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Purpose: After cardiac surgery, fluid bolus therapy (FBT) with 20% human albumin may facilitate less fluid and vasopressor administration than FBT with crystalloids. We aimed to determine whether, after cardiac surgery, FBT with 20% albumin reduces the duration of vasopressor therapy compared with crystalloid FBT. Methods: We conducted a multicentre, parallel-group, open-label, randomised clinical trial in six intensive care units (ICUs) involving cardiac surgery patients deemed to require FBT. We randomised 240 patients to receive up to 400 mL of 20% albumin/day as FBT, followed by 4% albumin for any subsequent FBT on that day, or to crystalloid FBT for at least the first 1000 mL, with use of crystalloid or 4% albumin FBT thereafter. The primary outcome was the cumulative duration of vasopressor therapy. Secondary outcomes included fluid balance. Results: Of 480 randomised patients, 466 provided consent and contributed to the primary outcome (mean age 65 years; median EuroSCORE II 1.4). The cumulative median duration of vasopressor therapy was 7 (interquartile range [IQR] 0–19.6) hours with 20% albumin and 10.8 (IQR 0–22.8) hours with crystalloids (difference − 3.8 h, 95% confidence interval [CI] − 8 to 0.4; P = 0.08). Day one fluid balance was less with 20% albumin FBT (mean difference − 701 mL, 95% CI − 872 to − 530). Conclusions: In patients after cardiac surgery, when compared to a crystalloid-based FBT, 20% albumin FBT was associated with a reduced positive fluid balance but did not significantly reduce the duration of vasopressor therapy. [ABSTRACT FROM AUTHOR]

Background/Objective: Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality. Methods: We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNaSD), an index of variability, and 28-day mortality. Results: Patients were 46 ± 19 years of age with a median initial GCS of 6 [4–8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0–3.9] mmol/L. Maximum daily serum sodium standard deviation (dNaSD) occurred at a median of 2 [1–4] days after admission. There was a significant progressive decrease in dNaSD over the first 7 days (coefficient − 0.15 95% CI [− 0.18 to − 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNaSD was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01–1.61), p = 0.048). Conclusions: Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients. [ABSTRACT FROM AUTHOR]

Two patients with ornithine transcarbamylase deficiency, a urea cycle disorder, were transferred to our intensive care unit within 12 months. Both were previously healthy men who initially presented with nondescript but progressive neurological symptoms after minor procedures (case summaries in Box 1). Each patient developed their initial neurological symptoms (headache, mental slowness, incoordination) about 24e48 hours after the likely precipitant, which in each case was a single dose of a corticosteroid. In Patient 1, sleepiness at 48 hours progressed to incoherence, blurred vision, and severe agitation that required intubation 2 days later. In Patient 2, headache, nausea, blurred vision and epigastric pain at 48 hours progressed over the following 2 days to confusion and slow speech; by the following day, coma had developed, requiring intubation. On their presentation to a peripheral hospital, an extensive panel of pathology investigations had been undertaken for each patient, including blood tests (full blood count, renal function tests, liver enzyme levels, coagulation profile and inflammatory markers), lumbar puncture and brain imaging (computed tomography and magnetic resonance imaging). The results of these investigations were all unremarkable. Identification of significant hyperammonaemia was delayed until about 36–48 hours after presentation to hospital. The patients were comatose when transferred to our hospital. Patient 1 had a prolonged stay in our intensive care unit, with a persistent minimally conscious state; Patient 2 proceeded to brain death and organ donation. [ABSTRACT FROM AUTHOR]

Liver abscess due to Klebsiella pneumoniae infection has been widely reported in Asia, but rarely reported in Australia until now. We describe four previously well Asian-born patients who presented across Australia with community-acquired K. pneumoniae liver abscesses. With prompt recognition, appropriate antibiotics and early drainage, outcome is significantly improved, although vigilance for metastatic complications is essential. [ABSTRACT FROM AUTHOR]

The article examines the cases of four Asian-born patients from across Australia with community acquired Klebsiella (K.) pneumonia liver abscesses. According to the authors, all the patients were admitted to the hospital after experiencing gastro-intestinal and other symptoms. Computer tomography scans revealed liver abscess and K. pneumoniae infection was diagnosed after abscess fluid or blood was cultured.