The role of hyperosmolar solutions in the physician’s practice
Background. The goal of infusion therapy (IT) is to maintain central euvolemia without excess sodium and water. The term “restrictive IT”, which allows hypovolemia, should be replaced by the term “IT with a zero balance”. Individualized targeted IT involves monitoring cardiac output, optimizing stroke volume, and preventing episodes of hypovolemia. Less stringent restrictions on preoperative nutrition contribute to better control of hemodynamic parameters.
Objective. To describe the role of hyperosmolar solutions in the physician’s practice.
Materials and methods. Analysis of literature sources on this issue.
Results and discussion. Support of perioperative euvolemia is the basis of the concept of enhanced recovery and improvement of the surgery outcomes. Clinical indices of tissue perfusion adequacy include mean blood pressure, central and abdominal perfusion pressure, diuresis, consciousness level, skin perfusion, lactate and blood pH, etc. Each patient with suspected hypovolemia should be physically examined with an emphasis on searching for bleeding, dehydration, and other causes of hypovolemia. Fluid deficiency should be compensated before surgery. Hyperhydration must also be detected and eliminated timely, as the diagnosis and prediction of pulmonary edema are difficult. There are 4 phases in IT of shock: rescue (achieving blood pressure and cardiac output required for survival), optimization (ensuring sufficient oxygen delivery and lactate control), stabilization (preventing organ dysfunction after achieving hemodynamic stability), and de-escalation (ensuring negative fluid balance). In resuscitation of patients with sepsis and septic shock, the use of hydroxyethyl starch (HES) is not recommended; crystalloids should be preferred over gelatin. If HES were still prescribed, their introduction should be stopped if there are signs of kidney damage or signs of coagulopathy. It is also proposed not to administer hyperoncotic solutions to critically ill patients outside of clinical trials. New colloidal solutions should be introduced into clinical practice only after the establishment of safety for the patient. Following an appeal by HES-manufacturing companies, the Pharmacovigilance and Risk Assessment Committee of the European Medicines Agency stated that HES could be used for massive bleeding at the discretion of the chief physician. Continued use of HES in the postoperative period should be further investigated, including monitoring of renal function for 90 days. In general, the use of HES in clinical practice remains relevant in conditions such as massive bleeding or penetrating trauma, as well as for preloading before regional anesthesia and IT of critical conditions without the risk of bleeding. Modern HES should be used and the dose should not exceed 30 ml/kg. The benefits of preoperative targeted preload optimization using HES are beyond doubt, while recommendations for the overall hazard of these solutions are debatable and inconclusive. The volume of injected solutions should be monitored during IT, as infusion of large volumes of crystalloids may cause pulmonary edema and large volumes of 0.9 % NaCl may lead to the development of hyperchloremic metabolic acidosis. Hypertonic solutions have been shown to be effective in reducing the number of abdominal complications of pancreatoduodenectomy, reducing the length of stay on mechanical ventilation in patients with hemorrhagic shock, and in a number of other interventions. Fluid resuscitation with a small volume of hypertonic saline after damage control operations significantly reduces the length of stay in the intensive care unit, decreases the likelihood of acute respiratory distress syndrome, sepsis and multiple organ failure, reduces 30-day mortality. In patients with brain injuries, hypertonic solutions reduce intracranial pressure and help to balance the fibrinolysis system by reducing secondary brain damage. Unfortunately, most (60 %) of the solutions on the market are unbalanced (Hohn R., 2014). The reasons for this include lower cost of the latter, the lack of understanding of the benefits of alternatives by doctors, the lack of awareness of the seriousness of these solutions’ disadvantages. Due to the risk of acidosis on the background of unbalanced solutions, chloride-restrictive IT should be followed. Hyperosmolar balanced solution Reosorbilact (“Yuria-Pharm”) helps to activate the sympathetic nervous system, which leads to increased blood pressure, decreased diuresis, adrenaline release and increase of circulating blood volume by contracting the spleen. Reosorbilact quickly normalizes hemodynamic parameters, microcirculation, laboratory and biochemical parameters, stabilizes and normalizes the function of external respiration and blood circulation. The use of osmotic drugs Reosorbilact and Xylate (“Yuria-Pharm”) is indicated for plasma volume replacement in hypovolemia of various origins.
Conclusions. 1. Perioperative euvolemia is the main principle of perioperative IT. 2. It is not recommended to use HES in intensive care. 3. HES remain relevant in acute hypovolemia and blood loss. 4. Balanced hyperosmolar solutions (Reosorbilact) are an alternative to HES in the treatment of patients with multiple organ failure in intensive care units.
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