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Purpose We aimed to compare retrospectively the rates of renal morbidity and mortality in surgical patients receiving 6% HES 130/0.4 to those receiving albumin. Methods From a Japanese nationwide medical database between 2014 and 2016, we identified adults who received HES 130/0.4 (HES group) or albumin (albumin group) as a single colloid solution on the day of surgery. After propensity score matching, the two groups were analyzed with [chi].sup.2 or Mann Whitney U test. The primary outcome was the incidence of acute kidney injury (AKI). Secondary outcomes included the incidence of renal-replacement therapy, hospital length of stay, in-hospital 30-day mortality, the use of vasoactive agents, and the fluid requirement on the day of surgery. Results Of 76,048 patients in the database, propensity score matching identified 289 matched pairs. There was no statistically significant difference in the incidence of AKI between the HES and the albumin group (15.2% vs. 20.8%, respectively: P = 0.08). The secondary outcomes did not differ between groups except the following. Median hospital stay was 5 days shorter in the HES group (18 vs. 23 days; P < 0.001), and the median net fluid requirement on the day of surgery was 15 mL/kg lower in the HES group (140 vs. 155 mL/kg, respectively; P = 0.01). Conclusions Postoperative renal morbidity and mortality did not differ between patients receiving HES 130/0.4 and those receiving albumin. HES 130/0.4 was associated with shorter hospital stay and less fluid requirement compared to albumin. These findings support the use of 6% HES 130/0.4 for perioperative volume replacement as an alternative to albumin. Trial registration UMIN000027896 and the date of registration was June 30, 2017 at https://www.umin.ac.jp/ctr/index-j.html., Author(s): Hideki Miyao [sup.1], Yoshifumi Kotake [sup.2] Author Affiliations: (1) grid.410802.f, 0000 0001 2216 2631, Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, , 1981, Kamoda, 350-8550, Kawagoe, Saitama, [...]

Ringer's ethyl pyruvate solution (REPS) has been protective against experimental renal, intestinal, and spinal ischemia and may be useful for organ protection in major vascular surgery. The purpose of this study was to investigate whether REPS attenuates organ injury in a rabbit model of supraceliac aortic cross-clamp that simulates thoracoabdominal aortic surgery. Following the Institutional Animal Care and Use Committee's approval, 20 rabbits were undergone cross-clamping of the supraceliac thoracic aorta for 30 min, and observed for 180 min after reperfusion. Either REPS (33 mg/kg/h of ethyl pyruvate) or Ringer's lactate solution were infused throughout the study period. Arterial pressure and aortic blood flow were continuously monitored. Blood lactate concentration, serum transaminase levels, neutrophil activation, and urinary N-acetyl-beta-glucosaminidase (NAG) activity were evaluated. After reperfusion, supraceliac aortic blood flow was significantly higher, and urinary NAG was significantly lower in animals that received REPS, while the other parameters were not significantly different. In conclusion, REPS attenuated the reduction of aortic blood flow and urinary NAG elevation after the cross-clamp of supraceliac aorta., Author(s): Takashige Yamada [sup.1], Daisuke Nishimura [sup.1], Kei Inoue [sup.1], Jungo Kato [sup.1], Hiroshi Morisaki [sup.1], Yoshifumi Kotake [sup.1] [sup.2] Author Affiliations: (1) grid.26091.3c, 0000 0004 1936 9959, Department of [...]

Background Both anesthetic-induced and ischemic preconditioning are protective against hepatic ischemia-reperfusion injury. However, the effects of these preventive methods on the metabolic function remain to be elucidated. We investigated the anesthetic conditioning and ischemic preconditioning on the metabolic function of the rabbit model of hepatic ischemia-reperfusion. Methods After approval by the institutional animal care and use committee, 36 Japanese White rabbits underwent partial hepatic ischemia for 90 min either under sevoflurane or propofol anesthesia. All the rabbits underwent 90 min of hepatic ischemia, and half of the rabbits in each group underwent additional 10-min ischemia and 10-min reperfusion before index ischemia. Hepatic microvascular blood flow was intermittently measured during reperfusion period, and galactose clearance, serum aminotransferase activities, and lactate concentrations were determined 180 min after reperfusion. Results Neither anesthetic conditioning with sevoflurane nor ischemic preconditioning altered hepatic microvascular blood flow during reperfusion and serum transaminase activities after reperfusion. However, galactose clearance of reperfused liver was significantly higher under sevoflurane anesthesia than propofol (0.016 ± 0.005/min vs. 0.011 ± 0.004/min). Statistically significant interaction between anesthetic choice and application of ischemic preconditioning suggests that the ischemic preconditioning is selectively protective under propofol anesthesia. Increase of blood lactate concentration was significantly suppressed under sevoflurane anesthesia compared to propofol (1.5 ± 0.8 vs. 3.9 ± 1.4 mmol/l) without any statistically significant interaction with the application of ischemic preconditioning. Conclusion Sevoflurane attenuated the decrease of galactose clearance and increase of the blood lactate after reperfusion compared to propofol. Application of ischemic preconditioning was significantly protective under propofol anesthesia., Author(s): Takashige Yamada [sup.1] , Hiromasa Nagata [sup.1] , Shizuko Kosugi [sup.1] , Takeshi Suzuki [sup.1] , Hiroshi Morisaki [sup.1] , Yoshifumi Kotake [sup.1] [sup.2] Author Affiliations: (Aff1) 0000 0004 [...]

Purpose The purpose of this prospective, observational study was to respiratory variation of stroke volume (stroke volume variation, SVV) against central venous pressure (CVP) and pulmonary artery diastolic pressure (PADP) as an estimate of right and left ventricular preload. Methods With IRB approval and informed consent, 31 patients undergoing living related renal transplantation were analyzed. Under general anesthesia with positive pressure ventilation, stroke volume index and SVV were continuously monitored with FloTrac/Vigileo monitor. Right ventricular end-diastolic volume index (RVEDVI) as well as CVP and PADP were continuously monitored with volumetric pulmonary artery catheter. Data of every 30 min interval were used for analysis. The relationship between RVEDVI and CVP, PADP, SVV was analyzed with non-linear regression and the goodness-of-fit was assessed with coefficient of determination ([R.sup.2]) of each regression curve. The ability of CVP, PADP and SVV to correctly differentiate RVEDVI 138 ml/ [m.sup.2], which were used to guide fluid administration, was also assessed with ROC analysis. Results Three hundred forty-eight data sets were obtained and analyzed. The goodness of fit between RVEDVI and SVV ([R.sup.2] = 0.48) was better than that between RVEDVI and CVP or PADP ([R.sup.2] = 0.19 and 0.33, respectively). The area under the ROC curve of SVV was significantly high compared to CVP or PADP. Conclusions This study confirmed the theoretical framework of right ventricular preload and ventricular filling pressure and respiratory variation of stroke volume. The result also suggests that SVV can correctly predict preload status compared to pressure-based indices. Keywords Preload responsiveness * Dynamic parameter * Static parameter * Right ventricular end-diastolic volume * Renal transplantation, Introduction Conventionally, pressure-based static parameter such as central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) has been used to guide fluid therapy. However, the validity of CVP and [...]

The purpose of this prospective study was to evaluate the accuracy and trending ability of a four-wavelength pulse-total hemoglobinometer that continuously and noninvasively measures hemoglobin in surgical patients. With IRB approval and informed consent, spectrophotometric hemoglobin (SpHb) was measured with a pulse-total hemoglobinometer manufactured by Nihon Kohden Corp (Tokyo, Japan) and compared to the CO-oximeter equipped with blood gas analyzer. Two hundred twenty-five samples from 56 subjects underwent analysis. Bland-Altman analysis revealed that the bias ± precision of the current technology was 0.0 ± 1.4 g/dl and -0.2 ± 1.3 g/dl for total samples and samples with 8 < Hb < 11 g/dl, respectively. The percentages of samples with intermediate risk of therapeutic error in error grid analysis and the concordance rate of 4-quadrant trending assay was 17% and 77%, respectively. The Cohen kappa statistic for Hb < 10 g/dl was 0.38, suggesting that the agreement between SpHb and CO-oximeter-derived Hb was fair. Collectively, wide limits of agreement, especially at the critical level of hemoglobin, and less than moderate agreement against CO-oximeter-derived hemoglobin preclude the use of the pulse-total hemoglobinometer as a decision-making tool for transfusion. Keywords Hemoglobin * Spectrophotometric * Pulse oximeter, The determination of hemoglobin (Hb) concentration is an essential test to initiate or withhold blood transfusion during the perioperative period. Traditionally, it has been measured intermittently with a CO-oximeter in [...]

Background This prospective observational study compared the volume effect between hydroxyethyl starch (HES) and crystalloid solution and its context dependency in intraoperative goal-directed fluid management. Methods With institutional review board (IRB) approval, 35 patients undergoing major gastrointestinal surgery were enrolled. Fluid challenge consisting of 250 ml of either bicarbonate Ringer solution (BRS) or low molecular weight pentastarch (HES 70/0.5) was given to maintain stroke volume index >35 ml/[m.sup.2]. The context of fluid challenge was classified as related to either epidural block (EB) or blood loss (BL) or as nonspecific. The primary end point was the interval between index fluid challenge and the next fluid challenge, and the secondary end point was the hemodynamic parameter at the end of fluid challenge. Differences in these parameters in each clinical context were compared between BRS and HES 70/0.5. A p value Keywords Goal-directed fluid management * Hydroxyethyl starch * Crystalloid * Stroke volume * Gastrointestinal surgery, Introduction Goal-directed fluid management is recommended to facilitate early recovery after surgery [1, 2]. Although not explicitly defined, it consists of a combination of restrictive crystalloid administration and fluid challenge [...]

Purpose Atrial natriuretic peptide (ANP) has been known to be protective against hepatic ischemia/reperfusion injury. The purpose of this study was to verify the hypothesis that ANP conserves microvascular circulation and reduces ischemia-reperfusion injury in the in vivo rabbit model. Methods With IRB approval, 30 male Japanese white rabbits under pentobarbital anesthesia were studied. These animals were randomly assigned to the following three groups (n = 10 each): control, ANP, and sham group. Animals in the ANP group received continuous infusion of ANP at 0.1 µg/kg/min throughout the study period. Animals in control and ANP groups underwent 90 min of partial hepatic ischemia by clamping the right hepatic artery and portal vein. Descending aortic blood flow (AoF) was monitored with a transit-time ultrasound flowmeter. Hepatic tissue microvascular blood flow (HTBF) at both right (ischemic) and left (nonischemic) lobe was intermittently evaluated with the hydrogen clearance method. After 180 min of reperfusion, hepatic injury was determined with serum AST and ALT. Galactose clearance of reperfused right lobe was also measured as an indicator of hepatic metabolic function. Histopathological change and the number of apoptotic hepatocytes were also evaluated. Results Systemic hemodynamic data including mean arterial pressure, heart rate, and AoF did not differ among the three groups during the study period. ANP attenuated ischemia-induced right HTBF decrease. ANP also suppressed histopathological degeneration, apoptosis, and decline in galactose clearance after reperfusion. Conclusions ANP attenuated hepatic microvascular dysfunction and hepatocyte injury after reperfusion without significant hemodynamic change. Keywords Atrial natriuretic peptide * Ischemia-reperfusion * Liver injury * Tissue microvascular blood flow, Introduction Attenuation or prevention of hepatic ischemia-reperfusion injury is an important clinical challenge in several settings such as liver surgery, liver transplantation, and shock state. The liver has several unique [...]

Enhancement of the endotoxin recognition pathway by ventilation with a large tidal volume in rabbits. Am J Physiol Lung Cell Mol Physiol 286:L1114-L1121, 2004. First published November 2l, 2003; 10.1152/ajplung.00296.2003.--Ventilation with a small tidal volume ([V.sub.t]) is associated with better clinical outcomes than with a large [V.sub.t], particularly in critical settings, including acute lung injury. To determine whether [V.sub.t] influences the lipopolysaccaharide (LPS) recognition pathway, we studied CD 14 expression in rabbit lungs and the release of TNF-[alpha] by cultured alveolar macrophages after 240 min of ventilation with a large (20 ml/kg) vs. a small (5 ml/kg) [V.sub.t]. We also applied small or large [V.sub.t] to lungs instilled with 50 [micro]g/kg of LPS. The alveolar macrophages collected after large V, ventilation revealed a 20-fold increase in LPS-induced TNF-[alpha] release compared with those collected after small [V.sub.t] ventilation, whereas TNF-[alpha] was undetectable without LPS stimulation. In animals ventilated with a large [V.sub.t], the expression of CD14 mRNA in whole lung homogenates and the expression of CD14 protein on alveolar macrophages, assessed by immunohistochemistry, were both significantly increased in the absence of LPS stimulation. A large [V.sub.t] applied to LPS-instilled lungs increased the pulmonary albumin permeability and TNF-[alpha] release into the plasma. These results suggest that mechanical stress caused by a large [V.sub.t] sensitizes the lungs to endotoxin, a phenomenon that may occur partially via the upregulation of CD14. acute lung injury; ventilator-induced lung injury