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Abstract Background Perioperative goal-directed hemodynamic therapy (GDHT) has been advocated in high-risk patients undergoing noncardiac surgery to reduce postoperative morbidity and mortality. We hypothesized that using cardiac index (CI)-guided GDHT in the postoperative period for patients undergoing high-risk surgery for cancer treatment would reduce 30-day mortality and postoperative complications. Methods A randomized, parallel-group, superiority trial was performed in a tertiary oncology hospital. All adult patients undergoing high-risk cancer surgery who required intensive care unit admission were randomly allocated to a CI-guided GDHT group or to a usual care group. In the GDHT group, postoperative therapy aimed at CI ≥ 2.5 L/min/m2 using fluids, inotropes and red blood cells during the first 8 postoperative hours. The primary outcome was a composite endpoint of 30-day all-cause mortality and severe postoperative complications during the hospital stay. A meta-analysis was also conducted including all randomized trials of postoperative GDHT published from 1966 to May 2017. Results A total of 128 patients (64 in each group) were randomized. The primary outcome occurred in 34 patients of the GDHT group and in 28 patients of the usual care group (53.1% vs 43.8%, absolute difference 9.4 (95% CI, − 7.8 to 25.8); p = 0.3). During the 8-h intervention period more patients in the GDHT group received dobutamine when compared to the usual care group (55% vs 16%, p

JUSTIFICATIVA E OBJETIVOS: O hidroxietilamido 130/0,4 (HES 130/0,4) é considerado um expansor plasmático efetivo quando comparado com cristaloides. Há controvérsia sobre sua superioridade em relação à otimização hemodinâmica e sobre possíveis efeitos prejudiciais na coagulação. O objetivo deste estudo foi comparar os efeitos do HES 130/0,4 com os da solução de Ringer lactato durante artroplastia de quadril em pacientes adultos sob raquianestesia e levou em consideração sangramento intraoperatório, parâmetros hemodinâmicos, coagulograma, necessidade de transfusão e desfechos clínicos. MÉTODOS: Neste estudo randômico e controlado, 48 pacientes agendados para artroplastia de quadril com raquianestesia foram alocados em dois grupos: 24 receberam uma pré-carga de HES 130/0,4 (15 mL.kg-1) e 24 receberam uma pré-carga de solução de Ringer lactato (30 mL. kg-1) antes da cirurgia. Mensurações hemodinâmicas, concentração de hemoglobina, parâmetros bioquímicos e testes de coagulação foram avaliados em três períodos durante o procedimento cirúrgico. Os pacientes receberam acompanhamento médico durante a internação e até 30 dias no período pós-operatório. O principal fator foi a necessidade de transfusão de hemácias entre os grupos durante a internação. Os fatores secundários foram parâmetros hemodinâmicos, tempo de internação, mortalidade e ocorrência de complicações clínicas. no período pós-operatório. O principal fator foi a necessidade de transfusão de hemácias entre os grupos durante a internação. Os fatores secundários foram parâmetros hemodinâmicos, tempo de internação, mortalidade e ocorrência de complicações clínicas. RESULTADOS: A transfusão de hemácias foi necessária em 17% dos pacientes do grupo HES e em 46% dos pacientes do grupo Ringer lactato (p = 0,029). Infecções pós-operatórias foram observadas com mais frequência no grupo de Ringer lactato (17%) em comparação com o grupo HES (0), p = 0,037. Não houve diferenças significativas entre os grupos em relação à mortalidade, ao tempo de internação e às complicações clínicas, exceto infecção. CONCLUSÕES: Durante a artroplastia de quadril, os pacientes tratados com hemodiluição hipervolêmica normal com hidroxietilamido 130/0,4 precisaram de menos transfusão e apresentaram índice menor de infecção em comparação com os pacientes que receberam Ringer lactato.JUSTIFICATIVA Y OBJETIVOS: El hidroxietilalmidón 130/0,4 (HES 130/0,4) está considerado como un expansivo plasmático efectivo cuando se le compara con los cristaloides. Existen controversias sobre su superioridad con relación a la optimización hemodinámica y sobre posibles efectos perjudiciales en la coagulación. El objetivo de este estudio, fue comparar los efectos del HES 130/0,4 con los de la solución de lactato de Ringer durante la artroplastia de cadera en pacientes adultos bajo raquianestesia, considerando el sangramiento intraoperatorio, los parámetros hemodinámicos, el coagulograma, la necesidad de transfusión y los resultados clínicos. MÉTODOS: En este estudio aleatorio y controlado, 48 pacientes citados para la artroplastia de cadera con raquianestesia fueron aleatoriamente divididos en dos grupos: 24 pacientes fueron ubicados para recibir una pre-carga de HES 130/0,4 (15 mL.kg-1) y 24 pacientes recibieron una pre-carga de solución de lactato de Ringer (30 mL.kg-1) antes de la cirugía. Las medidas hemodinámicas, concentración de hemoglobina, parámetros bioquímicos y los test de coagulación fueron evaluados en tres períodos durante el procedimiento quirúrgico. Los pacientes recibieron un acompañamiento médico durante el ingreso y de 30 días en el período del postoperatorio. El principal factor fue la necesidad de transfusión de hematíes entre los grupos durante el ingreso. Los factores secundarios fueron los parámetros hemodinámicos, tiempo de ingreso, mortalidad y aparecimiento de complicaciones clínicas. RESULTADOS: La transfusión de hematíes fue necesaria en un 17% de los pacientes del grupo HES y en un 46% de los pacientes del grupo lactato de Ringer (p = 0,029). Las infecciones postoperatorias fueron observadas con más frecuencia en el grupo lactato de Ringer (17%) en comparación con el grupo HES (0), p = 0,037. No hubo diferencias significativas entre los grupos con relación a la mortalidad, tiempo de ingreso y complicaciones clínicas, excepto en la infección. Conclusiones: Durante la artroplastia de cadera, los pacientes tratados con hemodilución hipervolémica normal con hidroxietilalmidón 130/0.4 necesitaron menos transfusión y presentaron un índice menor de infección en comparación con los pacientes que recibieron lactato de Ringer.BACKGROUND AND OBJECTIVES: Hydroxyethyl starch (HES) 130/0.4 is considered an effective plasma expander when compared to crystalloids. There is controversy around its superiority regarding hemodynamic optimization and about possible detrimental effects on coagulation. The aim of this study was to compare the effects of HES 130/0.4 to lactated Ringer solution during hip arthroplasty in adult patients under spinal anesthesia regarding intraoperative bleeding, hemodynamic parameters, coagulation profile, transfusion requirements and clinical outcomes. METHODS: In this randomized, controlled trial, 48 patients scheduled for hip arthroplasty with spinal anesthesia were randomized into two groups: 24 patients were allocated to receive a preload of 15 mL.kg-1 of HES 130/0.4 and 24 patients received a preload of 30 mL.kg-1 lactated Ringer solution before surgery. Hemodynamic measurements, hemoglobin concentrations, biochemical parameters and coagulation tests were evaluated in three periods during surgical procedure. Patients received medical follow-up during their hospital stay and up to postoperative 30 days. Primary outcome was the requirement of red blood cell transfusion between groups during hospital stay. Secondary outcome were hemodynamic parameters, length of hospital stay, mortality and occurrence of clinical postoperative complications. RESULTS: Red blood cell transfusion was required in 17% of patients in the HES group and in 46% in the Ringer group (p = .029). Postoperative infections were more frequently observed in the Ringer group (17%) compared to the HES group (0), p = .037. There were no significant differences between groups in mortality, hospital length of stay and clinical complications other than infection. Conclusions: During hip arthroplasty, patients treated with hypervolemic hemodilution with hydroxyethyl starch 130/0.4 required less transfusion and presented lower infection rate compared to patients who received lactated Ringer.

Background and objectives: Hydroxyethyl starch (HES) 130/0.4 is considered an effective plasma expander when compared to crystalloids. There is controversy around its superiority regarding hemodynamic optimization and about possible detrimental effects on coagulation. The aim of this study was to compare the effects of HES 130/0.4 to lactated Ringer solution during hip arthroplasty in adult patients under spinal anesthesia regarding intraoperative bleeding, hemodynamic parameters, coagulation profile, transfusion requirements and clinical outcomes. Methods: In this randomized, controlled trial, 48 patients scheduled for hip arthroplasty with spinal anesthesia were randomized into two groups: 24 patients were allocated to receive a preload of 15 mL.kg-1 of HES 130/0.4 and 24 patients received a preload of 30 mL.kg-1 lactated Ringer solution before surgery. Hemodynamic measurements, hemoglobin concentrations, biochemical parameters and coagulation tests were evaluated in three periods during surgical procedure. Patients received medical follow-up during their hospital stay and up to postoperative 30 days. Primary outcome was the requirement of red blood cell transfusion between groups during hospital stay. Secondary outcome were hemodynamic parameters, length of hospital stay, mortality and occurrence of clinical postoperative complications. Results: Red blood cell transfusion was required in 17% of patients in the HES group and in 46% in the Ringer group (p = .029). Postoperative infections were more frequently observed in the Ringer group (17%) compared to the HES group (0), p = .037. There were no significant differences between groups in mortality, hospital length of stay and clinical complications other than infection. Conclusions: During hip arthroplasty, patients treated with hypervolemic hemodilution with hydroxyethyl starch 130/0.4 required less transfusion and presented lower infection rate compared to patients who received lactated Ringer. Keywords: Arthroplasty, Replacement, Hip, Anesthesia, Spinal, Blood Transfusion, Hetastarch, Hemodilution

OBJECTIVE: Cancer patients frequently require admission to intensive care unit. However, there are a few data regarding predictive factors for mortality in this group of patients. The aim of this study was to evaluate whether arterial lactate or standard base deficit on admission and after 24 hours can predict mortality for patients with cancer. METHODS: We evaluated 1,129 patients with severe sepsis, septic shock, or postoperative after high-risk surgery. Lactate and standard base deficit collected at admission and after 24 hours were compared between survivors and non-survivors. We evaluated whether these perfusion markers are independent predictors of mortality. RESULTS: There were 854 hospital survivors (76.5%). 24 h lactate .1.9 mmol/L and standard base deficit , -2.3 were independent predictors of intensive care unit mortality. 24 h lactate .1.9 mmol/L and 24 h standard base deficit , -2.3 mmol/Lwere independent predictors of hospital death. CONCLUSION: Our findings suggest that lactate and standard base deficit measurement should be included in the routine assessment of patients with cancer admitted to the intensive care unit with sepsis, septic shock or after highrisk surgery. These markers may be useful in the adequate allocation of resources in this population.