12 de maio de 2011

Artigo: Contrasting Effects of Colloid and Crystalloid Resuscitation Fluids on Cardiac Vascular Permeability

Matthias Jacob, M.D., Dirk Bruegger, M.D., Markus Rehm, M.D., Ulrich Welsch, M.D., Ph.D., Peter Conzen, M.D., Bernhard F. Becker, M.D., Ph.D.
Anesthesiology 2006; 104:1223–31

Background: Fluid extravasation may lead to myocardial edema and consequent reduction in ventricular function. Albumin is presumed to interact with the endothelial glycocalyx. The authors’ objective was to compare the impact of different resuscitation fluids (human albumin, hydroxyethyl starch, saline) on vascular integrity. 

Methods: In an isolated perfused heart model (guinea pig), Krebs-Henseleit buffer was augmented with colloids (one third volume 5% albumin or 6% hydroxyethyl starch 130/0.4) or crystalloid (0.9% saline). Perfusion pressure and vascular fluid filtration (epicardial transudate formation) were assessed at different flow rates. After global, stopped-flow ischemia (37°C, 20 min), hearts were reperfused with the same resuscitation fluid additives. In a second series, the authors applied the respective perfusates after enzymatic digestion of the endothelial glycocalyx (heparinase, 10 U over 15 min).

Results: Both 5% albumin and 6% hydroxyethyl starch decreased fluid extravasation versus saline (68.4 +- 5.9, 134.8 +- 20.5, and 436.8 +- 14.7 l/min, respectively, at 60 cm H2O perfusion pressure; P < 0.05), the corresponding colloid osmotic pressures being 2.95, 5.45, and 0.00 mmHg. Digestion of the endothelial glycocalyx decreased coronary integrity in both colloid groups. After ischemia, a transient increase in vascular leak occurred with Krebs-Henseleit buffer containing hydroxyethyl starch and saline, but not with albumin. The authors observed no difference between intravascular and bulk interstitial colloid concentration in the steady state. Notwithstanding, electron microscopy revealed an intact endothelial glycocalyx and no interstitial edema in the albumin group. 

Conclusion: Ex vivo, albumin more effectively prevented fluid extravasation in the heart than crystalloid or artificial colloid. This effect was partly independent of colloid osmotic pressure and may be attributable to an interaction of albumin with the endothelial glycocalyx.

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