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J. F. Baron M. T. Grauer R. G. Strauss J.Treib
Reply Accepted: 19 August 1999 Sir: We would like to comment on the points raised by Riou and Cittanova regarding our perspective on the influence of HES on kidney function in our review [1]. So far, the renal problems after transplantation described by the authors have mostly been observed in France, where highly substituted HES is preferred [2]. In contrast, data from a recent retrospective study suggest that HES does not impair renal function. However, a higher serum creatinine was observed with HES 450/0.7, a highly substituted HES [3]. In addition, several studies have demonstrated that in high-risk surgical patients HES does not impair renal function [4, 5]. In our review, we point out that highly substituted HES preparations can result in increased plasma and tissue accumulation after repeated, high-dose administration. These effects can be lowered through the use of lower-substituted, rapidly degradable HES 200/0.5 or HES 70/0.5 [6, 7]. In Germany, where mostly lower-substituted HES preparations are used, as opposed to France, no data have been reported that HES causes renal impairment as described by Cittanova et al [2]. Based on this understanding of HES pharmacology, it seems reasonable to recommend lower-substituted HES preparations for volume replacement therapy in this clinical setting. We fully agree that additional research is necessary to further clarify this issue and we appreciate ongoing interest in basic research.
References 1. Treib J, Baron JF, Grauer MT, Strauss RG (1999) An international view of hydroxyethyl starches. Intensive Care Med 25: 258±268 2. Cittanova ML, Leblanc I, Legendre C, Mouquet C, Riou B, Coriat P (1996) Effect of hydroxyethyl starch in brain-dead kidney donors on renal function in kidney-transplant recipients. Lancet 348: 1620±1622
3. Deman A, Peeters P, Sennesael J (1999) Hydroxyethyl starch does not impair immediate renal function in kidney transplant recipients: a retrospective, multicentre analysis. Nephrol Dial Transplant 14: 1517±1520 4. Godet G, Fleron MH, Vicaut E, Zubicki A, Bertrand M, Riou B, Kieffer E, Coriat P (1997) Risk factors for acute postoperative renal failure in thoracic or thoracoabdominal aortic surgery: a prospective study. Anesth Analg 85: 1227±1232 5. Vogt NH, Bothner U, Lerch G, Lindner KH, Georgieff M (1996) Large-dose administration of 6 % hydroxyethyl starch 200/0.5 total hip arthroplasty: plasma homeostasis, hemostasis, and renal function compared to use of 5 % human albumin. Anesth Analg 83: 262±268 6. Baron J-F, Treib J (eds) (1998) Volume replacement. Springer, Berlin Heidelberg New York 7. Treib J (ed) (1999) Volume therapy. Springer, Berlin Heidelberg New York J. F. Baron Department of Anesthesiology, Hopital Broussais, University Pierre et Marie Curie, F-75014 Paris, France
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M. T. Grauer × J. Treib ( ) Department of Neurology, University Hospitals of the Saarland, D-66421 Homburg, Germany R. G. Strauss DeGowin Blood Center, University of Iowa Hospitals and Clinics, Departments of Pathology and Pediatrics, University of Iowa, College of Medicine, Iowa City, Iowa 52242-1182, USA
I. A. von Rosenstiel F. B. Plötz
ECLS in pertussis: does it have a role? Accepted: 19 August 1999 Sir: With great interest we have read the paper of Williams and coworkers [1] describing the fatal outcome of a 5-week-old infant with Bordetella pertussis infection. Just recently, a 2-week-old neonate with B. pertussis pneumonia was admitted to the pediatric intensive care unit because of
progressive respiratory distress. Approximately 10 h after intubation and mechanical ventilation under stable conditions, the infant abruptly developed severe pulmonary hypertension (PH) with echocardiographically confirmed large right-to-left shunting at the atrial level. Within 3 h the infant died of a failing heart on the ventilator due to refractory PH, resulting in severe respiratory and metabolic acidosis. As with the patient of Williams et al., we were also impressed with the extreme rapidity and severity with which the PH evolved. We therefore would like to emphasize again the high index of suspicion of PH in a subgroup of pertussis patients with signs of acute myocardial failure and acute lung injury (ALI), warranting an aggressive treatment approach, in particular since the incidence of pertussis in unimmunized infants is still increasing [2]. The mainstays of treatment for PH have been maintenance oxygenation and vasodilator therapy. Patients with pertussis needing respiratory ventilation often have ALI, indicating that they will only have partial relief of hypoxia from delivery of a high fractional inspired oxygen with conventional mechanical ventilation, due to intrapulmonary shunting and venous admixture. Despite various rescue therapies being used to improve oxygenation, mortality due to severe PH in B. pertussis infection is very high [2, 3]. Williams et al. postulated that the value of extracorporeal life support is questionable, since these patients with predominant cardiac failure have, invariably, a poor outcome despite maximal therapy. In this respect, combination of selective pulmonary vasodilators might be more successful to treat this severe PH. Next to inhaled nitric oxide (NO), the advent of prostacyclin (PGI2) as a useful therapeutic agent for PH has been reported in several trials in the setting of ALI [4]. All reports so far have agreed that PGI2 acts selectively on pulmonary circulation and is at least as effective as NO. Inhaled NO and inhaled PGI2 produce selective reduction in pulmonary vascular resistance through differing mechanisms. NO decreases pulmonary vascular resistance via cyclic guanosine monophosphate and PGI2 produces pulmonary vasodilation via cyclic adenosine monophosphate. Combining both drugs in the future to treat severe PH in the young infant with pertussis maybe a therapeutic option. Although the role of venous leukocyte thrombi remains speculative in the etiology of PH, it is possible to assume that pulmonary capillary obstruction by leukocytosis with stasis and secondary microthrombosis plays an important role in the development of PH [5]. It is feasible
