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Highly positive intraoperative fluid balance during cardiac surgery is associated with adverse outcome.

UNLABELLED: Hemodilution and increase in capillary permeability occurring with cardiopulmonary bypass (CPB) impose a risk for tissue edema and blood transfusion that may result in an increased complication rate after coronary artery bypass grafting (CABG). Of the 1280 consecutive patients undergoing isolated on-pump CABG, total fluid balance at the end of the operation was less than or equal to 500 mL in 1155 (Group 1) and more than 500 mL in 125 (Group 2). During CPB, blood was added to the reservoir only when the hematocrit fell to 17% or less and crystalloid solution only when the pump flow index fell below 2.0 L/min/m2. Anesthetic, surgical, and postoperative management and diagnoses were the same in all patients, and a single surgical and anesthesia team performed all operations. No patient was excluded from the study. RESULTS: Hypertension, diabetes, chronic obstructive pulmonary disease, New York Heart Association (NYHA) Class III-IV, use of angiotensin converting enzyme (ACE) inhibitors, chronic renal failure, and female gender were the significant preoperative risk factors for increased volume replacement during CPB. The groups were similar in body mass index, preoperative hematocrit values, total fluid balance in the intensive care unit (ICU), and total chest tube output. However, red blood cells' transfusion rate, readmission rate to the ICU and length of hospital stay were significantly higher in Group 2 patients. Multiple logistic regression revealed that age > 70 years (p < 0.001, Odds Ratio (OR): 2, 95% CI: 1.4-2.8), and total fluid balance > 500 mL at the end of the operation (p < 0.01, OR: 2.2, 95% CI: 1.5-3.2) were the predictors of increased length of stay. For transfusion of red blood cells, age > 70 years (p < 0.0001, OR: 2.3, 95% CI: 1.6-3.3), and total fluid balance > 500 mL at the end of the operation (p < 0.001, OR: 2, 95% CI: 1.3-2.9) were the only significant risk factors. This study suggests that intraoperative volume overload increases blood transfusion and length of hospital stay in patients undergoing CABG.

Aged↗

Rational fluid therapy during surgery.

Administration of intravenous fluids during surgery is commonplace, yet there is enormous variation in the type and quantity of fluid given. That so few problems have been encountered is testimony to the body's ability to deal with extreme variations in hydration. A considerable amount of research would be required to achieve a rational approach to fluid balance in every patient; some guidelines can, however, be provided.

Body Fluid Compartments↗

[Impairment of acid-base balance in renal failure].

It is very critical for the living organism to maintain homeostasis of body fluid volume and its electrolyte composition by renal regulation, including acid-base balance. In renal failure, impaired acid-base balance is inescapable because of disturbed urinary acidification, one of the major renal functions. Among all types of acid-base imbalance, metabolic acidosis is a major one in renal failure. For better understanding of this issue, several fundamental items for the renal mechanisms of urinary acidification must be discussed first, and the pathophysiological features and their relevant treatment for acid-base imbalances in renal failure, next. Moreover, some comments on the practical aspects, in long-term dialyze uremic patients, is also provided.

Acid-Base Imbalance↗

Effects of exercise on fluid exchange and body composition in man during 14-day bed rest.

To determine the cause of the body weight loss during bed rest (BR), fluid balance and anthropometric measurements were taken from seven men (19-21 yr) during three 2-wk BR periods which were separated by 3-wk ambulatory recovery periods. Caloric intake was 3,073 +/- 155 (SD) kcal/day. During two of the three BR periods they performed supine isotonic exercise at 68% of VO2max on the ergometer for 1 h/day; or supine isometric exercise at 21% of maximal leg extension force for 1 min followed by a 1-min rest for 1 h/day. No prescribed exercise was given during the other BR period. During BR, body weight decreased slightly with no exercise (-0.43 kg, NS), but decreased significantly (P less than 0.05) by -0.91 kg with isometric and by -1.77 kg with isotonic exercise. About one-third of the weight reduction with isotonic exercise was due to fat loss (-0.69 kg) and, the remainder, to loss of lean body mass (-0.98 kg). It is concluded that the reduction in body weight during bed rest has two major components: First, a loss of lean body mass caused by assumption of the horizontal body position that is independent of the metabolic rate. Second, a loss of body fat content that is proportional to the metabolic rate.

Adult↗

Fluid balance in rats of three different strains after inhibition of histamine catabolism.

The effect of metoprine, an inhibitor of histamine (HA) catabolism, on fluid balance was studied in Wistar (W) and Long-Evans (LE) rats. AVP deficient Brattleboro (BB) rats were used to evaluate which phenomena were AVP-related. W and LE rats were quite different: LE rats were "dry" rats, they drank less, had higher plasma AVP, smaller urine volume and excreted more AVP, and responded less to salt loading and water deprivation. Furthermore, LE and W rats responded differently to metoprine. When water was provided as drinking fluid, metoprine increased water intake and urine flow in W rats, but these changes were not significant in LE rats. In contrast, when the rats drank saline, urine output and saline consumption were similarly decreased in LE and W rats. Although no metoprine-induced changes in plasma AVP were observed, urinary excretion of AVP per 24 h was reduced in metoprine treated rats. Inhibition of HA catabolism by metoprine caused only minor changes in fluid balance of AVP deficient BB rats. The results show that significant differences in fluid balance can exist between rat strains and that increased availability of HA after IP given metoprine strongly affects body fluids in normal rats, especially those of the W strain. The results provide further support to the involvement of HA in the regulation of fluid balance, but to obtain a more complete picture, other factors, such as atrial natriuretic peptide, should be studied.

Animals↗

Salt and fluid balance in newborn infants.

About 5 years ago it was widely thought that preterm infants should be supplemented with extra sodium to avoid hyponatremia. It has, however, to be pointed out that VLBW infants during the first postnatal week run a risk of developing hypernatremia which makes it difficult to give general recommendations for sodium supplementation. Since the serum sodium level depends not only upon the balance between sodium intake and sodium excretion but also upon the water balance which may vary depending on the clinical condition of the baby, it seems advisable to monitor the serum sodium level in all preterm infants. Supplementation should be given in case of hyponatremia. In instances of hyponatremia it also has to be considered if the infant due to positive fluid balance has retained fluid in excess of sodium. As a general conclusion the importance of monitoring sodium balance in every preterm infant should be stressed. Disturbances are most likely to occur in VLBW infants and in infants with acute illnesses. The best way of assisting fluid balance is by repeated accurate measurements of the body weight. It should, however, be kept in ming that no reliable methods are available for the measurement of the body weight of a preterm infant who is under intensive care and who cannot be taken out of the incubator. Serum sodium levels may give information of the sodium balance but it has to be stressed that fluid and sodium balances are always interrelated and that it is desirable to have simultaneous estimations of both balances. Excess retention of fluid may be caused primarily by excess retention of sodium or by fluid.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

Loss of body weight and fat during exercise in a cold chamber.

Ten men spent one week in a cold climatic facility performing a simulated arctic military exercise demanding an energy expenditure of 13-16 MJ-day-1. Although the ration pack was adequate, extensive plate wastage led to a negative energy balance of 2.2 MJ-day-1. Fluid intake was also insufficient, with a 3.25% decrease of body weight, and a 9.7% decrease in skin thickness over the cold exposure. Extensive fat mobilization was indicated by a decrease of skinfold thicknesses, an increase of body density, and associated ketonuria and glycosuria. The fat breakdown far exceeded the calculated energy deficit, and it is postulated that much of the "surplus" energy was required for synthesis of additional muscle protein. In the arctic environment, both energy and fluid balances are better maintained because there are few distraction from the simple pleasure of preparing and eating meals.

Adipose Tissue↗

[Perioperative management of uremia and fluid balance in patients with compromised renal function undergoing open heart surgery].

Five patients with renal dysfunction underwent coronary artery bypass grafting (CABG). Three patients were in cardiogenic shock with acute myocardial infarction for whom CABG was carried out on emergent basis. Immediate preoperatively these patients were in almost anuria which was derived from sustained renal dysfunction plus decreased renal perfusion due to low cardiac output. The other two patients were operated on electively, and hemodynamic instability and artificial perfusion (cardiopulmonary bypass) affected their chronic renal disease (polycystic kidney and nephrosclerosis, respectively) so unfavorably that intraoperative anuria took place. In all patients intraoperative control of fluid balance and prevention of azotemia were accomplished by intraoperative hemofiltration (HF), in which 10 litters of body fluid was filtered out through a hemofiliter incorporated into the cardiopulmonary bypass circuit, and replaced with saline solution. In emergent cases (three patients) complete anuria was sustained and continuous hemodialysis/hemofilitration (CHDF) was successively performed to control water balance and to prevent exacerbation of uremia. Although they all were in profound low cardiac output state necessitating intraaortic balloon counterpulsation (IABP) and infusion of considerable amount of catecholamines, there was no hemodynamic instability occurred throughout the period of CHDF. In four cases renal function recovered significantly along with the recover from their cardiogenic shock so that they could wean from the hemodialysis therapy. In the remaining case intermittent hemodialysis was necessary in chronic phase. There were no hospital death nor late mortality. From this experience we might conclude that the combined use of intraoperative HF and successive postoperative CHDF is an effective method for controlling fluid balance and preventing uremia in cardiac surgical patients with severe renal dysfunction along with considerable hemodynamic instability.

Aged↗

Hyperbaric diuresis at a thermoneutral 31 ATA He-O2 environment.

The basic pattern of body water exchange was studied in four Japanese male divers during exposure to a thermoneutral 31 ATA (He-O2) environment for 3 d (Seadragon V). The hyperbaric chamber temperature was raised from 25 degrees C +/- 0.5 degrees C at 1 ATA (air) predive to 31.5 degrees C +/- 0.3 degrees C at 31 ATA. Both rectal and mean skin temperatures were measured every hour (including during sleep) and were maintained at the same level at both pressures. The exposure to 31 ATA induced an increase in the daily urine flow and a corresponding reduction in the insensible (and evaporative) water loss without changing the total daily water output. However, the daily fluid intake decreased by 600 ml at 31 ATA, and hence the divers developed a state of negative fluid balance, as reflected by a reduction in body weight and an increase in hematocrit. All changes in the pattern of body water exchange observed at 31 ATA were gradually reversed during subsequent decompression. As observed in a previous dive to 31 ATA (Seadragon IV) in which there was a subtle cold stress (as indicated by the 1 degree C reduction in mean skin temperature at 31 ATA), the increase in daily urine flow at pressure was almost entirely due to the increase in overnight urine flow. However, the hyperbaric nocturia observed in the present dive was a water diuresis in nature whereas that in the previous dive was an osmotic diuresis. These results indicate that the hyperbaric diuresis at 31 ATA is due to an increase in overnight urine flow and that the hyperbaric nocturia is not in any way related to the subtle cold stress attendant in many hyperbaric environments.

Adult↗

[Diagnosis of diencephalic disorders. Clinical study on the diagnosis of diencephalic disorders before and after surgery of tumors in the region of the sella and the diencephalon].

The clinical symptomatology of diencephalic disorders is studied in 193 patients operated because of tumors in the sellar region. A new classification of these tumors is established according to the localization and degree of compression of the hypothalamus. The following parameters were examined: body temperature, blood pressure, pulse rate, electrolytes, fluid balance, and serum glucose. In addition, hormonal tests for hypophyseal and diencephalic disorders were carried out. The analysis shows a significant postoperative temperature rise in patients with tumors in the hypothalamic region, depending on the degree of compression of the hypothalamus. There is no relation to histological findings or form of operative approach. Postoperative diabetes insipidus as well as endocrine diencephalic disorders correlate also with the degree of diencephalic lesion. The same results were found with glucose regulation. In contrast, blood pressure, pulse rate, and electrolytes show no differences in the groups tested.

Blood Glucose↗

Modified method of weighing for accurate fluid balance.

The modified method of weighing using an ordinary commercial weighing scale, an empty bottle and an intravenous set was presented. The method measures change in weight by varying the water content in the bottle that the subject carried during the weighing process. The technique was used for the study of evaporative water loss and may be tried in clinical practice when accurate fluid balance is required.

Body Weight↗

The role of albumin in fluid and electrolyte balance.

Albumin plays an important role in maintaining homeostasis within the body and depends on the cell membrane and the transport mechanism, including diffusion, osmosis, filtration, and active transport. The dissolved proteins, which are the only substances that do not penetrate the pores of the capillary membrane, are responsible for the osmotic pressure of the capillary membrane. Approximately 75% of the total colloid osmotic pressure is related to albumin.

Fluid Therapy↗

In vivo total body water assessment by total body electrical conductivity in rats suffering perturbations of water compartment equilibrium.

Total body electrical conductivity (TOBEC) is a simple and non-invasive method for the assessment of body composition in vivo. Information regarding the applicability of TOBEC in the condition of abnormal fluid balance is scarce. In the present paper we give the results of the comparison between TOBEC and total body water (TBW; assessed by the tritium dilution technique) in three groups of animals: (1) healthy (n 17), (2) expanded fluid volume by secondary biliary cirrhosis (SBC; n 9) and (3) Furosemide-treated rats (n 9). The TOBEC score and TBW by tritium dilution were found to be highly correlated in the pooled sample (r 0.90) and in normal (r 0.87), SBC (r 0.73) and Furosemide-treated (r 0.89) rats. However, the relationship between TOBEC and TBW, described by least-squares regression analysis, was found to be similar for SBC and normal rats but was significantly different for Furosemide-treated and normal rats. These findings suggest that TOBEC is unable to track TBW accurately when the ratio between intracellular and extracellular water is chronically or acutely altered.

Animals↗