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BackgroundThe current pilot study compares the impact of an intravenous infusion of Ringer’s lactate to an acetate-based solution with regard to acid–base balance. The study design included the variables of the Stewart approach and focused on the effective strong ion difference. Because adverse hemodynamic effects have been reported when using acetate buffered solutions in hemodialysis, hemodynamics were also evaluated.MethodsTwenty-four women who had undergone abdominal gynecologic surgery and who had received either Ringer’s lactate (Strong Ion Difference 28 mmol/L; n = 12) or an acetate-based solution (Strong Ion Difference 36.8 mmol/L; n = 12) according to an established clinical protocol and its precursor were included in the investigation. After induction of general anesthesia, a set of acid–base variables, hemodynamic values and serum electrolytes was measured three times during the next 120 minutes.ResultsPatients received a mean dose of 4,054 ± 450 ml of either one or the other of the solutions. In terms of mean arterial blood pressure and norepinephrine requirements there were no differences to observe between the study groups. pH and serum HCO3- concentration decreased slightly but significantly only with Ringer’s lactate. In addition, the acetate-based solution kept the plasma effective strong ion difference more stable than Ringer’s lactate.ConclusionsBoth of the solutions provided hemodynamic stability. Concerning consistency of acid base parameters none of the solutions seemed to be inferior, either. Whether the slight advantages observed for the acetate-buffered solution in terms of stability of pH and plasma HCO3- are clinically relevant, needs to be investigated in a larger randomized controlled trial.

Extracorporeal circulation (ECC) is an invaluable tool in lung transplantation (lutx). More than the past years, an increasing number of centers changed their standard for intraoperative ECC from cardiopulmonary bypass (CPB) to extracorporeal membrane oxygenation (ECMO) - with differing results. This meta-analysis reviews the existing evidence. An online literature research on Medline, Embase, and PubMed has been performed. Two persons independently judged the papers using the ACROBAT-NRSI tool of the Cochrane collaboration. Meta-analyses and meta-regressions were used to determine whether veno-arterial ECMO (VA-ECMO) resulted in better outcomes compared with CPB. Six papers - all observational studies without randomization - were included in the analysis. All were considered to have serious bias caused by heparinization as co-intervention. Forest plots showed a beneficial trend of ECMO regarding blood transfusions (packed red blood cells (RBCs) with an average mean difference of -0.46 units [95% CI = -3.72, 2.80], fresh-frozen plasma with an average mean difference of -0.65 units [95% CI = -1.56, 0.25], platelets with an average mean difference of -1.72 units [95% CI = -3.67, 0.23]). Duration of ventilator support with an average mean difference of -2.86 days [95% CI = -11.43, 5.71] and intensive care unit (ICU) length of stay with an average mean difference of -4.79 days [95% CI = -8.17, -1.41] were shorter in ECMO patients. Extracorporeal membrane oxygenation treatment tended to be superior regarding 3 month mortality (odds ratio = 0.46, 95% CI = 0.21-1.02) and 1 year mortality (odds ratio = 0.65, 95% CI = 0.37-1.13). However, only the ICU length of stay reached statistical significance. Meta-regression analyses showed that heterogeneity across studies (sex, year of ECMO implementation, and underlying disease) influenced differences. These data indicate a benefit of the intraoperative use of ECMO as compared with CPB during lung transplant procedures regarding short-term outcome (ICU stay). There was no statistically significant effect regarding blood transfusion needs or long-term outcome. The superiority of ECMO in lutx patients remains to be determined in larger multi-center randomized trials.

OBJECTIVES: Aortic surgery involving hypothermic circulatory arrest (HCA) results in a systemic inflammatory response that may negatively influence outcome. An extracorporeal haemadsorption (HA) device (CytoSorb®) that removes inflammatory triggers may improve haemodynamic and metabolic reactions due to excessive inflammation and, ultimately, outcome. METHODS: As a single-centre experience, the data of 336 patients who had undergone aortic surgery with HCA between 2013 and 2017 were retrospectively analysed. Patients with HA were matched to patients receiving standard therapy without HA (Control) by propensity score matching and compared subsequently. RESULTS: During aortic surgery with HCA, HA significantly reduced the requirement of norepinephrine (HA: 0.102 µg/kg/min; Control: 0.113; P = 0.043). Severe disturbances of acid–base balance as reflected by a pH lower than 7.19 (HA: 7.1%; Control: 11.6%; P = 0.139), maximum lactate concentrations (HA: 3.75 mmol/l; Control: 4.23 P = 0.078) and the need for tris-hydroxymethylaminomethane buffer (HA: 6.5%; Control: 13.7%; P = 0.045) were less frequent with HA. Compared to standard therapy, HA decreased the need for transfusion of packed red blood cells (1 unit; P = 0.021) and fresh frozen plasma (3 units; P = 0.001), but increased the requirement of prothrombin complex concentrate (800 IE, P = 0.0036). HA did not affect inflammatory laboratory markers on the first postoperative day. Differences in operative mortality (HA: 4.8%; Control: 8.8%) and the length of hospital stay (HA: 13.5 days; Control: 14) were not statistically significant. CONCLUSIONS: HA significantly reduces the need for vasopressors, the amount of transfusion and improves acid–base balance in aortic surgery with HCA. Multicentre prospective trials are required to confirm these results.

Background Determination of anticoagulant therapy is of pronounced interest in emergency situations. However, routine tests do not provide sufficient insight. This study was performed to investigate the impact of anticoagulants on the results of viscoelastometric assays using the ClotPro device. Methods This prospective, observational study was conducted in patients receiving dabigatran, factor Xa (FXa)-inhibitors, phenprocoumon, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) (local ethics committee approval number: 17–525-4). Healthy volunteers served as controls. Viscoelastometric assays were performed, including the extrinsic test (EX-test), intrinsic test (IN-test) Russel’s viper venom test (RVV-test), ecarin test (ECA-test), and the tissue plasminogen activator test (TPA-test). Results 70 patients and 10 healthy volunteers were recruited. Clotting time in the EX-test (CTEX-test) was significantly prolonged versus controls by dabigatran, FXa inhibitors and phenprocoumon. CTIN-test was prolonged by dabigatran, FXa inhibitors and UFH. Dabigatran, FXa inhibitors and UFH significantly prolonged CTRVV-test in comparison with controls (median 200, 207 and 289 vs 63 s, respectively; all p < 0.0005). Only dabigatran elicited a significant increase in CTECA-test compared to controls (median 307 vs 73 s; p < 0.0001). CTECA-test correlated strongly with dabigatran plasma concentration (measured by anti-IIa activity; r = 0.9970; p < 0.0001) and provided 100% sensitivity and 100% specificity for detecting dabigatran. Plasma concentrations (anti-XA activity) of FXa inhibitors correlated with CTRVV-test (r = 0.7998; p < 0.0001), and CTRVV-test provided 83% sensitivity and 64% specificity for detecting FXa inhibitors. Conclusions In emergency situations, ClotPro viscoelastometric assessment of whole-blood samples may help towards determining the presence and type of anticoagulant class that a patient is taking. Trial registration German clinical trials database ID: DRKS00015302.