Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy

Published on Mar 1, 2012in BJA: British Journal of Anaesthesia9.166
路 DOI :10.1093/BJA/AER515
Tom Woodcock12
Estimated H-index: 12
(University of Southampton),
Thomas M. Woodcock3
Estimated H-index: 3
(Australian School of Advanced Medicine)
Summary I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling's original model of semi-permeable capillaries subject to hydrostatic and oncotic pressure gradients within the extracellular fluid. Fluid therapy to support the circulation relies on applying a physiological paradigm that better explains clinical and research observations. The revised Starling equation based on recent research considers the contributions of the endothelial glycocalyx layer (EGL), the endothelial basement membrane, and the extracellular matrix. The characteristics of capillaries in various tissues are reviewed and some clinical corollaries considered. The oncotic pressure difference across the EGL opposes, but does not reverse, the filtration rate (the 鈥榥o absorption' rule) and is an important feature of the revised paradigm and highlights the limitations of attempting to prevent or treat oedema by transfusing colloids. Filtered fluid returns to the circulation as lymph. The EGL excludes larger molecules and occupies a substantial volume of the intravascular space and therefore requires a new interpretation of dilution studies of blood volume and the speculation that protection or restoration of the EGL might be an important therapeutic goal. An explanation for the phenomenon of context sensitivity of fluid volume kinetics is offered, and the proposal that crystalloid resuscitation from low capillary pressures is rational. Any potential advantage of plasma or plasma substitutes over crystalloids for volume expansion only manifests itself at higher capillary pressures.
Figures & Tables
馃摉 Papers frequently viewed together
5 Authors (Daniel Chappell, ..., Markus Rehm)
#1Michael F. M. James (UCT: University of Cape Town)H-Index: 41
#2W L Michell (UCT: University of Cape Town)H-Index: 2
Last. Rencia Gillespie (UCT: University of Cape Town)H-Index: 4
view all 6 authors...
Background The role of fluids in trauma resuscitation is controversial. We compared resuscitation with 0.9% saline vs hydroxyethyl starch, HES 130/0.4, in severe trauma with respect to resuscitation, fluid volume, gastrointestinal recovery, renal function, and blood product requirements. Methods Randomized, controlled, double-blind study of severely injured patients requiring>3 litres of fluid resuscitation. Blunt and penetrating trauma were randomized separately. Patients were followed up for 3...
#1Thorsten Annecke (LMU: Ludwig Maximilian University of Munich)H-Index: 16
#2J. Fischer (LMU: Ludwig Maximilian University of Munich)H-Index: 2
Last. Bernhard F. Becker (LMU: Ludwig Maximilian University of Munich)H-Index: 65
view all 8 authors...
Background Vascular endothelium is covered by a glycocalyx. Damage to the glycocalyx after systemic inflammation or ischaemia/reperfusion contributes to increased vascular permeability and leucocyte adhesion. The underlying mechanisms leading to ischaemia/reperfusion-induced glycocalyx shedding are incompletely understood, in terms of lack of oxygen, absence of flow, or return of oxygen. Methods Isolated guinea pig hearts perfused with Krebs鈥揌enseleit buffer at 37掳C underwent 20 min of either st...
#2David Rogerson (Royal Derby Hospital)H-Index: 10
Summary The objective of this review was to determine the optimal type or class of intravenous fluid to be used during peri-operative patient optimisation guided by oesophageal Doppler monitoring and to identify future directions for research. We undertook a literature review of patients undergoing major (general, colorectal, orthopaedic and urological) surgery, whose fluid therapy was managed using peri-operative oesophageal Doppler monitoring. We identified 10 studies that included 891 randomi...
#1Daniel Chappell (LMU: Ludwig Maximilian University of Munich)H-Index: 41
#2Bernhard HeindlH-Index: 19
Last. Bernhard F. BeckerH-Index: 65
view all 8 authors...
BACKGROUND: Adhesion of polymorphonuclear neutrophils and platelets to the vessel wall contributes to generating ischemia-reperfusion injury. Endothelial adhesion molecules are harbored within the glycocalyx, which covers every healthy vascular endothelium but is deteriorated by ischemia-reperfusion. Pretreating the heart with volatile anesthetics reduces myocardial infarct size and protects against ischemia-reperfusion injury. The authors analyzed a possible protective effect of sevoflurane on ...
#1P盲r I. Johansson (Copenhagen University Hospital)H-Index: 67
#2Jakob StensballeH-Index: 34
Last. Sisse R. OstrowskiH-Index: 53
view all 4 authors...
OBJECTIVE: To investigate the association between markers of acute endothelial glycocalyx degradation, inflammation, coagulopathy, and mortality after trauma. BACKGROUND: Hyperinflammation and acute coagulopathy of trauma predict increased mortality. High catecholamine levels can directly damage the endothelium and may be associated with enhanced endothelial glycocalyx degradation, evidenced by high circulating syndecan-1. METHODS: Prospective cohort study of trauma patients admitted to a Level ...
#1Dimos Karangelis (UTH: University of Thessaly)H-Index: 10
#2Athanasia P. Asimakopoulou (University of Patras)H-Index: 8
Last. Nikos K. Karamanos (University of Patras)H-Index: 62
view all 8 authors...
Glycosaminoglycans (GAGs) are functionally important molecules of the arterial wall and play a crucial role in atherogenesis. Chondroitin sulfate/dermatan sulfate proteoglycans (CS/DSPGs) participate in several biological events through their GAG chains, and are also involved in the development of atherosclerosis. The aim of this study was to compare the pre- and post-operative levels of CS in serum of patients after coronary artery bypass graft surgery using a highly sensitive reversed-polarity...
Fluid resuscitation is a fundamental intervention in the treatment of critically ill patients. However, there is little conclusive evidence to guide clinicians about the best type of resuscitation fluid; the appropriate timing, volume, and rate of fluid administration; and the optimal way to adequately monitor the efficacy and safety of fluid resuscitation in various clinical conditions.1 Although the complications associated with excessive volume of resuscitation fluid 鈥 such as pulmonary and i...
#1Kathryn Maitland (Kenya Medical Research Institute)H-Index: 58
#2Sarah Kiguli (Suffolk University)H-Index: 12
Last. Diana M. GibbH-Index: 63
view all 18 authors...
Methods We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml of 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania (stratum A); children with severe hypotension were randomly assigned to one of the bolus groups only (stratum B). All children received appropriate antimicrobial ...
#1Eun-Ho Lee (UOU: University of Ulsan)H-Index: 17
#2Ji-Hyun Chin (UOU: University of Ulsan)H-Index: 15
Last. In-Cheol Choi (UOU: University of Ulsan)H-Index: 14
view all 8 authors...
Objective The authors aimed to investigate whether immediate postoperative hypoalbuminemia could be associated with outcomes after off-pump coronary artery bypass graft (OPCAB) surgery. Design A retrospective analysis of the medical data. Setting Cardiac operating room and adult cardiovascular intensive care unit at a single institution. Participants Six hundred ninety adult patients underwent elective OPCAB surgery over a 30-month period. Interventions None. Measurements and Main Results To eva...
#1Cade Ja (Royal Melbourne Hospital)H-Index: 1
#2Truesdale M (Royal Melbourne Hospital)H-Index: 1
: Fluid resuscitation of patients with major trauma remains a controversial topic. We hypothesised that current practice amongst critical care registrars at our centre might differ from current clinical guidelines. Sixty-six registrars from anaesthesia, intensive care and emergency medicine completed a survey giving their preferences for fluid resuscitation in major trauma patients. Most (85%) appropriately would choose a crystalloid (normal saline 68%, Hartmann's solution 17%), although intensi...
Cited By421
#2Thomas Langer (University of Milan)H-Index: 22
Last. Philippe G. Jorens (University of Antwerp)H-Index: 69
view all 7 authors...
Abstract null null Purpose null We aimed to provide an extended analysis of the physiological handling of of the sodium burden induced by maintenance fluids. null null null Materials and methods null We revisited two studies that demonstrated, in healthy volunteers and in surgical patients, that maintenance fluids with 154聽mmol/L of sodium lead to a more positive fluid balance than a regimen containing 54聽mmol/L. We report different unpublished data on the renal handling of the imposed sodium bu...
Ricin toxin isolated from the castor bean (Ricinus communis) is one of the most potent and lethal molecules known. While the pathophysiology and clinical consequences of ricin poisoning by the parenteral route, i.e., intramuscular penetration, have been described recently in various animal models, the preceding mechanism underlying the clinical manifestations of systemic ricin poisoning has not been completely defined. Here, we show that following intramuscular administration, ricin bound prefer...
#1Kerbi Alejandro Guevara-Noriega (Guy's and St Thomas' NHS Foundation Trust)
#2Trixie Yap (Guy's and St Thomas' NHS Foundation Trust)H-Index: 1
view all 3 authors...
#1Esther Huimin Leow (Boston Children's Hospital)H-Index: 2
#2Judith Ju-Ming Wong (NUS: National University of Singapore)H-Index: 13
Last. Jan H. Lee (NUS: National University of Singapore)
view all 6 authors...
Objectives null To assess the association of cumulative fluid overload (FO) up to 14 days from the diagnosis of pediatric acute respiratory syndrome (PARDS) with pediatric intensive care unit (PICU) mortality, 28-day mechanical ventilation free days (VFD), and 28-day intensive care unit free days (IFD). We hypothesized that fluid overload, even beyond the acute period, would be associated with increased morbidity and mortality. null Methods null We conducted a retrospective cohort study of PARDS...
In the second phase of shock therapy, we regularly find fluid overload with edema in our patients, which not only involves the skin and interstitial tissue but can also impair kidney, liver and pulmonary function. Revision of the Starling principle and new insights into physiology of the endothelial glycocalyx have important implications for fluid therapy in intensive care medicine. Determination of fluid overload and an appropriate therapy with either diuretics or ultrafiltration are the focus ...
#1Esther B Bulle (UvA: University of Amsterdam)H-Index: 4
#2Robert B. Klanderman (UvA: University of Amsterdam)H-Index: 6
Last. Alexander P.J. Vlaar (UvA: University of Amsterdam)H-Index: 35
view all 6 authors...
Abstract null null Transfusion associated circulatory overload (TACO) is one of the leading causes of transfusion related morbidity and mortality. TACO is the result of hydrostatic pulmonary edema following transfusion. However, up to 50% of all TACO cases appear after transfusion of a single unit, suggesting other factors, aside from volume, play a role in its pathophysiology. TACO follows a two-hit model, in which the first hit is an existing disease or comorbidity that renders patients volume...
#1Yi Liu (Chinese PLA General Hospital)H-Index: 3
#2Gang Chen (Chinese PLA General Hospital)
Last. Zhi-peng Xu (Chinese PLA General Hospital)H-Index: 5
view all 10 authors...
New findings null What is the central question of the study? Massive infusion can destroy the endothelial glycocalyx (EG). We compared the serum concentrations of EG components, atrial natriuretic peptide (ANP), and the outcomes of patients with different levels of stroke volume variation (SVV). What is the main finding and its importance? With a decrease in SVV, the serum concentrations of EG components and ANP increased, while the oxygenation index decreased. When the intraoperative SVV was ma...
#1Justin E. Richards (UMB: University of Maryland, Baltimore)H-Index: 14
#2Ron E. Samet (UMB: University of Maryland, Baltimore)H-Index: 1
Last. Thomas E. Grissom (UMB: University of Maryland, Baltimore)H-Index: 10
view all 3 authors...
#1Huru Ceren Gokduman (Istanbul University)
#2Elif Aygun (Istanbul University)H-Index: 1
Last. Mehmet 陌lke B眉get (Istanbul University)H-Index: 7
view all 7 authors...
BACKGROUND AND OBJECTIVES The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. METHO...
This website uses cookies.
We use cookies to improve your online experience. By continuing to use our website we assume you agree to the placement of these cookies.
To learn more, you can find in our Privacy Policy.