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Postexercise hydration is fundamental to replace fluid loss from sweat. This study evaluated rehydration and gastrointestinal (GI) symptoms for each of three beverages: water (W), sports drink (SD), and skimmed, lactose-free milk (SLM) after moderate-intensity cycling in the heat. Sixteen college students completed three exercise sessions each to lose ≈2% of their body mass. They drank 150% of body mass loss of the drink assigned in randomized order; net fluid balance, diuresis, and GI symptoms were measured and followed up for 3 hr after completion of fluid intake. SLM showed higher fluid retention (∼69%) versus W (∼40%; p <.001); SD (∼56%) was not different from SLM or W (p >.05). Net fluid balance was higher for SLM (−0.26 kg) and SD (−0.42 kg) than W (−0.67 kg) after 3 hr (p <.001), resulting from a significantly lower diuresis with SLM. Reported GI disturbances were mild and showed no difference among drinks (p >.05) despite ingestion of W (1,992 ± 425 ml), SD (1,999 ± 429 ml), and SLM (1,993 ± 426 ml) in 90 min. In conclusion, SLM was more effective than W for postexercise rehydration, showing greater fluid retention for the 3-hr follow-up and presenting with low-intensity GI symptoms similar to those with W and SD. These results confirm that SLM is an effective option for hydration after exercise in the heat. [ABSTRACT FROM AUTHOR]

The article presents a case study of congenital chloride diarrhea (CCD) that was misdiagnosed as Hirschsprung's disease, highlighting the importance of accurate diagnosis to avoid unnecessary surgery. Topics discussed include the clinical presentation and genetic factors of CCD, diagnostic challenges associated with distinguishing CCD from similar conditions, and the management strategies that can be employed to treat the disorder effectively.

Background: Hemodynamic monitoring is crucial for the comprehensive management of children with sepsis, particularly those involving the kidneys. Sepsis-associated acute kidney injury (S-AKI) is closely linked to poor outcomes. Recently, ultrasonography modalities have been widely accepted as a non-invasive, rapid, and reliable tool for assessing volume status. We conducted research to determine intravascular volume based on ultrasound examination in S-AKI patients. Methods: A prospective cohort study was conducted between December 2023 and March 2024 in the Pediatric Intensive Care Unit (PICU) at Hasan Sadikin General Hospital. We divided the patients into two groups: those with sepsis without AKI and those with S-AKI. The intravascular volume was measured by the IVC/Ao (inferior vena cava/abdominal aorta) ratio using two-dimensional ultrasonography and USCOM before and 24 h after fluid treatment. The results were analyzed using SPSS 25, with a significance level of p < 0.05. Results: A total of 36 pediatric patients (aged 1 month–18 years) with sepsis were included. The IVC/Ao ratio before and after the fluid intervention demonstrated significant differences between the two groups (p < 0.001). USCOM Cardiac Index (CI) before and after the intervention also showed significant differences between the two groups (p < 0.001). Patients with S-AKI exhibited a poor hemodynamic response in the IVC/Ao ratio two-dimensional ultrasonography and USCOM examination. Conclusions: IVC/Ao ratio measurement is as accurate as USCOM and can be used as a simple and cost-effective alternative for hemodynamic monitoring. [ABSTRACT FROM AUTHOR]

Children with chronic kidney disease (CKD) can have an inherent vulnerability to dehydration. Younger children are unable to freely access water, and CKD aetiology and stage can associate with reduced kidney concentrating capacity, which can also impact risk. This article aims to review the risk factors and consequences of mild dehydration and underhydration in CKD, with a particular focus on evidence for risk of CKD progression. We discuss that assessment of dehydration in the CKD population is more challenging than in the healthy population, thus complicating the definition of adequate hydration and clinical research in this field. We review pathophysiologic studies that suggest mild dehydration and underhydration may cause hyperfiltration injury and impact renal function, with arginine vasopressin as a key mediator. Randomised controlled trials in adults have not shown an impact of improved hydration in CKD outcomes, but more vulnerable populations with baseline low fluid intake or poor kidney concentrating capacity need to be studied. There is little published data on the frequency of dehydration, and risk of complications, acute or chronic, in children with CKD. Despite conflicting evidence and the need for more research, we propose that paediatric CKD management should routinely include an assessment of individual dehydration risk along with a treatment plan, and we provide a framework that could be used in outpatient settings. [ABSTRACT FROM AUTHOR]

Positive end-expiratory pressure results in a sustained positive intrathoracic pressure, which exerts pressure on intrathoracic vessels, resulting in cardiopulmonary interactions. This sustained positive intrathoracic pressure is known to decrease cardiac preload, and thus, decrease venous return, ultimately reducing both the stroke volume and stressed blood volume of the cardiovascular system. Currently, cardiovascular and pulmonary care are provided independently of one another. That positive end-expiratory pressure alters both stroke volume and stressed blood volume suggests both the pulmonary and cardiovascular state should be conjointly optimised. Optimising these systems in isolation may benefit one system, but have highly detrimental effects on the other. A combined cardiopulmonary model has the potential to provide a better understanding of patient specific pulmonary and cardiovascular state, as well as resulting cardiopulmonary interactions. This would enable simultaneous optimisation of all cardiovascular and pulmonary parameters. Cardiopulmonary interactions are highly patient specific and unpredictable, making accurate modelling of these interactions challenging. A previously validated cardiopulmonary model was found to have increasing errors at high positive end-expiratory pressures. A new iteration, the alpha model, was introduced to resolve this issue. This paper aims to review the alpha model against its predecessors, the previous cardiopulmonary model, and the original three chamber cardiovascular system model. All models are used to identify cardiovascular system parameters from measurements of 4 pigs during a preload reduction manoeuvre. Outputs and parameter estimations from models are compared to assess the relative performance of the alpha model against its predecessors. The novel alpha model was able to reduce model errors under high positive end-expiratory pressure, resulting in more accurate model outputs. At high positive end-expiratory pressures (20cmH2O), the alpha model had an average error of 11.24%, while the original cardiopulmonary model had a much higher error of 52.21%. Furthermore, identified outputs of the alpha model more closely matched those of the 3 chamber model than the previous cardiopulmonary model. On average, at high positive end-expiratory levels, identified model parameters from the alpha model showed a 6.21% difference to those of the 3 chamber model, while the cardiopulmonary model displayed a 39.43% difference. The alpha model proved to be more stable than the original cardiopulmonary model, making it a good candidate for model based care. However, it produced similar parameter outputs to the simpler three chamber cardiovascular model, bringing into question whether the additional complexity is justified, especially considering the low availability of clinical data in the ICU. There is a critical need for model based care to guide important procedures in ICU, such as fluid therapy. Candidate models should be continuously reviewed in order to guarantee the best possible care. [ABSTRACT FROM AUTHOR]

During the disease trajectory, patients with advanced heart failure are often hospitalised with a high probability of admission to the intensive care setting. Using a case study, this article explores the care given to a patient with decompensated heart failure in an intensive care unit (ICU). It will discuss the significance of holistic assessment and effective symptom management, in particular the research related to breathlessness management. The importance of effective communication within the ICU multidisciplinary team, including with the patient/family will be explored, as the ICU environment can often lead to communication breakdown, patients being unable to voice their wishes and over-medicalisation. The effectiveness of early involvement of the palliative care team in ICU will be examined, including the use of tools such advance care planning and a treatment escalation plan and whether use of these can enable a better patient and family experience at the end of life. The role of palliative care champions will be discussed. [ABSTRACT FROM AUTHOR]

The document contains abstracts from the 2024 Scandinavian Society of Anaesthesia and Intensive Care Congress in Oulu, Finland, covering various studies on topics such as postpartum depression risk, propofol dose requirements, inappropriate prescribing patterns, and care for children with neurodevelopmental disorders. The studies aim to provide insights into mortality rates, patient outcomes, and quality of life in different medical contexts, emphasizing the need for tailored approaches and standardized practices to improve patient outcomes. The document also discusses studies related to critical care in patients with acute brain injury, traumatic brain injury, cardiac arrest, sepsis, and aneurysmal subarachnoid hemorrhage, highlighting potential benefits of interventions in improving survival rates and patient outcomes. Additionally, the text presents findings from research studies in the field of anesthesiology and pain management, exploring topics such as postoperative delirium prediction, pain catastrophizing, pain management protocols, and the feasibility of different pain relief methods. The studies underscore the importance of tailored care, multidisciplinary approaches, and standardized guidelines in improving patient outcomes and quality of care in anesthesia and critical care settings. [Extracted from the article]

Objective: To evaluate the utility of Pulse index Contour Continuous Cardiac Output (PiCCO) monitoring in critically ill patients. Study Design: Cross-sectional study. Setting: Intensive Care Unti of Sindh Institute of Urology and Transplant, Karachi, Pakistan. Period: October 2022 to March 2023. Methods: Patients presenting with various types of shock, requiring high-dose vasopressors or inotropes, and not responding to initial fluid therapy were analyzed. Demographic details, SOFA score, APACHE score, and invasive hemodynamic parameters using the PiCCO system were documented. Results: Out of 142 ICU admissions, 38 patients were included in the study. Most patients were males (73%) with a median age of 39 years. Significant changes were observed in the cardiac index, cardiac performance index, global ejection fraction, and systemic vascular resistance index (SVRI), all with p-values less than 0.05. The interventions included the initiation of inotropes in 22 patients (57.8%), diuretics in 4 patients (10.5%), and intravenous fluids in 19 patients (50%). Additionally, vasopressor doses were adjusted in 18 patients (47.3%). Initially, patients were presumed to have pure septic shock based on CO2 gap, mixed venous saturation, and echocardiographic assessment. However, after applying PiCCO monitoring, the diagnosis was revised to mixed shock in 21 patients (55.2%). Conclusion: PiCCO monitoring appears to be a valuable tool in the ICU for managing patients with complex hemodynamic profiles, facilitating targeted interventions that lead to significant improvements in hemodynamic stability. [ABSTRACT FROM AUTHOR]

Background and Aim: We aimed to evaluate comparative outcomes of aggressive versus non‐aggressive intravenous fluid (IVF) therapy in patients with acute pancreatitis. Methods: A systematic search of electronic data sources and bibliographic reference lists were conducted. All randomized controlled trials (RCTs) reporting outcomes of aggressive versus non‐aggressive IVF therapy in acute pancreatitis were included and their risk of bias were assessed. Effect sizes were determined for overall mortality, systemic inflammatory response syndrome (SIRS), sepsis, respiratory failure, pancreatic necrosis, severe pancreatitis, clinical improvement, AKI, and length of stay using random‐effects modeling. Trial sequential analysis was conducted to determine risk of types 1 or 2 errors. Results: We included 10 RCTs reporting 993 patients with acute pancreatitis who received aggressive (n = 475) or non‐aggressive (n = 518) IVF therapy. Aggressive IVF therapy was associated with significantly higher rate of sepsis (OR: 2.68, P = 0.0005) and longer length of stay (MD: 0.94, P < 0.00001) compared with the non‐aggressive approach. There was no statistically significant difference in mortality (RD: 0.02, P = 0.31), SIRS (OR: 0.93, P = 0.89), respiratory failure (OR: 2.81, P = 0.07), pancreatic necrosis (OR: 1.98, P = 0.06), severe pancreatitis (OR: 1.31, P = 0.38), clinical improvement (OR: 1.12, P = 0.83) or AKI (OR: 1.06, P = 0.91) between the two groups. Sub‐group analysis demonstrated higher morbidity and mortality associated with the aggressive approach in more severe disease. Trial sequential analysis detected risk of type 2 error. Conclusions: Aggressive IVF therapy may be associated with higher morbidity in patients with acute pancreatitis compared with the non‐aggressive approach, particularly in patients with more severe disease. It may also prolong length of hospital stay. The available evidence is subject to type 2 error indicating the need for adequately powered RCTs. [ABSTRACT FROM AUTHOR]

Intestinal ligation during ovariohysterectomy has not been previously reported in dogs. Risk factors for this complication appear to be the same as those for ureteral injury, namely decreased surgical visualization due to small patient size and small incision size. This case report describes how the presentation of intestinal ligation in a 2‐kg, 11‐month‐old chihuahua can mimic that of iatrogenic ureteral injury with vomiting, anorexia, and severe azotemia. Ultrasound served as a key diagnostic to visualize intestinal mechanical obstruction, an encircling ligature around a segment of jejunum with no blood flow on Doppler interrogation, and normal appearance and blood flow of the ureters and kidneys. The treatment consisted of aggressive fluid therapy, circulatory support, and emergent resection and anastomosis of the necrotic portion of the intestines. Within 48 h, the dog's azotemia was resolved, and it was reported to be doing well at 1‐month follow‐up. [ABSTRACT FROM AUTHOR]

Purpose: This case report describes a patient with a pelvic kidney associated with an aortoiliac aneurysm amenable to open repair. Methods: We chose the selective cold renal perfusion to preserve renal function. Results: Other techniques such as transient or permanent extra-anatomic bypass, extracorporeal circulation and proximal aortic double clamping are also described in this report. Conclusions: Choosing the renal perfusion technique depended on the anatomical evaluations of the kidney and the renal artery location during the preoperative period. [ABSTRACT FROM AUTHOR]

The article focuses on a 3-year-old boy with autism and speech delay who presented with general malaise and refusal to eat, leading to dehydration concerns. Topics include his clinical presentation with constipation and poor intake, his initial emergency room evaluation for dehydration, and his physical examination findings, which showed mild signs of dehydration but no other acute symptoms.s.

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Objective This study aimed to assess the beneficial effects of N-acetylcysteine (NAC) in the treatment of contrast-induced nephropathy (CIN). Materials and Methods A prospective study was conducted in the department of cardiology of a tertiary health care hospital. A sample of 100 patients who had developed CIN through coronary angioplasty were categorized into two groups: one group treated with intravenous fluids (IVF) monotherapy and the other group treated with the combination of IVF and NAC therapy. Statistical Analysis The data were analyzed using statistical software SPSS software version 26 and statistical significance was set at p < 0.05. Independent t -test and paired t -test were used to analyze the parameters. Results The rate of incidence of CIN was found to be 10%. We observed that the IVF + NAC combination therapy significantly decreases the serum creatinine compared to IVF monotherapy (p = 0.004). Both therapies show similar treatment outcomes with no significant difference (p = 0.556) in the case of estimated glomerular filtration rate (eGFR). Based on creatinine clearance, the results show adding NAC does not impact any additional benefits (p = 000). The duration of hospital stay of the NAC group was reduced significantly (p = 0.000). Conclusion At present, we found that the treatment outcomes which we analyzed based on factors such as serum creatinine, eGFR, and creatinine clearance, are too inconsistent to conclude the beneficial effect of NAC in the management of CIN. [ABSTRACT FROM AUTHOR]

This article presents a case report of a patient who had both COVID-19 and systemic capillary leak syndrome (SCLS), resulting in severe myocardial injury. The patient experienced symptoms such as fever, fatigue, and respiratory distress, and was diagnosed with cardiogenic shock and SCLS. The patient received treatment including mechanical circulatory support, steroids, and intravenous immunoglobulin, which led to an improvement in cardiac function. The article emphasizes the challenges faced in treating patients with COVID-19-related myocardial injury and SCLS, and highlights the potential treatment options available. [Extracted from the article]

Background: Dengue virus remains a major public health problem with one of the hallmark pathologies is the vascular leakage caused by endothelial dysfunction which can lead to Dengue Hemorrhagic Fever (DHF) manifestation. In the status quo, no specific therapy has been discovered but rather heavily relies on judicious and frequent monitoring of intravenous fluids administration. The current guideline has discussed the roles of fluid therapy during the Dengue Shock Syndrome (DSS) stage, however, administration of early fluid intervention for DHF grade I and II remains uncharted territory. In addition, the choice and timing of colloid administration remains underexplored. As one of the widely available colloids, 5% albumin has known physiological properties that potentially minimize plasma leakage. Therefore, this study aimed to evaluate the benefit of early intervention of 5% albumin in adults with DHF in the hope of preventing the lethal progression to DSS and further, shorten the length of stay (LOS) for patients. Methods: We conducted a multicenter, open-labeled, randomized controlled trial in Jakarta and Banten to compare the effect of early intervention with 5% albumin in adult patients with DHF compared to Ringer's Lactate (RL). Statistical analyses were conducted using unpaired t-test and Mann-Whitney for normally and abnormally distributed data respectively. Results: Adult patients with a diagnosis of DHF grade I and II that being hospitalized to receive the early intervention of 5% albumin had significantly lower levels of hemoconcentration 4, 12, and 24 h (p = 0.002, 0.001, 0.003, respectively), higher platelet counts 4 h (p = 0.036), higher serum albumin levels 48 h (p = 0.036), lower proteinuria 24 and 48 h post-albumin administration (p < 0.001, < 0.001, respectively), and shorter LOS (p < 0.001) when compared to the RL group. Conclusion: Early intervention of 5% albumin showed better control on vascular integrity and function compared to ringer lactate in hospitalized adults with grade I & II DHF, thus halting the progression of DHF into DSS and other related complications which leads to faster recovery and shorter length of stay. Trial registration: The study was registered to www.clinicaltrial.gov with trial registration number NCT04076254, and registration date October 31st 2016. [ABSTRACT FROM AUTHOR]

Introduction: In adult horses, the development and evaluation of enteral electrolyte solutions containing sodium acetate for correcting hyperchloremic metabolic acidosis are still lacking, although these electrolyte and acid-base imbalances are commonly observed. The objective of this study was to evaluate the alkalinizing effect of two enteral electrolyte solutions containing different concentrations of acetate, administered via nasogastric tube in continuous flow, in adult horses with experimental hyperchloremic metabolic acidosis. Methods: Six mares aged between 3 and 10 years were used in a 6×2 crossover design, with each animal receiving both treatments. The horses were subjected to a protocol to induce hyperchloremic metabolic acidosis. They then received one of two treatments: HighAcetate (81.4 mmol/L) and LowAcetate (22.7 mmol/L) at an infusion rate of 15 mL/kg/h for 12 h. Plasma, serum, and urinary biochemical assessments; hematocrit; urinary volume, pH, and specific gravity; and blood gas analysis were measured at the following time points: T-12 h (beginning of the 12-h fast), T0h (end of fasting and beginning of the acidosis induction phase), every 2 h during the hyperchloremic metabolic acidosis induction phase (Ti2h and Ti4h), every 2 h during the 12-h enteral hydration phase (Tt2h, Tt4h, Tt6h, Tt8h, Tt10h, and Tt12h), with one sample taken at T24h (24 h after the start of acidosis induction) and another at T36h (36 h after the start of acidosis induction). Data were analyzed using descriptive statistics and analysis of variance based on a factorial design of repeated measures, with Tukey's post-hoc test or the Kruskal-Wallis test with Dunn's post-hoc test for non-parametric tests. Results: At the end of the induction phase, the animals developed moderate to severe hyperchloremic metabolic acidosis. The HighAcetate solution effectively corrected electrolyte and acid-base imbalances before the end of the treatment phase (Tt12h), while the LowAcetate solution was not effective in correcting those changes. Conclusion: The HighAcetate (81.4 mmol/L) solution is deemed an effective and safe alternative for the treatment of hyperchloremic metabolic acidosis in horses. [ABSTRACT FROM AUTHOR]

Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters. [ABSTRACT FROM AUTHOR]

Background: Our aim was to evaluate the influence of staged goal directed therapy (GDT) on postoperative pulmonary complications (PPCs), intraoperative hemodynamics and oxygenation in patients undergoing Mckeown esophagectomy. Methods: Patients were randomly divided into three groups, staged GDT group (group A, n = 56): stroke volume variation (SVV) was set at 8–10% during the one lung ventilation (OLV) stage and 8–12% during the two lung ventilation (TLV) stage, GDT group (group B, n = 56): received GDT with a target SVV of 8–12% During the entire surgical procedure, and control group (group C, n = 56): conventional fluid therapy was administered by mean arterial pressure (MAP), central venous pressure (CVP), and urine volume. The primary outcome was the incidence of postoperative pulmonary complications within Postoperative days (POD) 7. The secondary outcomes were postoperative lung ultrasound (LUS) B-lines artefacts (BLA) scoring, incidence of other complications, the length of hospital stay, intraoperative hemodynamic and oxygenation indicators included mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), cardiac output (CO), oxygenation index (OI), respiratory indices (RI), alveolar-arterial oxygen difference (Aa-DO2). Results: Patients in group A and group B had a lower incidence of PPCs (7/56 vs. 17/56 and 9/56 vs. 17/56, p < 0.05), and a fewer B-lines score on postoperative ultrasound (4.61 ± 0.51 vs. 6.15 ± 0.74 and 4.75 ± 0.62 vs. 6.15 ± 0.74, p < 0.05) compared to group C. The CI, CO, MAP, and OI were higher in group A compared to group B and group C in the stage of thoracic operation. During the abdominal operation stage, patients in group A and group B had a better hemodynamic and oxygenation indicators than group C. Conclusions: In comparison to conventional fluid therapy, intraoperative staged GDT can significantly reduce the incidence of postoperative pulmonary complications in patients undergoing McKeown esophagectomy, facilitating patient recovery. Compared to GDT, it can improve intraoperative oxygenation and stabilize intraoperative hemodynamics in patients. Trial registration: This study was registered in the Chinese Clinical Trial Registry on 24/11/2021 (ChiCTR2100053598). [ABSTRACT FROM AUTHOR]

Background: During gynecological laparoscopic surgery, pneumoperitoneum and the Trendelenburg position (TP) can lead to increased intracranial pressure (ICP). However, it remains unclear whether perioperative fluid therapy impacts ICP. The purpose of this research was to evaluate the impact of restrictive fluid (RF) therapy versus conventional fluid (CF) therapy on ICP in gynecological laparoscopic surgery patients by measuring the ratio of the optic nerve sheath diameter (ONSD) to the eyeball transverse diameter (ETD) using ultrasound. Methods: Sixty-four patients who were scheduled for laparoscopic gynecological surgery were randomly assigned to the CF group or the RF group. The main outcomes were differences in the ONSD/ETD ratios between the groups at predetermined time points. The secondary outcomes were intraoperative circulatory parameters (including mean arterial pressure, heart rate, and urine volume changes) and postoperative recovery indicators (including extubation time, length of post-anaesthesia care unit stay, postoperative complications, and length of hospital stay). Results: There were no statistically significant differences in the ONSD/ETD ratio and the ONSD over time between the two groups (all p > 0.05). From T2 to T4, the ONSD/ETD ratio and the ONSD in both groups were higher than T1 (all p < 0.001). From T1 to T2, the ONSD/ETD ratio in both groups increased by 14.3%. However, the extubation time in the RF group was shorter than in the CF group [median difference (95% CI) -11(-21 to -2) min, p = 0.027]. There were no differences in the other secondary outcomes. Conclusion: In patients undergoing laparoscopic gynecological surgery, RF did not significantly lower the ONSD/ETD ratio but did shorten the tracheal extubation time, when compared to CF. Trial registration: ChiCTR2300079284. Registered on December 29, 2023. [ABSTRACT FROM AUTHOR]

Introduction: Ileostomy, frequently created after colorectal resections, hinders the physiologic function of the colon and can lead to dehydration and acute kidney injury due to high stoma outputs. This study aimed to evaluate the effectiveness of preventive measures on ileostomy-induced dehydration and related readmissions in a high-volume unit. Methods: In this prospective cohort study at a high-volume colorectal surgery department in Turkiye, the Prospective Ileostomy-induced Dehydration Prevention Bundle Project (PIDBP) was assessed from March 2021 to March 2022. The study enrolled patients undergoing colorectal surgery with ileostomy and involved comprehensive inpatient stoma care, education, and a structured post-discharge follow-up. The follow-up included the "Hydration follow-up scale" to monitor ileostomy output and related complications. The primary outcome was the readmission rate due to dehydration-related complications. The patients receiving the bundle intervention were compared with patients treated in the preceding year, focusing on the effectiveness of interventions such as dietary adjustments, fluid therapy, and pharmacological management. Results: In the study, 104 patients were analyzed, divided into 54 pre-bundle and 50 bundle group patients, with no significant differences in patient characteristics. While the overall readmission rate due to dehydration was 12.5%, a significant reduction in dehydration-related readmissions was observed in the bundle group compared to the pre-bundle group (2% vs. 22%, p = 0.002). Univariate analysis identified high stoma output (> 800 ml/24 h) (p < 0.001), chronic renal failure (CRF) (p = 0.01), postoperative ileus (p = 0.03), higher ASA status (p = 0.04), extended hospital stays (p = 0.03), and small bowel resections (especially in J-pouch patients) (p < 0.001) as significant predictors of readmission. Multivariate analysis revealed that the mean ileostomy output before discharge was the sole significant predictor of dehydration-related readmission (OR 1.01), with an optimal cutoff of 877.5 ml/day identified with an area under the curve (AUC) of 0.947, demonstrating high sensitivity (92.3%) and specificity (86.8%) in predicting readmission risk. Conclusion: The Prospective Ileostomy-induced Dehydration Prevention Bundle Project significantly reduced readmission rates after colorectal surgery. [ABSTRACT FROM AUTHOR]

Fluid therapy is a fundamental part of supportive therapy in critical care. However, it is also a suspected risk for endothelial glycocalyx degradation which is associated with poor clinical outcomes. This secondary analysis of RESPONSE randomized trial compares the effect of follow-up strategy (FU) on endothelial biomarkers to that of 500 ml crystalloid fluid bolus (FB) in oliguric, hemodynamically optimized intensive care unit (ICU) patients. 130 adult subjects were enrolled in two Finnish ICUs from January 2017 to November 2020. Blood and urine samples of 63 patients in FU group and 67 patients in FB group were collected before and after the intervention and analyzed using enzyme-linked immunosorbent assays. Single fluid bolus, given after median of 3887 ml (interquartile range 2842; 5359 ml) resuscitation fluids in the preceding 24 h, increased plasma hyaluronan concentration compared to the follow-up strategy (difference in medians 29.2 ng/ml with 95% CI [14.5ng/ml; 55.5ng/ml], P < 0.001). No treatment effect was detected in the plasma levels of syndecan-1, , angiopoietin-2, angiopoietin receptors Tie2 and Tie1, or in soluble thrombomodulin in the adjusted median regression analysis. The increase in hyaluronan was independent of its simultaneous renal clearance but correlated moderately with the increase in endothelium-specific Tie1. The follow-up strategy did not show consistent endothelium-sparing effect but protected against hyaluronan increase. The mechanisms and consequences of hyaluronan fluctuations need further clarification. Trial registration: clinicaltrials.gov, NCT02860572. Registered 1 August 2016, https://www.clinicaltrials.gov/study/NCT02860572?term=NCT02860572&rank=1 [ABSTRACT FROM AUTHOR]

Background: Cytokine release syndrome (CRS) is an acute systemic inflammatory syndrome characterized by fever and multiple organ failure, which is triggered by immunotherapy or certain infections. Immune checkpoint inhibitors rarely cause immune-related adverse event- cytokine release syndrome (irAE-CRS). This article presents a case report of irAE-CRS triggered by coronavirus disease 2019 (COVID-19). Case presentation: A 60-year-old man with type 2 diabetes received nivolumab treatment for esophagogastric junction carcinoma and experienced two immune-related adverse events: hypothyroidism and skin disorder. Eleven days before his visit to our hospital, he had a fever and was diagnosed with COVID-19. Five days before his visit, he developed a fever again, along with general malaise, water soluble diarrhea, and myalgia of the extremities. On admission, the patient was in a state of multiple organ failure, and although the source of infection was unknown, a tentative diagnosis of septic shock was made. The patient's condition was unstable despite systemic management with antimicrobial agents, high-dose vasopressors, and intravenous fluids. We suspected CRS due to irAE (irAE-CRS) based on his history of nivolumab use. Steroid pulse therapy (methylprednisolone 1 g/day) was started, and the patient temporarily recovered. However, his respiratory condition worsened; consequently, he was placed on a ventilator and tocilizumab was added to the treatment. His muscle strength recovered to the point where he could live at home, and was subsequently discharged. Conclusion: In patients previously treated with immune checkpoint inhibitors, irAE-CRS should be considered as a differential diagnosis when multiple organ damage is observed in addition to inflammatory findings. It is recommended to start treatment with steroids; if the disease is refractory, other immunosuppressive therapies such as tocilizumab should be introduced as early as possible. [ABSTRACT FROM AUTHOR]

Background: Patients with severe infection often require careful fluid management. Intravenous linezolid can increase the fluid volume, whereas oral linezolid can effectively limit the fluid volume. However, the differences in the treatment effect and incidence of thrombocytopenia between oral and intravenous linezolid in patients with severe infection remain unclear. Methods: Patients who received linezolid in the intensive care unit of PLA General Hospital from December 2010 to December 2020 were divided into an oral group and intravenous group according to the route of administration, and we further established the PO group and PO-match group by propensity score matching. The anti-infection effect of linezolid and incidence of thrombocytopenia were compared between the two groups. Results: In total, 177 patients were enrolled in the study (59 in PO group and 118 in PO-match group). The microbial clearance rate and clinical cure rate were similar between the two groups (70.0% vs. 79.3%, P = 0.293; 72.9% vs. 83.9%, P = 0.213). The 30-day mortality rate was slightly higher in the PO group than in the PO-match group, but the difference was not statistically significant (13.6% vs. 6.8%, P = 0.138). There was no difference in the incidence of thrombocytopenia between the two groups (62.7% vs. 65.3%, P = 0.739). Conclusions: There were no significant differences in the treatment effect or incidence of thrombocytopenia between oral and intravenous administration of linezolid in patients with severe infection. [ABSTRACT FROM AUTHOR]

Introduction. Fluid therapy is an intervention widely used in clinical practice. However, its application is not without risks and requires a careful evaluation of patient’s tolerance and response to volume. The empirical practice of fluid resuscitation can be potentially lethal. The purpose of this review was to provide an overview of the physiological and therapeutic principles for the administration of intravenous fluids in critically ill patients, addressing special populations, such as surgical, septic, and trauma patients. Methods. A narrative review was carried out based on articles published in PUBMED, ScienceDirect, and LILACS between 2001 and 2023. MESH terms fluid therapy, crystalloid solutions, and colloids were employed. Results. A total of 371 articles were found, of which randomized clinical trials studies, narrative reviews, systematic reviews, and meta-analyses that analyzed the role of crystalloids and colloids were selected. Manuscripts published on dates outside the search range, which were considered relevant for the description of the pathophysiology and the rationale for the use of intravenous fluids, were included. Conclusion. Reflective resuscitation is based on a holistic understanding of physiology and individualization of fluid therapy. The liberal use of intravenous fluids has potential harmful effects and resuscitation strategies should be guided by individual dynamic and static measures, which provide a safe framework for fluid management. [ABSTRACT FROM AUTHOR]

Why you should read this article: • UK care homes are an important example of a complex environment where research is essential but faces multiple challenges in terms of rigour and methodology • This paper offers a variety of important methodological strategies to identify and address challenges that could impact findings and the ability to carry out research • It highlights the importance of taking a critical stance with all elements of the research process and illustrates the need to identify and mitigate challenges when conducting research in complex environments. Background: The evidence base for hydration practice in care homes is underdeveloped. High-quality research is therefore needed to determine what practices support older people with dementia in drinking sufficient fluid. However, methodological developments are needed to be able to do this. Aim: To highlight the methodological issues researchers encountered during a feasibility cluster, randomised controlled trial of ThinkDrink, a hydration care guide for people with dementia living in UK care homes. Discussion: This is a challenging area because of the complexity of recruitment, participation and data collection in care homes. Researchers must pay extra attention to rigour and quality in the design of their studies. There may be multiple challenges, so various strategies may be required. Conclusion: It is important that researchers continue to reflect on rigorous approaches to develop evidence in a crucial area of care, despite these challenges. Implications for practice: Researchers working in complex environments face a variety of challenges to complete methodologically rigorous research. It is important for researchers to be critical of research processes and data, to mitigate and overcome these challenges. [ABSTRACT FROM AUTHOR]

Objective: The endothelial glycocalyx layer (EGL) is the interface between the blood and the endothelium that regulates permeability. This study compared the effects of liberal and restrictive fluid therapies on atrial natriuretic peptide (ANP) release and EGL products in radical cystectomy surgery. We hypothesized that a liberal regimen would damage the glycocalyx layer, resulting in a higher serum EGL product concentration than restrictive therapy. Materials and Methods: Patients were randomized into two groups for restrictive (group R) or liberal (group L) regimens. Group R received 2 mL/kg/h Ringer’s lactate and 2 mcg/kg/h norepinephrine infusion, whereas group L received only Ringer’s lactate infusion at 10 mL/kg/h rate during the surgery. Preoperative and postoperative blood samples were obtained to evaluate ANP levels and glycocalyx degradation products. The stroke volume index, cardiac index, stroke volume variation, and systemic vascular resistance index parameters were recorded at 30-min intervals throughout the surgery. The length of stay in the hospital and intensive care unit and postoperative complications were recorded. Results: The study was completed with 39 patients. Postoperative ANP levels were higher in group L in both between- and within group examination (p<0.05). EGL constituents; syndecan-1 and hyaluronan concentrations, were higher in group L (p<0.05). Advanced hemodynamic parameters indicated insignificant changes between the groups (p>0.05). Postoperative complications and length of stay data were similar (p>0.05). Conclusion: ANP, hyaluronan, and syndecan-1 concentrations can be used as an indirect measurement method to show EGL damage and hypervolemia in major urologic surgeries. Advanced hemodynamic monitoring was ineffective for confirming hypervolemia. [ABSTRACT FROM AUTHOR]

Objectives Neurosurgical patients often receive 0.9% normal saline (NS) during the perioperative period. Theoretically, a balanced salt solution (BSS) is better than 0.9% saline. We compared the effects of two different fluids on acid–base balance, renal function, and neurological outcome in patients who underwent clipping following subarachnoid hemorrhage from a ruptured intracranial aneurysm. Materials and Methods Patients in group NS (n = 30) received 0.9% saline and group BSS (N = 30) received BSS (Plasmalyte-A) in the perioperative period for 48 hours. Comparison of arterial pH, bicarbonate, and base deficit measured preoperatively, intraoperatively (first and second hour), and postoperatively (at 24 and 48 hours) was the primary outcome of the study. The secondary outcome compared serum electrolytes, renal function tests, urine neutrophil gelatinase-associated lipocalin (NGAL), serum cystatin C, and the neurological outcome using modified Rankin score (MRS) at discharge, 1, and 3 months. Results In group NS, significantly low pH at 1-hour intraoperative period was seen compared with group BSS (7.37 ± 0.06 vs. 7.40 ± 0.05, p = 0.024). The bicarbonate level in group NS was significantly lower and the base deficit was higher at second intraoperative hour (bicarbonate: 17.49 vs. 21.99 mEq/L, p = 0.001; base deficit: 6.41 mmol/L vs. 1.89 mmol/L, p = 0.003) and at 24 hours post-surgery (bicarbonate: 20.38 vs. 21.96 mEq/L, p = 0.012; base deficit: 3.56 mmol/L vs. 2.12 mmol/L, p = 0.034)). Serum creatinine was higher in group NS at 24 hours (0.66 vs. 0.52 mg/dL, p = 0.013) and 48 hours (0.62 vs. 0.53 mg/dL, p = 0.047). Serum urea, electrolytes, cystatin, urine NGAL, and MRS were comparable. Conclusion In neurosurgical patients undergoing clipping for ruptured intracranial aneurysm, using a BSS during the perioperative period is associated with a better acid–base and renal profile. However, the biomarkers of kidney injury and long-term outcomes were comparable. [ABSTRACT FROM AUTHOR]

The article presents a neonatal case where cardiac tamponade developed as a complication of a peripherally inserted central catheter (PICC). Topics discussed include the potential risks associated with PICC placement, the management of pericardial effusion, and the importance of timely detection and intervention to prevent severe outcomes.

This article explores the management of patients with aneurysmal subarachnoid hemorrhage (aSAH) and the challenges in determining fluid balance and blood transfusion thresholds. The authors analyze a clinical trial and find that positive fluid balance is associated with lower hemoglobin levels and an increased risk of secondary infarctions and unfavorable neurologic outcomes. Packed red cell transfusions are also found to be predictive of worse neurologic outcomes. The study suggests that careful, goal-directed circulation management is crucial for maximizing favorable functional outcomes in patients with aSAH. The article emphasizes the importance of maintaining a mean daily neutral fluid balance and targeting euvolemia, while also highlighting the need for consensus among healthcare professionals on definitions and personalized management. It raises questions about the implementation of fluid balancing and the design of randomized trials for fluid management strategies. Overall, the article provides practical insights for managing patients with aSAH. [Extracted from the article]

Fluid therapy is the principal mechanism by which a clinician can stabilize a hemodynamically compromised patient. To ensure the provision of fluids is therapeutic, it is essential to know the osmolality of the administered fluid relative to the plasma of the species being treated. The clinical utility of common isotonic fluids for reptiles was determined through comparisons to the plasma osmolality of 15 Australian reptile species representing 3 genera. All sampled species had an osmolality that was either comparable, or significantly hyperosmolar, to that of the isotonic fluids. Pairwise comparisons revealed a significant difference (P < 0.05) between monitor lizards (Varanus spp.; x ¯ = 329.71 mOsm/kg) and carpet pythons (Morelia spp.; x ¯ = 294.92 mOsm/kg), and at a species-subspecies level, between eastern carpet pythons (Morelia spilota mcdowelli; x ¯ = 318.25 mOsm/kg) and Bredli carpet pythons (Morelia spilota bredli; x ¯ = 306.33 mOsm/kg). In support of previous studies, almost all species demonstrated a wider tolerable range in plasma osmolality than would be expected in mammals. Lizards in the genus Varanus demonstrated the most clinically significant results, with all species means being greater than any commercial isotonic fluid. The facultatively aquatic Mertens water monitor (Varanus mertensi) was the species with the most significant difference ( x ¯ = 344.50 mOsm/kg). A preliminary exploration of taxonomic rank (at the genus and species level) and habitat aridity was also performed to assess their utility as indicators for estimating the plasma osmolality of an unmeasured species. Neither were found to be suitable. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this therapeutic update is to provide pharmacists with a general overview of the pathophysiology of hyperchloremia and describe strategies to help prevent development of this electrolyte abnormality in hospitalized patients. Summary Hyperchloremia is an electrolyte abnormality associated with an increased incidence of acute kidney injury and metabolic acidosis. Intravenous (IV) fluids utilized for volume resuscitation, medication diluents, and total parental nutrition all may contribute to the development of hyperchloremia. Current evidence suggests that administration of balanced crystalloids for either fluid resuscitation or maintenance fluids may impact serum chloride levels and patient outcomes. In multiple randomized controlled trials, administering balanced crystalloids for fluid resuscitation in critically ill patient populations did not decrease mortality. However, further analyses of subpopulations within these trials have demonstrated that patients with sepsis may benefit from receiving balanced crystalloids for initial fluid resuscitation. Results from several small studies suggest that altering the composition of these IV fluids may help prevent development of hyperchloremia. Conclusion Management of hyperchloremia is preventative in nature and can be mitigated through management of resuscitation fluids, medication diluents, and total parenteral nutrition. Inpatient pharmacists should be aware of the potential risk of fluid-associated hyperchloremia and assist with optimal fluid management to prevent and manage hyperchloremia. [ABSTRACT FROM AUTHOR]

Aim: To determine whether it was feasible, safe and acceptable for ambulance clinicians to use capillary blood ketone meters for 'high‐risk' diabetic ketoacidosis (DKA) recognition and fluid initiation, to inform the need for a full‐powered, multi‐centre trial. Methods: Adopting a stepped‐wedge controlled design, participants with hyperglycaemia (capillary blood glucose >11.0 mmol/L) or diabetes and unwell were recruited. 'High‐risk' DKA intervention participants (capillary blood ketones ≥3.0 mmol/L) received paramedic‐led fluid therapy. Participant demographic and clinical data were collated from ambulance and hospital care records. Twenty ambulance and Emergency Department clinicians were interviewed to understand their hyperglycaemia and DKA care experiences. Results: In this study, 388 participants were recruited (Control: n = 203; Intervention: n = 185). Most presented with hyperglycaemia, and incidence of type 1 and type 2 diabetes was 18.5% and 74.3%, respectively. Ketone meter use facilitated 'high‐risk' DKA identification (control: 2.5%, n = 5; intervention: 6.5%, n = 12) and was associated with improved hospital pre‐alerting. Ambulance clinicians appeared to have a high index of suspicion for hospital‐diagnosed DKA participants. One third (33.3%; n = 3) of Control and almost half (45.5%; n = 5) of Intervention DKA participants received pre‐hospital fluid therapy. Key interview themes included clinical assessment, ambulance DKA fluid therapy, clinical handovers; decision support tool; hospital DKA management; barriers to hospital DKA care. Conclusions: Ambulance capillary blood ketone meter use was deemed feasible, safe and acceptable. Opportunities for improved clinical decision making, support and safety‐netting, as well as in‐hospital DKA care, were recognised. As participant recruitment was below progression threshold, it is recommended that future‐related research considers alternative trial designs. Clinicaltrials.gov: NCT04940897. [ABSTRACT FROM AUTHOR]

Introduction: Fluid accumulation is associated with adverse outcomes in critically ill patients admitted to the intensive care unit (ICU). Fluid administration in the ICU may be a clinically relevant source of fluid accumulation in ICU patients. However, the extent is unknown, and no standard definition exists. We aim to provide epidemiological data on fluid accumulation, risk factors, use of fluid removal strategies, patient outcomes and describe current fluid administration practices in the ICU. Methods: We will conduct an international 14‐day inception cohort study including a minimum of 1000 acutely admitted adult ICU patients. Data will be collected from medical records and laboratory reports at baseline and daily from ICU admission to discharge with a maximum of 28 days. Follow‐up will be performed on day 90 after inclusion. The primary outcome is the number of patients with fluid accumulation. Secondary outcomes include the number of days with fluid accumulation, use of active fluid removal, days alive without life support at day 28, days alive and out of hospital day 90, and all‐cause mortality at day 90. Furthermore, we will assess risk factors for fluid accumulation and its association with 90‐day mortality and report on the types of fluid administration. Conclusion: This international inception cohort study will provide contemporary epidemiological data on fluid administration and fluid accumulation in adult ICU patients. [ABSTRACT FROM AUTHOR]

Intravenous fluids are commonly prescribed to children in hospitals. However, there are risks associated with their use. In order to safely prescribe these clinicians should understand the indications for their use, the principles underpinning their use and know the likely complications associated with intravenous fluid administration in children. Intravenous fluids should be prescribed depending on individual needs of each child and with careful monitoring and re-assessment. This review aims to provide a general approach to fluid prescription in children, providing some background of different physiological principles, different fluid composition, and the role of anti-diuretic hormone in fluid homeostasis. Fluid prescription is discussed, with an approach taking into consideration resuscitation boluses, dehydration, replacing ongoing losses and maintenance requirements. Case examples are provided to further facilitate readers' comprehension. Electrolyte abnormalities and an approach to the management of deranged electrolytes is addressed. Complications associated with fluid administration are highlighted, in particular, emphasizing the assessment and emergency management of the child with suspected cerebral oedema or hyponatraemic encephalopathy. Special consideration and discussion is given to the differing approach to fluid management of children in the setting of burns or diabetic ketoacidosis. [ABSTRACT FROM AUTHOR]

• Normal saline has been considered to have deleterious effects on kidney function. • We compared balanced solution versus saline in off-pump coronary bypass surgery. • The study did not demonstrate a significant difference in acute kidney injury. To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline. Randomized controlled trial. Single tertiary care center. Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020. Balanced solution-based chloride-restrictive intravenous fluid strategy. The primary outcome was acute kidney injury within 7 postoperative days, as defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline. The incidence of acute kidney injury was 4.4% (8/180) in the balanced group and 7.3% (13/178) in the saline group. The difference was not statistically significant (risk difference, −2.86%; 95% confidence interval [CI], −7.72% to 2.01%; risk ratio, 0.61, 95% CI, 0.26 to 1.43; p = 0.35). Compared with the balanced group, the saline group had higher levels of intraoperative serum chloride and lower base excess, which resulted in a lower pH. In patients undergoing off-pump bypass surgery with a normal estimated glomerular filtration rate, the intraoperative balanced solution-based chloride-restrictive intravenous fluid administration strategy did not decrease the rate of postoperative acute kidney injury compared with the saline-based chloride-liberal intravenous fluid administration strategy. [ABSTRACT FROM AUTHOR]

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Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids' impact on blood pressure changes. This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning. Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann's solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500–600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts. This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids. [ABSTRACT FROM AUTHOR]

Emergency medical services (EMS) clinicians are tasked with early fluid resuscitation for patients with sepsis. Traditional methods for prehospital fluid delivery are limited in speed and ease-of-use. We conducted a comparative effectiveness study of a novel rapid infusion device for prehospital fluid delivery in suspected sepsis patients. This pre-post observational study evaluated a hand-operated, rapid infusion device in a single large EMS system from July 2021-July 2022. Prior to device deployment, EMS clinicians completed didactic and simulation-based device training. Data were extracted from the EMS electronic health record. Eligible patients included adults with suspected sepsis treated by EMS with intravenous fluids. The primary outcome was the proportion of patients receiving goal fluid volume (at least 500 mL) prior to hospital arrival. Secondary outcomes included in-hospital mortality, disposition, and length of stay. Multivariable logistic regression was used to compare outcomes between 6-month pre- and post-implementation periods (July-December 2021 and February-July 2022, respectively), adjusting for patient demographics, abnormal prehospital vital signs, and EMS transport interval. Of 1,180 eligible patients (552 in the pre-implementation period; 628 in the post-implementation period), the mean age was 72 years old, 45% were female, and 25% were minority race-ethnicity. Median (interquartile range) fluid volume (in mL) increased between the pre- and post-implementation periods (600 [400,1,000] and 850 [500–1,000], respectively). Goal fluid volume was achieved in 70% of pre-implementation patients and 82% of post-implementation patients. In adjusted analysis, post-implementation patients were significantly more likely to receive goal fluid volume than pre-implementation patients (adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.51–2.66). Pre-post in-hospital mortality was not significantly different (aOR 0.91, 95% CI 0.59–1.39). In a single EMS system, sepsis education and introduction of a rapid infusion device was associated with achieving goal fluid volume for suspected sepsis. Further research is needed to assess the clinical effectiveness of infusion device implementation to improve sepsis patient outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: The purpose of this study was to evaluate the efficacy of using the pleth variability index (PVi) to guide fluid therapy in dogs undergoing surgery under general anesthesia compared to conventional fixed-fluid-rate administration. Twenty-seven dogs meeting specific criteria were randomly assigned to either a conventional fluid management (CFM) group or a PVi-guided (PVi) group. The CFM group received a fixed rate of fluid, while the PVi group had their fluid rate adjusted based on their PVi values. Results showed that dogs in the PVi group received less total fluid and experienced fewer hypotensive episodes compared to the CFM group. In addition, the mean arterial pressure (MAP) was significantly higher in the PVi group during surgery. These findings suggest that PVi-guided fluid therapy may result in more targeted fluid administration and improve the hemodynamic stability in anesthetized dogs. However, further studies with larger sample sizes are needed to confirm these results and explore the broader applicability of the PVi in veterinary anesthesia. The aim of this prospective, randomized clinical trial was to evaluate the use of the pleth variability index (PVi) to guide the rate of intraoperative fluid therapy compared to a traditional fixed-fluid-rate approach in ASA 1–2 dogs undergoing surgery. Twenty-seven dogs met the inclusion criteria and were randomly assigned to the conventional fluid management group (CFM, n = 12) or the PVi-guided group (PVi, n = 15). The CFM group received a fixed rate of 5 mL kg−1 h−1 of crystalloid solution, while in the PVi group the rate was continuously adjusted based on the PVi: PVi < 14% = 3 mL kg−1 h−1; 14% ≤ PVi ≥ 20% = 10 mL kg−1 h−1; and PVi > 20% = 15 mL kg−1 h−1. Hypotension (MAP < 65 mmHg) in the CFM was treated with a maximum of two fluid boluses (5 mL kg−1 in 10 min) and in the case of no response, dobutamine (1–3 mcg kg−1 min−1) was administered. In the PVi group, the treatment of hypotension was similar, except when the PVi > 14%, when dobutamine was started directly. Total fluid volume was significantly lower in the PVI group (0.056 ± 0.027 mL kg−1 min−1) compared to the CFM group (0.132 ± 0.115 mL kg−1 min−1), and the incidence of hypotension was lower (p = 0.023) in the PVi group (0%) compared to the CFM group (41%). The mean arterial pressure (MAP) was significantly higher in the PVi group during surgery. Dobutamine was never administered in either group. Preliminary data suggest that the PVi may be considered as a potential target to guide fluid therapy in dogs; larger studies are needed, especially in cases of cardiovascular instability. [ABSTRACT FROM AUTHOR]

Septic abortion can lead to severe maternal morbidity and mortality. The management of septic abortion can be complicated by a history of radical trachelectomy and transabdominal cerclage placement. A 33-year-old G1P0 at 17 weeks and 6 days gestation presented in severe septic shock after being diagnosed 6 days prior with previable rupture of membranes at an outside hospital and managed expectantly. History was notable for cervical adenocarcinoma status post radical trachelectomy and transabdominal cerclage placement. Due to uterine occlusion from the cerclage, the patient underwent emergent uterine evacuation via an abdominal approach. The risks and benefits of expectant management of pre-viable rupture of membranes in patients with abdominal cerclage should be weighed very cautiously. Among women with abdominal cerclage for whom uterine evacuation is indicated, a transabdominal approach may be necessary. [ABSTRACT FROM AUTHOR]

Fluid creep occurs when resuscitation after extensive burn injury reaches volumes higher than predicted. Since this has been described in patients with high opioid requirements, continuous analgesics and sedatives, including dexmedetomidine, have been avoided during resuscitation. This study sought to describe the impact of dexmedetomidine on fluid resuscitation requirements. This retrospective cohort study included adult patients with burns greater than 20% total body surface area (TBSA) resuscitated between January 2017 and June 2022 at a regional burn center. Patients deceased within 48 hours of burn were excluded. The primary outcome was volume of fluid required in the first 24 and 48 hours postburn. Secondary outcomes were the incidence of fluid-related adverse events within 7 days postburn. A total of 170 patients were included: 55 in the dexmedetomidine cohort and 115 in the control cohort. After propensity matching for variables associated with fluid creep, the dexmedetomidine cohort required 4.2 ± 1.7 mL/kg/%TBSA in the first 24 hours compared to 3.6 ± 1.1 mL/kg/%TBSA in the control cohort (P = 0.03). The difference was no longer significant at 48 hours (P = 0.11). There were no differences in the incidence of acute respiratory distress syndrome, delayed escharotomy/fasciotomy, intra-abdominal hypertension, or renal replacement therapy. Dexmedetomidine exposure during acute resuscitation resulted in increased fluid requirements in the first 24 hours, suggesting it is independently associated with fluid creep; however, this increase was not sustained at 48 hours. Clinical significance of this finding is unclear, as there was no increase in adverse events related to excessive fluid resuscitation between cohorts. [ABSTRACT FROM AUTHOR]

Abstract Fluid therapy is a fundamental part of supportive therapy in critical care. However, it is also a suspected risk for endothelial glycocalyx degradation which is associated with poor clinical outcomes. This secondary analysis of RESPONSE randomized trial compares the effect of follow-up strategy (FU) on endothelial biomarkers to that of 500 ml crystalloid fluid bolus (FB) in oliguric, hemodynamically optimized intensive care unit (ICU) patients. 130 adult subjects were enrolled in two Finnish ICUs from January 2017 to November 2020. Blood and urine samples of 63 patients in FU group and 67 patients in FB group were collected before and after the intervention and analyzed using enzyme-linked immunosorbent assays. Single fluid bolus, given after median of 3887 ml (interquartile range 2842; 5359 ml) resuscitation fluids in the preceding 24 h, increased plasma hyaluronan concentration compared to the follow-up strategy (difference in medians 29.2 ng/ml with 95% CI [14.5ng/ml; 55.5ng/ml], P

Abstract Background Fluid administration is the first line treatment in intensive care unit (ICU) patients with sepsis and septic shock. While fluid boluses administration can be titrated by predicting preload dependency, the amount of other forms of fluids may be more complex to be evaluated. We conducted a retrospective analysis in a tertiary hospital, to assess the ratio between fluids given as boluses and total administered fluid intake during early phases of ICU stay, and to evaluate the impact of fluid strategy on ICU mortality. Data related to fluid administration during the first four days of ICU stay were exported from an electronic health records system (ICCA®, Philips Healthcare). Demographic data, severity score, norepinephrine dose at ICU admission, overall fluid balance and the percentage of different fluid components of the overall volume administered were included in a multivariable logistic regression model, evaluating the association with ICU survival. Results We analyzed 220 patients admitted with septic shock and sepsis-induced hypotension from 1st July 2021 to 31st December 2023. Fluid boluses and maintenance represented 49.3% ± 22.8 of the overall fluid intake, being balanced solution the most represented (40.4% ± 22.0). The fluid volume for drug infusion represented 34.0% ± 2.9 of the total fluid intake, while oral or via nasogastric tube fluid intake represented 18.0% ± 15.7 of the total fluid intake. Fluid volume given as boluses represented 8.6% of the total fluid intake over the four days, with a reduction from 25.1% ± 24.0 on Day 1 to 4.8% ± 8.7 on Day 4. A positive fluid balance [OR 1.167 (1.029–1.341); p = 0.021] was the most important factor associated with ICU mortality. Non-survivors (n = 66; 30%) received a higher amount of overall inputs than survivors only on Day 1 [2493 mL vs. 1855 mL; p = 0.022]. Conclusions This retrospective analysis of fluids given over the early phases of septic shock and sepsis-induced hypotension showed that the overall volume given by boluses ranges from about 25% on Day 1 to about 5% on Day 4 from ICU admission. Our data confirms that a positive fluid balance over the first 4 days of ICU is associated with mortality.

Abstract Acute kidney injury (AKI) prevalence in surgical patients is high, emphasizing the need for preventative measures. This study addresses the insufficient evidence on nephroprotective intraoperative fluid resuscitation and highlights the drawbacks of relying solely on serum creatinine/urine output to monitor kidney function. This study assessed the impact of intraoperative fluid management on AKI in female breast cancer patients undergoing autologous breast reconstruction, utilizing novel urinary biomarkers (TIMP-2 and IGFBP-7). In a monocentric prospective randomized controlled trial involving 40 patients, liberal (LFA) and restrictive (FRV) fluid management strategies were compared. TIMP-2 and IGFBP-7 biomarker levels were assessed using the NephroCheck (bioMerieux, France) test kit at preoperative, immediate postoperative, and 24-h postoperative stages. FRV showed significantly higher immediate postoperative biomarker levels, indicating renal tubular stress. FRV patients had 21% (4/19) experiencing AKI compared to 13% (2/15) in the LFA group according to KDIGO criteria (p = 0.385). Restrictive fluid resuscitation increases the risk of AKI in surgical patients significantly, emphasizing the necessity for individualized hemodynamic management. The findings underscore the importance of urinary biomarkers in early AKI detection.

Abstract Background Parenteral fluid (PF) therapy of patients in end-of-life (EOL) is controversial. The purpose of this study was to assess associations between PF, quality of the EOL care process and symptom burden in dying cancer patients, using a population-based approach. Methods This was a nationwide retrospective register study of all adult cancer deaths with documented information on PF in the last 24 h of life as reported to the Swedish Register of Palliative Care during a three-year period (n = 41,709). Prevalence and relief of symptoms during the last week of life as well as EOL care process quality indicators were assessed in relation to PF in those patients who had a documented decision to focus on EOL care (immediately dying, n = 23,112). Odds ratios were calculated, adjusting for place of death (hospital vs. non-hospital). Results PF was administered to 30.9% of immediately dying patients in hospitals compared to 6.5% outside of hospitals. PF was associated with a higher likelihood for breathlessness and nausea. In patients screened for EOL symptoms with a validated instrument, PF was inversely associated with the likelihood of complete relief of breathlessness, respiratory secretions, anxiety, nausea and pain. Several palliative care quality indicators were inversely associated with PF, including EOL conversations and prescriptions of injectable drugs as needed. These associations were more pronounced in hospitals. Conclusions Parenteral fluid therapy in the last 24 h of life was associated with inferior quality of the EOL care process and with increased symptom burden in imminently dying cancer patients.

Abstract Background Dynamic arterial elastance (Eadyn) has been investigated for its ability to predict hypotension during the weaning of vasopressors. Our study focused on assessing Eadyn’s performance in the context of critically ill adult patients admitted to the intensive care unit, regardless of diagnosis. Main body Our study was conducted in accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. The protocol was registered in PROSPERO (CRD42023421462) on May 26, 2023. We included prospective observational studies from the MEDLINE and Embase databases through May 2023. Five studies involving 183 patients were included in the quantitative analysis. We extracted data related to patient clinical characteristics, and information about Eadyn measurement methods, results, and norepinephrine dose. Most patients (76%) were diagnosed with septic shock, while the remaining patients required norepinephrine for other reasons. The average pressure responsiveness rate was 36.20%. The synthesized results yielded an area under the curve of 0.85, with a sensitivity of 0.87 (95% CI 0.74–0.93), specificity of 0.76 (95% CI 0.68–0.83), and diagnostic odds ratio of 19.07 (95% CI 8.47–42.92). Subgroup analyses indicated no variations in the Eadyn based on norepinephrine dosage, the Eadyn measurement device, or the Eadyn diagnostic cutoff to predict cessation of vasopressor support. Conclusions Eadyn, evaluated through subgroup analyses, demonstrated good predictive ability for the discontinuation of vasopressor support in critically ill patients.

Abstract Background Pancreatic surgery is associated with a significant risk for acute kidney injury (AKI) and clinically relevant postoperative pancreatic fistula (CR-POPF). This investigation evaluated the impact of intraoperative volume administration, vasopressor therapy, and blood pressure management on the primary outcome of AKI and the secondary outcome of a CR-POPF after pancreatic surgery. Methods This retrospective single-center cohort investigated 200 consecutive pancreatic surgeries (January 2018–December 2021). Patients were categorized for the presence/absence of AKI (Kidney Disease Improving Global Outcomes) and CR-POPF. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes. Results AKI was identified in 20 patients (10%) with significant univariate differences in demographics (body mass index and gender), comorbidities, indices of chronic renal insufficiency, and an increased AKI Risk score. Surgical characteristics, intraoperative fluid, vasopressor, and blood pressure management were similar in patients with and without AKI. Patients with AKI had increased blood loss, lower urine output, and packed red blood cell administration. After multivariate analysis, male gender (OR = 7.9, 95% C.I. 1.8–35.1) and the AKI Risk score (OR = 6.3, 95% C.I. 2.4–16.4) were associated with the development of AKI (p