I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling’s original model of semi-permeable capillaries subject to hydrostatic and oncotic pressure gradients within the extracellular fluid. Fluid therapy to support the circulation relies on applying a physiological paradigm that better explains clinical and research observations. The revised Starling equation based on recent research considers the contributions of the endothelial glycocalyx layer (EGL), the endothelial basement membrane, and the extracellular matrix. The characteristics of capillaries in various tissues are reviewed and some clinical corollaries considered. The oncotic pressure difference across the EGL opposes, but does not reverse, the filtration rate (the ‘no absorption’ rule) and is an important feature of the revised paradigm and highlights the limitations of attempting to prevent or treat oedema by transfusing colloids. Filtered fluid returns to the circulation as lymph. The EGL excludes larger molecules and occupies a substantial volume of the intravascular space and therefore requires a new interpretation of dilution studies of blood volume and the speculation that protection or restoration of the EGL might be an important therapeutic goal. An explanation for the phenomenon of context sensitivity of fluid volume kinetics is offered, and the proposal that crystalloid resuscitation from low capillary pressures is rational. Any potential advantage of plasma or plasma substitutes over crystalloids for volume expansion only manifests itself at higher capillary pressures.
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Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Woodcock TE, Woodcock TM. Br J Anesth 2012, 108 : 384-94
Ishikawa S, Greisdale DEG, Lohser J. Acute kidney injury after lung resection surgery: incidence and perioperative risk factors. Anesth Analg 2012, 114: 1256-62
BACKGROUND: Postoperative acute kidney injury (AKI) is associated with increased perioperative morbidity and mortality in a variety of surgical settings, but has not been well studied after lung resection surgery. In the present study, we defined the incidence of postoperative AKI, identified risk factors, and clarified the relationship between postoperative AKI and outcome in patients undergoing lung resection surgery.
METHODS: A retrospective, observational study of patients who underwent lung resection surgery between January 2006 and March 2010 in a tertiary care academic center was conducted. Postoperative AKI was diagnosed within 72 hours after surgery based on the Acute Kidney Injury Network creatinine criteria. Logistic regression was used to model the association between perioperative factors and the risk of AKI within 72 hours after surgery. The relationship between postoperative AKI and patient outcome including mortality, days in hospital, and the requirement of reintubation was investigated.
RESULTS: A total of 1129 patients (pneumonectomy n = 71, bilobectomy n = 30, lobectomy n = 580, segmentectomy n = 35, wedge resection/bullectomy n = 413) were included in the final analysis. Patients were an average of 61 years (SD 15) and 50% were female. AKI was diagnosed in 67 patients (5.9%) based on Acute Kidney Injury Network criteria (stage 1, n = 59; stage 2, n = 8; and stage 3, n = 0) within 72 hours after surgery, and only 1 patient required renal replacement therapy. Multivariate analysis demonstrated an independent association between postoperative AKI and hypertension (adjusted odds ratio [OR] 2.0, 95% confidence interval [CI]: 1.1-3.8), peripheral vascular disease (OR 4.4, 95% CI: 1.8-10), estimated glomerular filtration rate (OR 0.8, 95% CI: 0.69-0.93), preoperative use of angiotensin II receptor blockers (OR 2.2, 95% CI: 1.1-4.4), intraoperative hydroxyethyl starch administration (OR 1.5, 95% CI: 1.1-2.1), and thoracoscopic (versus open) procedures (OR 0.37, 95% CI: 0.15-0.90). Development of AKI was associated with increased rates of tracheal reintubation (12% vs 2%, P < 0.001), postoperative mechanical ventilation (15% vs 3%, P < 0.001), and prolonged hospital length of stay (10 vs 8 days, P < 0.001). There was no difference in mortality between the 2 groups (3% vs 1%, P = 0.12).
CONCLUSIONS: Preoperative risk factors for AKI after lung resection surgery overlap with those established for other surgical procedures. Perioperative management seems to influence the risk of AKI after lung resection; in particular, the use of synthetic colloids may increase the risk, whereas thoracoscopic procedures may decrease the risk of AKI. Early postoperative AKI is associated with respiratory complications and prolonged hospitalization.