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PubMed2006

How perioperative fluid balance influences postoperative outcomes.

Fasting, anaesthesia and surgery affect the body's physiological capacity not only to control its external fluid and electrolyte balance but also the internal balance between the various body fluid compartments. Conversely, abnormalities of fluid and electrolyte balance may adversely affect organ function and surgical outcome. Perioperative fluid therapy has a direct bearing on outcome, and prescriptions should be tailored to the needs of the patient. The goal of fluid therapy in the elective setting is to maintain the effective circulatory volume while avoiding interstitial fluid overload whenever possible. Weight gain in elective surgical patients should be minimized in an attempt to achieve a 'zero fluid balance status'. On the other hand, these patients should arrive in the anaesthetic room in a state of normal fluid and electrolyte balance so as to avoid the need to resuscitate fluid-depleted patients in the anaesthetic room or after the induction of anaesthesia. Optimal fluid delivery should be part of an overall care package that involves minimization of the period of preoperative fasting, preoperative carbohydrate loading, thoracic epidural analgesia, avoidance of nasogastric tubes, early mobilization, and early return to oral feeding, as exemplified by the enhanced recovery after surgery programme.

Fluid Therapy↗
PubMed2005

Can bioimpedance determine the volume of distribution of antibiotics in sepsis?

The relationship between the volume of distribution, assessed according to the two-compartmental pharmacokinetic model, and extracellular water estimated by bioimpedance was studied in mechanically ventilated patients with sepsis and capillary leak. A prospective observational study was performed in a twenty-bed general intensive care unit in the university hospital. Patients received either vancomycin (n = 16) or netilmicin (n = 12) for more than 48 hours. Those with ascites, pleural effusion, on renal replacement therapy or with haemodynamic instability were excluded. Serum concentrations of drugs were taken for pharmacokinetic analysis before, 1 hour and 4 hours after the 30 minute infusion. Bioimpedance measurement was performed at the time of the third sampling. The protocol was repeated after 24 hours. Fluid balance during the 24 hour interval was recorded. Extracellular water was increased and represented 45.6 to 46.6% of total body water Fluid balance correlated with the change of extracellular water (r = 0.82, P < 0.0001) and total body water (r = 0.74, P < 0.0001). Volumes of distribution of vancomycin (0.677 +/- 0.339 l/kg) and netilmicin (0.505 +/- 0.172 l/kg) were increased compared to normal values. A correlation was demonstrated between volume of distribution (Vd(area)) of vancomycin and extra cellular water/total body ratio (r = 0.70, P < 0.0001). The central compartment distribution volume (V1) of netilmicin correlated with extracellular water/total body water ratio (r = 0.60, P < 0.003). Serum concentrations above the recommended therapeutic range were detected in 81.2% of patients on vancomycin and in 50% of patients on netilmicin. Increased volumes of distribution can be estimated by the bioimpedance measurements but are not associated with requirements for higher dosage of the glycopeptide or aminoglycoside antibiotics.

Anti-Bacterial Agents↗
PubMed2005

Relation between pH and the strong ion difference (SID) in body fluids.

Acid-base balance evaluation according to the Henderson-Hasselbalch equation enable us to assess the contribution of respiratory (pCO2) and/or non-respiratory (metabolic, HCO3(-)) components to the acid-base balance status. A new approach to acid-base balance evaluation according to Stewart-Fencl, which is based on a detailed physical-chemical analysis of body fluids shows that metabolic acid-base balance disorders are characterized not only by [HCO3(-)]. According to this concept independent variables must be taken into an account. The abnormality of concentration of one or more of the independent variable(s) determines the pH of a solution. The independent variables are: 1. strong ion difference (SID); 2. total concentration of nonvolatile weak acids [A(tot)]; 3. in agreement with the Henderson-Hasselbalch concept also pCO2. Traditional evaluation of acid-base balance disorders is based on the pH of body fluids (though pH may be within normal range if several acid-base balance disturbances are present). In order to maintain this view and simultaneously to respect the Stewart-Fencl principle, we invented a new equation, which uses only the independent variables to define the pH of body fluids. This analysis shows that for a given value of pCO2, the pH of body fluids is determined by a difference between SID and [A(tot)-]. pH = 6.1 + log((SID - [A(tot)-])/(0.03pCO2)) or in itemized form: pH = 6.1 + log((([Na+] + [K+] + [Ca2+] + [Mg2+] - [Cl-] - [UA-]) - (k1[Alb] + k2[P(i)]))/(0.03 x pCO2)). Evaluation of the individual components of this equation enables us to detect, which of the independent variable (or a combination of independent variables) deviates from the normal range and therefore which one or ones is a cause of the acid-base balance disorder. At the end of this paper we give examples of a practical application of this equation.

Acid-Base Equilibrium↗