Understanding and extending the Starling principle

Published on Apr 27, 2020in Acta Anaesthesiologica Scandinavica2.105
路 DOI :10.1111/AAS.13603
C. Charles Michel18
Estimated H-index: 18
(ICL: Imperial College London),
Tom Woodcock12
Estimated H-index: 12
,
Fitz Roy E Curry60
Estimated H-index: 60
(UC Davis: University of California, Davis)
Sources
Abstract
The Starling Principle states that fluid movements between blood and tissues are determined by differences in hydrostatic and colloid osmotic (oncotic) pressures between plasma inside microvessels and fluid outside them. The Revised Starling Principle recognizes that, because microvessels are permeable to macromolecules, a balance of pressures cannot halt fluid exchange. In most tissues, steady oncotic pressure differences between plasma and interstitial fluid depend on low levels of steady filtration from plasma to tissues for which the Revised Principle provides the theory. Plasma volume is normally maintained by fluid losses from filtration being matched by fluid gains from lymph. Steady state fluid uptake into plasma only occurs in tissues such as intestinal mucosa and renal peri-tubular capillaries where a protein-free secretion of adjacent epithelia contributes significantly to interstitial fluid volume and keeps interstitial oncotic pressure low Steady filtration rates in different tissues are disturbed locally by reflex changes in capillary pressure and perfusion. The rapid overall decline in capillary pressure after acute blood loss initiates rapid fluid uptake from tissue to plasma, i.e. autotransfusion. Fluid uptake is transient, being rapid at first then attenuating but low levels may continue for more than an hour. The Revised Principle highlights the role of oncotic pressure of small volumes of interstitial fluid within a sub-compartment surrounding the microvessels rather than the tissue's mean interstitial fluid oncotic pressure. This maximizes oncotic pressure differences when capillary pressure are high and enhances initial absorption rates when pressures are low, accelerating short term regulation of plasma volume. EDITORIAL COMMENT: In this special article, which is one of a pair of invited narrative reviews, the author group focuses on review and reassessment of the model for fluid movement between capillary plasma and tissue, including recent developments in thinking.
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#1Emma Hasselgren (Karolinska University Hospital)H-Index: 3
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Last. Robert G. HahnH-Index: 54
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BACKGROUND:Albumin may persist intravascularly for a shorter time in patients after major surgery than in healthy volunteers due to a surgery-induced breakdown (shedding) of the endothelial glycocalyx layer.METHODS:In this nonrandomized clinical trial, an IV infusion of 3 mL/kg of 20% albumin was gi
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#1Markus Zdolsek (Link枚ping University)H-Index: 5
#2Robert G. Hahn (KI: Karolinska Institutet)H-Index: 54
Last. Joachim Zdolsek (Link枚ping University)H-Index: 12
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BackgroundAlthough hyperoncotic albumin may be used to recruit oedema, its effectiveness remains unclear. Therefore, this issue was studied during infusion experiments in healthy volunteers. Method ...
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#1Tom Woodcock (University of Southampton)H-Index: 12
#2Thomas M. Woodcock (Australian School of Advanced Medicine)H-Index: 3
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...
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Application of Onsager's symmetry relations to the process of diffusion of a solution through a membrane shows that measured osmotic pressures deviate from those calculated thermodynamically in proportion to the permeability of the membrane to the solute molecules. Therefore little is learned from one dynamic osmotic measurement but by simultaneous measurements of osmotic pressure and permeation at different membranes the entire molecular weight distribution of the solute can be computed.
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#1J. Rodney Levick (St George's Hospital)H-Index: 14
#2C. Charles Michel (ICL: Imperial College London)H-Index: 18
Microvascular fluid exchange (flow J v) underlies plasma/interstitial fluid (ISF) balance and oedematous swelling. The traditional form of Starling's principle has to be modified in light of insights into the role of ISF pressures and the recognition of the glycocalyx as the semipermeable layer of endothelium. Sum-of-forces evidence and direct observations show that microvascular absorption is transient in most tissues; slight filtration prevails in the steady state, even in venules. This is due...
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#1X. Zhang (ISMMS: Icahn School of Medicine at Mount Sinai)H-Index: 1
#2Roger H. Adamson (UC Davis: University of California, Davis)H-Index: 31
Last. Sheldon Weinbaum (CUNY: City University of New York)H-Index: 71
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A phenomenon that has defied explanation for two decades is the time scale for transient reabsorption in the classic experiments of Michel and Phillips on individually perfused frog mesentery microvessels. One finds that transient reabsorption lasts <2 min before a new steady state of low filtration is established when the lumen pressure is abruptly dropped from a high to a low value. Our experiments in frog and rat venular microvessels under a variety of conditions revealed the same time trend ...
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#1Roger H. Adamson (UC Davis: University of California, Davis)H-Index: 31
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We hypothesized that ultrafiltrate crossing the luminal endothelial glycocalyx through infrequent discontinuities (gaps) in the tight junction (TJ) strand of endothelial clefts reduces albumin diffusive flux from tissue into the 鈥榩rotected region鈥 of the cleft on the luminal side of the TJ. Thus, the effective oncotic pressure difference (蟽螖蟺) opposing filtration is greater than that measured between lumen and interstitial fluid. To test this we measured 蟽螖蟺 across rat mesenteric microvessels pe...
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The interstitial fluid pressure ( P isf ) has been measured in the exposed superfused mesenteries of anaesthetised rats using the micropipette servo-null technique. When mesenteries were superfused with Ringer-Locke solutions, P isf was close to atmospheric pressure with mean 卤 S . E . M . values of -0.46 卤 0.14 cmH 2 O ( n = 22). Superfusing with paraffin oil did not alter P isf significantly, but P isf could be lowered considerably by removing fluid from the upper surface of the mesentery. Mea...
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We tested the hypothesis that the effective oncotic force that opposes fluid filtration across the microvessel wall is the local oncotic pressure difference across the endothelial surface glycocalyx and not the global difference between the plasma and tissue. In single frog mesenteric microvessels perfused and superfused with solutions containing 50 mg/ml albumin, the effective oncotic pressure exerted across the microvessel wall was not significantly different from that measured when the perfus...
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#1Xiaping Hu (CUNY: City University of New York)H-Index: 2
#2Sheldon Weinbaum (CUNY: City University of New York)H-Index: 71
Abstract In this paper we quantitatively investigate the hypothesis proposed by Michel ( Exp. Physiol. 82, 1鈥30, 1997) and Weinbaum ( Ann. Biomed. Eng. 26, 1鈥17, 1998) that the Starling forces are determined by the local difference in the hydrostatic and colloid osmotic pressure across the endothelial surface glycocalyx, which we propose is the primary molecular sieve for plasma proteins, rather than the global difference in the hydrostatic and oncotic pressure across the capillary wall between ...
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