Document Detail


Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy.
MedLine Citation:
PMID:  22290457     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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 'no 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.
Authors:
T E Woodcock; T M Woodcock
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Publication Detail:
Type:  Journal Article; Review     Date:  2012-01-29
Journal Detail:
Title:  British journal of anaesthesia     Volume:  108     ISSN:  1471-6771     ISO Abbreviation:  Br J Anaesth     Publication Date:  2012 Mar 
Date Detail:
Created Date:  2012-02-16     Completed Date:  2012-04-10     Revised Date:  2012-06-28    
Medline Journal Info:
Nlm Unique ID:  0372541     Medline TA:  Br J Anaesth     Country:  England    
Other Details:
Languages:  eng     Pagination:  384-94     Citation Subset:  IM    
Affiliation:
Critical Care Service, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, UK. tom.woodcock@me.com
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MeSH Terms
Descriptor/Qualifier:
Basement Membrane / metabolism
Blood Proteins / physiology
Capillary Permeability / physiology
Endothelium, Vascular / metabolism*
Extracellular Matrix / metabolism
Fluid Therapy / methods*
Glycocalyx / metabolism*
Humans
Microcirculation / physiology
Models, Cardiovascular*
Plasma Substitutes / therapeutic use
Chemical
Reg. No./Substance:
0/Blood Proteins; 0/Plasma Substitutes
Comments/Corrections
Comment In:
Br J Anaesth. 2012 Jun;108(6):1035; author reply 1035-6   [PMID:  22593129 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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