Despite equal blood loss from chest drains, both colloids interfered with blood coagulation and produced greater haemodilution, which was associated with more transfusion of blood products compared with crystalloid use only.

Soft tissue infections constitute a serious complication following surgery in diabetic patients and frequently require the administration of vancomycin. However, despite antibiotic treatment, mortality of patients with postoperative infections remains high and might be related to an impaired penetration of anti-infective agents to target tissues. Therefore, the present study was designed to measure vancomycin tissue concentrations in six diabetic and six nondiabetic patients after cardiac surgery. Vancomycin was administered as a continuous intravenous infusion at an infusion rate of 80 to 120 mg/h. Vancomycin concentrations in soft tissues and plasma were measured in all patients during steady state as "therapeutic window" concentrations in plasma by microdialysis on day 8 ؎ 4 after initiation of vancomycin treatment. Vancomycin tissue concentrations in diabetic patients were significantly lower than in nondiabetics (3.7 mg/liter versus 11.9 mg/liter; P ‫؍‬ 0.002). The median vancomycin tissue /vancomycin plasma concentration ratio was 0.1 in diabetic patients and 0.3 in nondiabetics (P ‫؍‬ 0.002). Our study demonstrated that vancomycin penetration into target tissues is substantially impaired in diabetic patients versus nondiabetics. Insufficient tissue concentrations could therefore possibly contribute to failure of antibiotic treatment and the development of antimicrobial resistance in diabetic patients.

T he optimal perioperative fluid management regimen for patients having major surgery is still being debated. Crystalloids (eg, Ringer's lactate [RL]), and colloids such as hydroxyethyl starch (HES) and 5% human serum albumin (HA) are used for intraoperative fluid management in patients undergoing cardiac surgery. The latter 2 expand circulating volume to a greater extent than crystalloids and could be used for a restrictive fluid therapy regimen. Human serum albumin and HES, however, can affect blood coagulation and contribute to increased transfusion requirements. This randomized, double-blind, single-center study was performed over 4 years to compare external blood loss from chest drains among groups receiving 5% HA, 6% HES 130/0.4, or RL as the main infusion during cardiac surgery.Eighty patients each were randomized to receive 50 mL/kg per day of either HA, HES, or RL 50 mL/kg per day, with additional RL given as required. Fluid administration was started with 250 to 500 mL of the study solution during anesthesia induction. Intraoperative fluid therapy with the study solution was restricted to two-thirds of the maximally allowed daily dose (33.3 mL/kg). The last 16.7 mL/kg was kept for initial volume replacement in the intensive care unit (ICU). Rotation thromboelastometry ex vivo coagulation variables were examined. The primary outcome was clinical bleeding based on chest tube drainage during the first 24 hours. Blood transfusion, thromboelastometry variables, perioperative fluid balance, renal function, mortality, and ICU and hospital stays were also evaluated.The final cohort included 76, 81, and 79 patients in the HA, HES, and RL groups, respectively. Median chest tube drainage over 24 hours postoperatively did not differ among the groups (HA, 835 mL; HES, 700 mL; RL, 670 mL; P = 0.0850). The groups differed, however, in the quantity of blood transfusion (packed red blood cells [PRBCs] for HA and HES 300 mL, 0 for RL; P < 0.0004). Most units of PRBCs were given perioperatively during the first 24 hours. No intergroup differences were apparent for transfused FFP and platelets. Fibrinogen was required in 12%, 16%, and 4% of patients in the HA, HES, and RL groups, respectively (P = 0.0383). No differences were found in the 3 groups for the amount of coagulation factor concentrates given. Packed red blood cells were given to 58%, 61%, and 24% of patients in the HA, HES, and RL groups, respectively (P = 0.0013) and any blood product to 62%, 64%, and 35%, respectively (P = 0.0003). During surgery, hemoglobin (Hb) values declined from baseline in all groups, but those in the RL group showed the least decline during surgery and at arrival in the ICU (P < 0.0001 for both). At 24 hours postoperatively, HA patients had the lowest Hb values compared with HES and RL groups (P < 0.0001 for both). The Hb values did not differ among the 3 groups on postoperative day (POD) 6. Maximal clot firmness decreased in all groups during surgery but stayed in the reference range in the HA and RL groups; the lowest value was seen ...

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SummaryAfter cardiac surgery, patients with low left ventricular ejection fraction probably benefit the most from accurate monitoring of continuous cardiac output. Thirty patients with impaired ventricular function were studied, and intermittent bolus thermodilution and continuous pulse contour (LiDCO plusTM) cardiac output compared. Following lithium dilution calibration, a total of 220 paired results were recorded. Thermodilution and LiDCO measurements ranged from 2.3 to 11.0 and 2.6 to 10.8 l.min−1, respectively. Corresponding means (SD) were 6.1 (1.6) and 6.2 (1.9) l.min−1, with coefficients of variance of 26 and 31%, respectively. The correlation coefficient was 0.82, bias 0.28 l.min−1 with upper and lower limits of agreement 1.96 and −1.41 l.min−1; the percentage error was 27%. LiDCO showed good correlation, marginal bias and acceptable limits of agreement and percentage error. It could therefore potentially replace thermodilution as a means of measuring cardiac output in the ICU, particularly when determination of pulmonary artery pressure is not required.

Data indicate that postoperative interstitial antibiotic concentration is influenced by perioperative atelectasis formation. Our findings suggest the re-evaluation of clinical dosing schemas of antibiotic therapy in a variety of diseases associated with atelectasis formation.

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