RESUMEN
OBJECTIVE: Women report more severe postoperative complaints than men (e.g. nausea and pain) and expectations of complaints prior to surgery influence the postoperative complaints. Therefore, the aim of this study was to explore if gender differences in complaint expectation can account for differences in postoperative complaints. A further objective was to investigate the effective load of complaints and to look for gender differences. METHODS: In total 281 patients (128 men and 153 women) were included in the study and all patients underwent elective general surgery. Patients were asked for symptom expectations and symptom experiences prior to surgery. After surgery they answered the Anesthesiological Questionnaire (ANP) a validated self-rating method for the assessment of postoperative symptoms and complaints. The symptoms referred to in the questionnaire included sensation of cold, sensation of heat, nausea and vomiting, tickly throat, croakiness, dry mouth and thirst, difficulty in breathing, sore throat, pain in the area of surgery, pain in the area of infusion, muscle pain, back pain, headache, difficulties in urination, difficulty in awakening and feeling of somatic discomfort. In addition patients rated the affective load of the postoperative complaints. RESULTS: In previous surgery women reported experiencing more postoperative somatic complaints than men. Sex-related differences were significant (p < 0.05) for sensation of cold, nausea and vomiting, tickly throat, croakiness, sore throat, pain and the feeling of somatic discomfort. Likewise, women expected more intensive postoperative complaints following the forthcoming operation. After surgery women reported significantly more severe complaints in negative symptoms of the ANP (e.g. nausea and vomiting, pain and somatic discomfort). Effect sizes of sex-related differences varied according to the symptom (e.g. for pain effect strength d = 0.50, for nausea d = 0.60 and for thirst d = 0.13). Effect sizes decreased when the effect of expectation was statistically controlled. Logistic regression revealed that expectation was an independent predictor for the sensation of severe nausea (odds ratio OR 4.3] and intensive postoperative pain (OR 2.6). Regardless of gender, postoperative pain, nausea and dry mouth/thirst were symptoms with the highest affective load. CONCLUSIONS: Preoperative expectations increase gender differences in somatic complaints following surgery. Anesthesiological education of patients should influence dysfunctional expectations. Postoperative pain, nausea and thirst should be the main targets of interventions to improve patient complaints.
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Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/psicología , Adolescente , Adulto , Afecto , Anciano , Anestesia , Procedimientos Quirúrgicos Electivos , Femenino , Alemania , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/epidemiología , Dolor Postoperatorio/psicología , Faringitis/epidemiología , Faringitis/psicología , Náusea y Vómito Posoperatorios/epidemiología , Náusea y Vómito Posoperatorios/psicología , Cuidados Preoperatorios , Prevalencia , Autoinforme , Factores Sexuales , Encuestas y Cuestionarios , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Inhibition of the Na (+)/H (+) exchanger (NHE) is cardioprotective, but dosage and timing of NHE-inhibitors are critical for their efficacy. We studied the effect of a new dosing regime of the NHE-inhibitor cariporide on myocardial function and damage after cardioplegic arrest (CPA) and determined its myocardial and serum concentrations. METHODS: 3 pigs received a bolus of 180 mg cariporide intravenously (i. v.) and were sacrificed shortly thereafter to allow measurement of the myocardial concentrations of cariporide. Subsequently, 10 pigs were randomized to receive either i. v. cariporide (bolus followed by an infusion of 40 mg/h) or placebo. Cardiopulmonary bypass was initiated, and the heart was arrested for 60 minutes by infusion of St. Thomas Hospital solution. Left ventricular (LV) function was studied using microsonometry. Myocardial damage was assessed by troponin T. Serum concentrations of cariporide were measured throughout the study, and myocardial concentrations were measured before the end of CPA and 180 minutes thereafter. RESULTS: Cariporide was present in all myocardial specimens (median: 1.4 ng/mg) studied previously. In the main study, LV function or myocardial damage did not differ significantly between the groups at any time point. Stable serum cariporide concentrations were achieved (3.4 +/- 0.5 microg/ml). Cariporide was detectable in only one of the myocardial biopsies obtained before the end of CPA, but 180 minutes thereafter, the myocardial cariporide concentration was 2.5 +/- 0.3 ng/mg. CONCLUSION: We observed no effect of i. v. cariporide on LV function or myocardial damage after cardioplegic arrest. Our data suggest that cariporide is washed out of the myocardium by repeated application of crystalloid cardioplegia. Thus, the mode of delivery also appears to be critical for cardioprotection with NHE-inhibitors.
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Antiarrítmicos/sangre , Guanidinas/sangre , Miocardio/metabolismo , Compuestos de Potasio/administración & dosificación , Intercambiadores de Sodio-Hidrógeno/sangre , Intercambiadores de Sodio-Hidrógeno/efectos de los fármacos , Sulfonas/sangre , Análisis de Varianza , Animales , Antiarrítmicos/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Puente Cardiopulmonar , Circulación Coronaria/efectos de los fármacos , Modelos Animales de Enfermedad , Relación Dosis-Respuesta a Droga , Femenino , Guanidinas/administración & dosificación , Paro Cardíaco Inducido , Frecuencia Cardíaca/efectos de los fármacos , Contracción Miocárdica/efectos de los fármacos , Isquemia Miocárdica/sangre , Isquemia Miocárdica/etiología , Isquemia Miocárdica/fisiopatología , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Proyectos de Investigación , Volumen Sistólico/efectos de los fármacos , Sulfonas/administración & dosificación , Porcinos , Troponina T/sangre , Función Ventricular Izquierda/efectos de los fármacosRESUMEN
BACKGROUND: To counteract the contribution of angiotensin II to shock-induced ischaemic organ damage pharmacologic blockade of the renin-angiotensin-system (RAS) is currently under investigation. To evaluate potential side-effects of RAS blockade regarding capillary leak, we studied alterations in microvascular permeability in various organs during haemorrhagic shock (HS) in rats pretreated with candesartan (AT(1)-receptor antagonism) or enalaprilat (ACE-inhibition). METHODS: Thirty-eight instrumented and anaesthetized animals received either candesartan, enalaprilat or placebo. Within each of the three groups 6-7 animals were exposed to HS and 6 animals of each group served as normovolaemic controls. After 30 min of shock, 50 mg kg(-1) Evans blue (EB) was injected i.v. followed by a distribution period of 20 min. Exsanguination was performed with saline, before harvesting organs to quantify albumin-bound EB extravasation. RESULTS: To reduce cardiac output from 37.5 (1.3) to 20.4 (1.1) ml min(-1) [mean (SEM)] in the shock groups, withdrawal of 4.0 (0.25) ml [mean (SEM)] blood was necessary. Simultaneously mean arterial pressure decreased from 77.5 (3.2) to 36.1 (2) mm Hg. Serum lactate increased significantly from 1.3 (0.1) to 3.5 (0.24) mmol litre(-1). Treatment with candesartan increased EB extravasation in the kidney in normovolaemic controls. Specific AT(1) and ACE-blockade before acute non-resuscitated HS significantly increased EB extravasation in the rat ileum by 53 and 66%, respectively. CONCLUSION: This observation of increased microvascular albumin extravasation should be borne in mind for any interventional use of candesartan or enalaprilat during circulatory stress.
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Bencimidazoles/farmacología , Permeabilidad Capilar/efectos de los fármacos , Enalaprilato/farmacología , Choque Hemorrágico/fisiopatología , Tetrazoles/farmacología , Bloqueadores del Receptor Tipo 1 de Angiotensina II/farmacología , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Animales , Compuestos de Bifenilo , Colorantes , Azul de Evans , Extravasación de Materiales Terapéuticos y Diagnósticos/etiología , Hemodinámica/efectos de los fármacos , Íleon/irrigación sanguínea , Riñón/irrigación sanguínea , Ácido Láctico/sangre , Masculino , Consumo de Oxígeno/efectos de los fármacos , Ratas , Ratas Sprague-Dawley , Sistema Renina-Angiotensina/efectos de los fármacosRESUMEN
Tracheobronchial candidosis is an impetuous complication in intensive care medicine. This article presents a concept to compare diagnostic procedure, Candida species and resistant species of different intensive care units with each other. This concept should encourage bench marking between similar intensive care units. The report and retrospective analysis of the intensive care course offer the opportunity to reflect own decisions and to adjust them to the current therapy strategies. Both procedures should improve the antimycotic therapy for intensive care units and should avoid the occurrence of resistant species. Candida species are often detected in the respiratory system of ventilated patients in intensive care, but this alone is no indication for antimycotic therapy. A strict retention is recommended, but this retention is diminished by an unclear infection, critical situation of the patient in the case of multiple organ failure, additional infection and long term ventilation. A therapy strategy for individual situations should be established and a close diagnostic procedure should be performed. A positive blood culture or detection of Candida species in two or more diagnostic materials indicate an early antimycotic therapy.
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Candidiasis/tratamiento farmacológico , Antifúngicos/uso terapéutico , Enfermedades Bronquiales/diagnóstico , Enfermedades Bronquiales/tratamiento farmacológico , Enfermedades Bronquiales/microbiología , Candida/aislamiento & purificación , Candidiasis/diagnóstico , Candidiasis/microbiología , Humanos , Unidades de Cuidados Intensivos , Respiración Artificial , Enfermedades de la Tráquea/diagnóstico , Enfermedades de la Tráquea/tratamiento farmacológico , Enfermedades de la Tráquea/microbiología , Ventiladores MecánicosRESUMEN
BACKGROUND AND OBJECTIVE: The anaesthesiologist's preoperative interview with the patient is important in preparing the patient for surgery. Its potential protective influence on adverse side-effects from anaesthesia and convalescence is rarely investigated within the context of other perioperative factors. Structural equation modelling allows detection and quantification of all causal relationships and mediator effects in multivariate models. Therefore, this method is presented as a tool and applied to discover the influence of the preoperative interview within socio-demographic variables and duration of surgery on complaints and recovery after anaesthesia. METHODS: The influence of individual satisfaction with the anaesthesiologist's preoperative interview on postoperative events such as nausea/vomiting, difficulties in recovering from anaesthesia, experience of postoperative pain, physical discomfort and satisfaction with convalescence expressed by the patient was analysed by means of structural equation modelling. The variables gender, age and duration of surgery were also included as predictors in the analyses. The model in the total sample of 710 patients was then analysed for structural differences between groups treated either with propofol (n = 204) or with isoflurane + nitrous oxide (n = 267) for maintenance of anaesthesia. RESULTS: The model revealed that the anaesthesiologist's preoperative interview in combination with associated mediating side-effects explains 45% of the variance of 'feeling physical discomfort' and 18% of the variance of 'satisfaction with convalescence'. The same model could be fitted in the propofol and the isoflurane + nitrous oxide group. Moreover, the structure and the strength of causal relations between variables were identical in the two groups. CONCLUSIONS: The anaesthesiologist's efforts to improve the interview with the patient by more reassuring and proper information will result in less side-effects from anaesthesia and better recovery from surgery. It could be demonstrated that structural equation modelling is a powerful tool for detection of causal relationships and mediator effects in perioperative medicine.
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Periodo de Recuperación de la Anestesia , Anestesia/efectos adversos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anestésicos/efectos adversos , Causalidad , Femenino , Humanos , Isoflurano , Masculino , Persona de Mediana Edad , Modelos Teóricos , Óxido Nitroso , Dolor Postoperatorio , Satisfacción del Paciente , Náusea y Vómito Posoperatorios , PropofolRESUMEN
Respiratory depression and apnoea during anaesthesia may lead to hypoxia and myocardial ischaemia. A self-inflating miniature bag-mask device was assembled combining characteristics from the Ambu-bag and the Kuhn-system. This bag-mask device permitted ventilation during anaesthesia-induced apnoea in rats until a safe airway by tracheotomy was achieved.
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Respiración Artificial/instrumentación , Respiración Artificial/veterinaria , Anestesia General/efectos adversos , Anestesia General/veterinaria , Animales , Apnea/etiología , Apnea/terapia , Apnea/veterinaria , Masculino , Ratas , Ratas Sprague-DawleyRESUMEN
OBJECTIVE: The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction. The questionnaire consists of two parts. Part 1 assesses the intensity of symptoms regarding the postoperative period in the "recovery-room and the first hours on the ward" (19 items) and the "current state" (17 items). Part 2 assesses patient satisfaction with the anaesthetic care as well as the unspecific perioperative care and postoperative convalescence. The questionnaire was designed to fulfill the criteria of reliability and validity and to serve as a practicable means of auditing the quality of routine clinical practice. METHODS: A total of 1,112 patients older than 18 years completed the questionnaire after an elective operation. Additionally data concerning the type of anaesthesia were recorded from the anaesthesia chart. To determine retest-reliability, 94 patients competed the ANP twice postoperatively. RESULTS: The participants of the survey represented 74.6% of the total collective. Out of 19 items 16 had a retest-reliability of r(tt)>0.70, the 3 other items had a reliability of r(tt)>0.50. Reliability (Cronbach's Alpha) of the patient satisfaction scales was between r(tt)=0.76 and r(tt)=0.91. In relation to the period immediately after anaesthesia,women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with perioperative care. Younger patients (18-49 years old) described more postoperative complaints than older patients and a lesser degree of satisfaction with perioperative care. There were plausible differences in postoperative complaints between patients who received general vs. regional anaesthesia. Patients reported less postoperative complaints after TIVA than after volatile anaesthetics. The configuration of patient characteristics and anaesthesia gives indications to "risk groups" who predominantly suffer after anaesthesia. CONCLUSIONS: The Anaesthesiological Questionnaire (ANP) is a reliable and valid method for the assessment of postoperative complaints and patient satisfaction.
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Anestesia , Comportamiento del Consumidor , Complicaciones Posoperatorias/epidemiología , Encuestas y Cuestionarios/normas , Adolescente , Adulto , Factores de Edad , Anciano , Anestesia/efectos adversos , Anestesia por Inhalación , Anestesia Intravenosa , Femenino , Humanos , Masculino , Persona de Mediana Edad , Garantía de la Calidad de Atención de Salud , Reproducibilidad de los Resultados , Medición de RiesgoAsunto(s)
Anestesia , Procedimientos Quirúrgicos Vasculares , Aorta/cirugía , Humanos , Complicaciones Intraoperatorias/prevención & control , Enfermedades Renales/inducido químicamente , Síndromes de Neurotoxicidad/prevención & control , Cuidados Posoperatorios , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/psicología , StentsAsunto(s)
Anestesia/métodos , Aneurisma de la Aorta/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Aorta/diagnóstico por imagen , Aorta/patología , Aorta/cirugía , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/patología , Transfusión Sanguínea , Procedimientos Quirúrgicos Electivos , Humanos , Monitoreo Intraoperatorio , UltrasonografíaRESUMEN
The authors considered three protocols for spinal anesthesia using sheep as a model. An appropriate spinal anesthesia method would obviate the need for general anesthesia in certain surgical approaches.
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Anestesia Raquidea/veterinaria , Ovinos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Anestésicos/administración & dosificación , Anestésicos/efectos adversos , Animales , Arritmias Cardíacas/inducido químicamente , Arritmias Cardíacas/veterinaria , Modelos Animales , Ovinos/fisiología , Ovinos/cirugíaRESUMEN
PURPOSE: The cardiovascular effects of volatile anesthetics during sepsis sets patients at high risk for hemodynamic deterioration. We compared the microcirculatory alterations in skeletal muscle under anesthesia with isoflurane, enflurane, and halothane in an endotoxemic rat preparation. MATERIALS AND METHODS: Twenty-one Sprague-Dawley rats under continuous hemodynamic monitoring and intravital microscopy of the spinotrapezius muscle were studied during two level lipopolysaccharide (0.2 mg/kg and 2 mg/kg) induced sepsis. The effects of equianesthetic concentrations (1.5 minimum alveolar concentration [MAC]) of either isoflurane [n:7], enflurane [n:7], or halothane [n:7] on microcirculatory vasoregulation were measured and histopathologic changes were evaluated. RESULTS: During low-dose endotoxemia, arteriolar vasodilation under isoflurane was nearly abolished (P < .05). At high-dose endotoxemia, this lack of vasodilatory effect was similar (P < .05). Animals receiving 1.5 MAC of enflurane during low-dose endotoxin presented a significant decrease in arteriolar diameter by -11.3 (+/-2.9%), this response was less during high-dose endotoxemia (-7.0, +/-2.9%). Halothane caused pronounced vasoconstriction by -20 (+/-3.7%) during low-dose endotoxemia and moderate but significant constriction during high-dose endotoxemia (-7.9, +/-2.6%). CONCLUSIONS: Isoflurane, enflurane, and halothane exert significantly different effects on vasoregulation of skeletal muscle arterioles in the endotoxemic rat.
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Anestésicos por Inhalación/farmacología , Endotoxemia/fisiopatología , Músculo Esquelético/efectos de los fármacos , Animales , Endotoxemia/patología , Enflurano/farmacología , Femenino , Halotano/farmacología , Hemodinámica/efectos de los fármacos , Isoflurano/farmacología , Microcirculación/efectos de los fármacos , Ratas , Ratas Sprague-DawleyRESUMEN
Compensation for acute blood loss requires cardiovascular integrity. In older people, asymptomatic cardiovascular impairment is common. In these subjects, even moderate blood loss is often treated by external volume replacement although its benefits are not clear. We investigated the effect of 450 ml of blood loss on the microcirculation and compensatory mechanisms in healthy older blood donors. Red blood cell count, plasma viscosity and protein concentration were measured. Plasma volume replacement was calculated using haematocrit. We measured microcirculation tissue perfusion by laser Doppler fluxmetry prior to, during and after blood donation. Blood loss was immediately accompanied by a median rapid water shift of 208 ml (interquartile range 134-298 ml). Haemodilution led to a decrease in haematocrit, protein and plasma viscosity. We observed no changes in cutaneous microcirculation. Moderate blood loss is tolerated in older cardiovascularly asymptomatic patients without having an impact on microcirculation. This may reduce the need for external volume replacement.
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Donantes de Sangre , Hipovolemia/fisiopatología , Microcirculación/fisiología , Anciano , Proteínas Sanguíneas/análisis , Viscosidad Sanguínea , Recuento de Eritrocitos , Femenino , Transferencias de Fluidos Corporales/fisiología , Hematócrito , Humanos , Flujometría por Láser-Doppler , Masculino , Persona de Mediana Edad , Estadísticas no ParamétricasRESUMEN
OBJECTIVE: There is an increasing demand for internal clinical quality assurance. For this reason methods for the assessment of patients' satisfaction and postoperative symptoms and complaints are needed. This article describes a new questionnaire for the measurement of these aspects. METHODS: The questionnaire consists of two parts. Part 1 assesses the intensity of symptoms related to the postoperative periods "recovery room", "first hours on ward" and "current state". Part 2 measures patients' satisfaction with anesthesiological care, unspecific perioperative care and postoperative convalescence. 431 patients completed the questionnaire after an elective operation. RESULTS: Results demonstrate a plausible difference in patients' symptoms between the three postoperative periods. The difference between the remembered complaints in the "recovery room" and the "first hours on ward" is of small degree. Related to the period immediately after anesthesia, women describe a worse state of health than men. Male and female patients do not differ in their satisfaction with anesthesiological care. Older patients describe greater satisfaction with perioperative care than younger ones. There are only a few significant correlations between the intensity of symptoms in the "recovery room" and data from anesthesiological documentation. CONCLUSIONS: The new questionnaire is sensitive for the change of symptoms in the course of postoperative time. Considering the results, a modification of the questionnaire ist suggested. This instrument is to be used in a greater and representative sample of patients now.
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Anestesia , Satisfacción del Paciente , Complicaciones Posoperatorias/epidemiología , Adulto , Factores de Edad , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Garantía de la Calidad de Atención de Salud , Sala de Recuperación , Factores Sexuales , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
We evaluated the changes of tissue layer thickness in circumscribed superficial tissue areas with a 10-MHz A-mode and a 20-MHz B-mode ultrasound device under alterations in body posture and plasma volume to detect fluid shifts between the different compartments. In 20 male volunteers, we measured tissue thickness by A mode and corium and subcutis thickness by B mode at the forehead before and 30 min after three procedures: change from upright to supine position (P1); change from upright to 30 degrees head-down-tilt position (P2); infusion of 10 ml/kg body wt of Ringer solution (P3). We found a significant correlation between baseline tissue thickness and the sum of corium and subcutis thicknesses (r = 0.75, P < 0.01). The changes of body posture and plasma volume resulted in significant increases of tissue thickness (P1, 2.9%; P2, 11.6%; P3, 5.8%) and corium thickness (P1, 4.7%; P2, 8.1%; P3, 9.1%) but not of the sum of chorium and subcutis thicknesses. We conclude that fluid shifts from the intravascular to the extravascular compartment are detectable by evaluating corium thickness with a B-mode, or more easily tissue thickness with an A-mode, ultrasound device.
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Espacio Extracelular/fisiología , Edema Pulmonar/diagnóstico por imagen , Ultrasonografía/instrumentación , Ultrasonografía/métodos , Adulto , Permeabilidad Capilar/fisiología , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/fisiopatología , Humanos , Presión Hidrostática , Masculino , Miniaturización , Edema Pulmonar/fisiopatología , Piel/diagnóstico por imagenRESUMEN
BACKGROUND: The rate of intercompartmental fluid volume changes during hemodialysis (HD) is a major determinant of dialysis-induced hypotension and lacks direct monitoring. The aim of the study was to evaluate the feasibility of tissue thickness (TT) measurement in monitoring the mobilization of interstitial fluids during HD. METHODS: We studied the intradialytic changes in forehead TT and inferior vena cava diameter (IVCD) in 20 patients. Plasma refilling was calculated from changes in hematocrit (Hct) and ultrafiltration rates. RESULTS: During ultrafiltration of 2,437 +/- 117 ml (mean +/- SEM), Hct increased significantly from 27.9 +/- 0.7 to 30.0 +/- 0.9%. IVCD decreased significantly from 9.7 +/- 0.2 to 6.1 +/- 0.4 mm/m(2). We found a simultaneously pronounced reduction in TT from 4. 46 +/- 0.12 to 3.78 +/- 0.12 mm (> or =15.3%) with a significant correlation to plasma refilling (0.613). CONCLUSION: Volume changes in the peripheral shell tissues during HD can be monitored directly and noninvasively by A-mode ultrasound.
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Transferencias de Fluidos Corporales/fisiología , Hemodiafiltración/efectos adversos , Ultrasonografía/métodos , Adulto , Anciano , Presión Sanguínea/fisiología , Volumen Sanguíneo/fisiología , Mareo/etiología , Femenino , Frente/diagnóstico por imagen , Frente/fisiopatología , Frecuencia Cardíaca/fisiología , Hematócrito , Humanos , Hipotensión/diagnóstico por imagen , Hipotensión/etiología , Masculino , Persona de Mediana Edad , Calambre Muscular/etiología , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/fisiopatologíaRESUMEN
We have studied changes in peripheral tissue thickness with a novel hand-held ultrasound device during the perioperative course of 60 healthy surgical patients in three different intraoperative body positions. The nil-by-mouth period led to a significant decrease in forehead tissue thickness. Standardized infusion therapy with Ringer's solution at a rate of 8 ml kg-1 h-1 resulted in a gradual increase in tissue thickness, which was significantly different from preoperative baseline values after 90 min. Packed cell volume decreased significantly after the start of infusion and remained low over the rest of the observation time. Different body positions did not influence changes in tissue thickness. We conclude that changes in perioperative tissue thickness in healthy patients can be detected easily by ultrasound, independent of body position. This method may prove useful for the non-invasive assessment of fluid balance state.