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      Low doses of esmolol and phenylephrine act as diuretics during intravenous anesthesia

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          Abstract

          Introduction

          The renal clearance of infused crystalloid fluid is very low during anaesthesia and surgery, but experiments in conscious sheep indicate that the renal fluid clearance might approach a normal rate when the adrenergic balance is modified.

          Methods

          Sixty females (mean age, 32 years) undergoing laparoscopic gynecological surgery were randomized to control group and received only the conventional anesthetic drugs and 20 ml/kg of lactated Ringer's over 30 mins. The others were also given an infusion of 50 μg/kg/min of esmolol (beta 1-receptor blocker) or 0.01 μg/kg/min of phenylephrine (alpha 1-adrenergic agonist) over 3 hours. The distribution and elimination of infused fluid were studied by volume kinetic analysis based on urinary excretion and blood hemoglobin level.

          Results

          Both drugs significantly increased urinary excretion while heart rate and arterial pressure remained largely unaffected. The urine flows during non-surgery were 43, 147, and 176 ml in the control, esmolol, and phenylephrine groups, respectively (medians, P < 0.03). When surgery had started the corresponding values were 34, 65 and 61 ml ( P < 0.04). At 3 hours, averages of 9%, 20%, and 25% of the infused volume had been excreted in the three groups ( P < 0.01). The kinetic analyses indicated that both treatments slowed down the distribution of fluid from the plasma to the interstitial fluid space, thereby preventing hypovolemia.

          Conclusions

          Esmolol doubled and phenylephrine almost tripled urinary excretion during anesthesia-induced depression of renal fluid clearance.

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          Most cited references 15

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          Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.

          To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. Current fluid administration in major surgery causes a weight increase of 3-6 kg. Complications after colorectal surgery are reported in up to 68% of patients. Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown. We did a randomized observer-blinded multicenter trial. After informed consent was obtained, 172 patients were allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects. The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, P = 0.013) and per-protocol (30% versus 56%, P = 0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, P = 0.007) and tissue-healing complications (16% versus 31%, P = 0.04) were significantly reduced. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P = 0.12). No harmful adverse effects were observed. The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection.
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            Volume kinetics for infusion fluids.

             R Hahn (2010)
            Volume kinetics is a method used for analyzing and simulating the distribution and elimination of infusion fluids. Approximately 50 studies describe the disposition of 0.9% saline, acetated and lactated Ringer's solution, based on repeated measurements of the hemoglobin concentration and (sometimes) the urinary excretion. The slow distribution to the peripheral compartment results in a 50-75% larger plasma dilution during an infusion of crystalloid fluid than would be expected if distribution had been immediate. A drop in the arterial pressure during induction of anesthesia reduces the rate of distribution even further. The renal clearance of the infused fluid during surgery is only 10-20% when compared with that in conscious volunteers. Some of this temporary decrease can be attributed to the anesthesia and probably also to preoperative psychologic stress or dehydration. Crystalloid fluid might be allocated to "nonfunctional" fluid spaces in which it is unavailable for excretion. This amounts to approximately 20-25% during minor (thyroid) surgery.
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              Kinetics of isotonic and hypertonic plasma volume expanders.

               Dan Drobin,  R Hahn (2002)
              Major differences in plasma volume expansion between infusion fluids are fairly well known, but there is a lack of methods that express their dynamic properties. Therefore, a closer description enabled by kinetic modeling is presented. Ten healthy male volunteers received, on different occasions, a constant-rate intravenous infusion over 30 min consisting of 25 ml/kg of 0.9% saline, lactated Ringer's solution, acetated Ringer's solution, 5 ml/kg of 7.5% saline, or 3 ml/kg of 7.5% saline in 6% dextran. One-, two-, and three-volume kinetic models were fitted to the dilution of the total venous hemoglobin concentration over 240 min. Osmotic fluid shifts were considered when hypertonic fluid was infused. All fluids induced plasma dilution, which decreased exponentially after the infusions. The ratio of the area under the dilution-time curve and the infused fluid volume showed the following average plasma-dilution dose-effect (efficiency), using 0.9% saline as the reference (= 1): lactated Ringer's solution, 0.88; acetated Ringer's solution, 0.91; hypertonic saline, 3.97; and hypertonic saline in dextran, 7.22 ("area approach"). Another comparison, based on kinetic analysis and simulation, showed that the strength of the respective fluids to dilute the plasma by 20% within 30 min was 0.94, 0.97, 4.44, and 6.15 ("target dilution approach"). Between-subject variability was approximately half as high for the latter approach. The relative efficiency of crystalloid infusion fluids differs depending on whether the entire dilution-time profile or only the maximum dilution is compared. Kinetic analysis and simulation is a useful tool for the study of such differences.
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                Author and article information

                Journal
                Crit Care
                Crit Care
                Critical Care
                BioMed Central
                1364-8535
                1466-609X
                2012
                30 January 2012
                : 16
                : 1
                : R18
                Affiliations
                [1 ]Department of Anesthesiology, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, 310003 Hangzhou, China
                [2 ]Department of Obstetrics and Gynecology, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, 310003 Hangzhou, China
                [3 ]Zhejiang Hospital, 12 Linying Road, 310013 Hangzhou, China
                [4 ]Yuhuan County People's Hospital, Changle Road, Yuhan County, 317600 Taizhou City, Zhejiang, China
                [5 ]Section for Anesthesia, Linköping University, 581 85 Linköping, Sweden
                Article
                cc11175
                10.1186/cc11175
                3396255
                22289281
                Copyright ©2012 Li et al.; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research

                Emergency medicine & Trauma

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