed blood was sampled for plasma ions, acid‐base status, haemoglobin, and glucose. This cycle was repeated at 15‐min intervals until death. The primary endpoint was change in plasma bicarbonate within each fluid group. Secondary endpoints included time to death and cardiac function. Results: During haemodilution, chloride‐treated rats showed significantly greater decreases in plasma bicarbonate and strong ion difference levels compared with acetate‐ and lactate‐treated rats. Time to death, total volume of fluid administered: chloride group 56 (3) ml, lactate group 62 (3) ml, and acetate group 65 (3) ml; haemodynamic and tissue oxygenation changes were, however, similar between groups. Conclusions: With progressive haemodilution, resuscitation with a chloride‐based solution induced more acidosis compared with lactate‐ and acetate‐based solutions, but outcomes were similar. No short‐term impact was seen from hyperchloraemia in this model.

A new option in airway management: evaluation of the TotalTrack® video laryngeal mask

Background: The TotalTrack® Video Laryngeal Mask (VLM) is a novel airway management device consisting of a disposable laryngeal mask paired with a reusable video display. Prior to the commencement of this study, there was no published literature on the performance of the TotalTrack®. Methods: The device was evaluated in sixty patients without predictors for difficult airway under general anaesthesia with neuromuscular blockade. Primary outcomes were laryngeal mask seal pressures and success of tracheal intubation through the device. Results: Insertion and ventilation was successful in 98.3% of cases. Median static leak and maximal inflation pressures of the laryngeal mask component were 32 and 40 cmH₂O respectively. Tracheal intubation through the device was successful in 95% of cases, with a mean intubation time of 9.5 s. No gastric insufflation occurred. Haemodynamic variability was found to be clinically insignificant. No significant side-effects were reported. Conclusions: In this initial study, the TotalTrack® VLM was found to be effective as a laryngeal mask airway, exhibiting good sealing pressures. It facilitated predictable, easy intubating conditions under video guidance, with minimal interruption of ventilation.

Evidence-based approach to the use of starch-containing intravenous fluids: an official response by two Western Cape University Hospitals

Circular 114/2013 issued by the Western Cape Pharmacy Services entitled, Suspension of use of infusion solutions containing hydroxyethyl starch at Western Cape Government Health Facilities until further notice, resulted in the the non-availability of starch-containing solutions for clinical use. The reasoning behind the circular was based on the Medicines and Healthcare Products Regulatory Agency (MHRA) class 2 recall of starch solutions and the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee, who stated that: “The benefits of infusion solutions containing hydroxyethyl starch no longer outweigh the risks, and (we) therefore recommend that the marketing authorisations for these medicines are suspended”. The two Western Cape University Hospitals have responded with a joint statement which is presented to SAJAA readers. The statement suggests withdrawals of corn-based starch solutions are based on flawed interpretation of the available data, particularly the suggestion that they cause renal dysfunction. The statement then interrogates why the use of corn-based starch solutions benefits patient care and improves outcome. Lastly, the problems of the alternative therapeutic options are examined. The conclusion reached is that the use of corn-based starch solutions should be reinstated. We believe this well-researched, evidence-based approach is worth publishing to a wider audience.

Balanced colloids in cardiac surgery

Considerable attention has been given to so-called “balanced solutions” (such as Ringer’s lactate, and more recent derivatives) as alternatives to the less physiological “abnormal” 0.9% saline. Colloids prepared in “balanced” electrolyte solutions have also been developed, alongside similar colloids in saline. This is a consequence of the observation that excessive use of saline will result in hyperchloraemic acidosis, which has been identified as a potential side-effect of saline-based solutions. There is debate about the extent of the morbidity associated with this condition, although the risk is probably quite low. It has been suggested that the use of balanced solutions may avoid this effect.

Anaesthesia and unexpected phaeochromocytoma

An unexpected phaeochromocytoma represents one of the most serious events in anaesthesia, and unless well managed, carries a very high mortality. Although the problem is not common, anaesthetists may be faced with an unexpected phaeochromocytoma either in intensive care, or as a complication of almost any surgical procedure. Phaeochromocytoma is frequently undiagnosed as it may present with a bewildering array of symptomatology (Table I) and patients may be normotensive or even hypotensive, depending on the nature and expression of the tumour. Preoperative absence of symptoms does not exclude the diagnosis. Patients may also present with a variety of medical emergencies. The most hazardous presentation is that of phaeochromocytoma multisystem crisis which carries a very high mortality.

The assessment of intravascular volume

There are numerous reasons for the accurate assessment of intravascular fluid volume status. Some of the most often cited are: concerns regarding urine output, considerations for organ and tissue perfusion or even a desire for optimising fluid status, per se. Most practitioners agree that an underlying theme is the goal of attaining optimal cardiac output, either in the surgical setting or in intensive care. Intravenous fluid loading is often used as first line therapy for patients with hypotension or circulatory failure, but cardiac output responds positively after fluid challenge in only half the patients. For the remainder of patients fluid loading may be associated with adverse consequences.

Anaesthesia for Lung Volume Reduction Surgery

natural history of the disease or reduce mortality. Bronchodilators improve lung function, exercise capacity, and quality of life in patients with COPD, but are of limited ben- efit to patients without reversible airway disease. As the medi- cal management of these patients appears to offer only lim- ited benefits, various attempts have been made to improve the quality of life and possibly to reduce mortality through a vari- ety of surgical techniques over the past 90 years including pneumoperitoneum formation, phrenic nerve paralysis, thora- coplasty, denervation of the lung, and stabilization and fixa- tion of the trachea. None of these techniques resulted in any substantial benefit to the patients. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a common condition with high morbidity and mortality rates. 1 The con- dition, which is primarily a complication of smoking, is a chronic, slowly progressive disorder characterised by airway obstruction. 2 The definition includes chronic bronchitis and emphysema with permanent destructive enlargement of distal pulmonary airspaces. Consequently, there is loss of normal lung architecture resulting in loss of elastic recoil of lung tis- sue leading to collapse of small airways, expiratory airflow limitation, air trapping, hyperinflation of the lungs and pro- gressive enlargement of the thoracic cage. Expansion of the thorax leads to flattening of the diaphragm, in-drawing of the lower ribs and compromised chest wall mechanics. The ribs are lifted and flattened leading to increased total lung capac- ity and residual volume, with reduced FEV 1 and increased work of breathing. As the disease progresses, patients must breathe at a higher lung volume to achieve the flows necessary to meet ventilatory requirements. At end-stage disease, the patient is dyspnoeic and has a severely restricted exercise capacity. 3 Once the patient has reached a stage where the FEV 1 < 0.75 L, the 1-year mortality is in the region of 30% 4 and the patient will require frequent hospital admission for treatment of exacer- bations of the condition. Medical management options The goals of therapy in emphysema are to halt the progressive decline in lung function, prevent exacerbations of the disease, improve exercise capacity and quality of life, and prolong sur- vival. The only treatment shown to alter the rate of progres- sion of COPD is cessation of smoking. 5 Exacerbations of dis- ease are treated with antibiotics, steroids, β-adrenergic ago- nists, theophylline, and anticholinergics. Although these in- terventions shorten the duration of individual episodes and minimize symptoms, there is little evidence that they alter the