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Background: Diarrhea is a leading cause of death among children <5 years of age and can have long-term adverse consequences for human development. The World Health Organization has recommended the therapeutic use of zinc for the treatment of diarrhea, along with oral rehydration solutions, since 2004. We studied recent trends in the use of zinc to treat diarrhea in 23 low- and middle-income countries., Methods: A repeated cross-sectional design of 46 Demographic and Health Surveys from 23 countries was used to estimate the average annual change in zinc treatment across recent years. The earlier surveys were conducted in different years from 2009 to 2014, and the latest surveys were conducted in different years from 2015 to 2023, with an average gap of 6 years between surveys. A diarrhea episode during the 2 weeks before the survey and the treatment of diarrhea using zinc and oral rehydration solutions among children <5 years old was identified using an interview with mothers., Results: In the pooled sample, the treatment of diarrhea in children <5 years of age using zinc increased from 2% in the earlier surveys to 27% in the more recent surveys, or an average annual increase of 4 percentage points (pp). The prevalence of zinc treatment increased in all 23 countries, ranging from 9 pp per year on average in Sierra Leone to 1 pp in Cambodia., Conclusions: A large increase in the use of therapeutic zinc to treat diarrhea in children was observed in recent years. However, coverage remains incomplete., (Copyright © 2024 by the American Academy of Pediatrics.)

Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED., (© 2021. The Author(s).)

Background: While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival., Methods: We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted., Data Synthesis: We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%-50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%-72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%-60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%-26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%-73.0%) and North America (45.5%, 95%-CI: 16.7%-75.8%). GRADE assessment indicated high certainty of evidence for pooled survival., Conclusions: When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock., (© 2021. The Author(s).)

Background: Accurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates., Methods: Five pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received., Results: Differences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers' resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001)., Conclusions: This variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

Background: We designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes., Methods: Stroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness., Results: Analysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6-48.8) vs liberal 44.0 (34.9-61.9) ml m -2 ; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32-4.05) vs 2.42 (1.94-3.26) L min -1  m -2 ; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant)., Conclusions: The liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups., Clinical Trial Registration: ACTRN12615000125527., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To examine the changes over time of pediatric acute pancreatitis (AP) severity, management, and disease outcomes at our academic tertiary center., Methods: We reviewed 223 pediatric AP admissions (2002-2018) and used a time-to-event regression model to study changes over time. Disease outcomes were analyzed using a subgroup of 89 patients in whom only the AP event determined length of hospital stay and duration of opioid use., Results: There was an increase in mild, but not severe, AP episodes over the examined period. June 2014 was identified as a single cutoff point for change in AP management and disease outcomes independent of each other and of disease severity. Timing of initiating enteral nutrition decreased from 5 to 1.6 days (P < 0.0001) in the entire cohort and from 4.1 to 1.8 days in the subgroup (P = 0.0001) after June 2014. Length of hospitalization decreased from 6 to 3.3 days (P = 0.0008) and days of opioid use from 4.1 to 1.3 (P = 0.002) after June 2014., Conclusions: Timing of initiating enteral nutrition has significantly reduced at our center after June 2014. In parallel, we observed a significant improvement in disease outcomes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes., Methods: We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access., Results: We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children., Conclusions: Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards - treatments that have a solid evidence base and are well established as targets for usual care - and also evolving standards - treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.

Resuscitation of the critically ill patient with fluid and blood products is one of the most widespread interventions in medicine. This is especially relevant for trauma patients, as hemorrhagic shock remains the most common cause of preventable death after injury. Consequently, the study of the ideal resuscitative product for patients in shock has become an area of great scientific interest and investigation. Recently, the pendulum has swung towards increased utilization of blood products for resuscitation. However, pathogens, immune reactions and the limited availability of this resource remain a challenge for clinicians. Technologic advances in pathogen reduction and innovations in blood product processing will allow us to increase the safety profile and efficacy of blood products, ultimately to the benefit of patients. The purpose of this article is to review the current state of blood product based resuscitative strategies as well as technologic advancements that may lead to safer resuscitation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate., Main Text: The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications., Conclusions: The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.

Background: Postoperative ileus is a common complication of intraabdominal surgeries, including radical cystectomy with reported rates as high as 32%. Perioperative fluid administration has been associated with improvement in postoperative ileus rates, but it is difficult to generalize because earlier studies lacked standardized definitions of postoperative ileus and other relevant outcomes. The hypothesis was that targeted individualized perioperative fluid management would improve postoperative ileus in patients receiving radical cystectomy., Methods: This is a parallel-arm, double-blinded, single-center randomized trial of goal-directed fluid therapy versus standard fluid therapy for patients undergoing open radical cystectomy. The primary outcome was postoperative ileus, and the secondary outcome was complications within 30 days post-surgery. Participants were at least 21 yr old, had a maximum body mass index of 45 kg/m and no active atrial fibrillation. The intervention in the goal-directed therapy arm combined preoperative and postoperative stroke volume optimization and intraoperative stroke volume variation minimization to guide fluid administration, using advanced hemodynamic monitoring., Results: Between August 2014 and April 2018, 283 radical cystectomy patients (142 goal-directed fluid therapy and 141 standard fluid therapy) were included in the analysis. Postoperative ileus occurred in 25% (36 of 142) of patients in the goal-directed fluid therapy arm and 21% (30 of 141) of patients in the standard arm (difference in proportions, 4.1%; 95% CI, -5.8 to 13.9; P = 0.418). There was no difference in incidence of high-grade complications between the two arms (20 of 142 [14%] vs. 23 of 141 [16%]; difference in proportions, -2.2%; 95% CI, -10.6 to 6.1; P = 0.602), with the exception of acute kidney injury, which was more frequent in the goal-directed fluid therapy arm (56% [80 of 142] vs. 40% [56 of 141] in the standard arm; difference in proportions, 16.6%; 95% CI, 5.1 to 28.1; P = 0.005; P = 0.170 after adjustment for multiple testing)., Conclusions: Goal-directed fluid therapy may not be an effective strategy for lowering the risk of postoperative ileus in patients undergoing open radical cystectomy.

While fluid replacement therapy is a primary treatment modality used in vaso-occlusive crises for sickle cell disease, data is limited on its safety, efficacy, and variability. We performed a retrospective analysis on 157 unique patient encounters from 49 sickle cell patients hospitalized with a vaso-occlusive episode at our institution from 2013 to 2017. The median length of hospital stay was 4 days (IQR 2-7). The mean total amount of intravenous fluid administered during the hospitalization was 7.4 L (Std 9.6). The mean total amount of fluid intake including intravenous fluids, blood transfusions, and oral fluids was 14.2 L (Std 18.2). Multivariate analyses revealed significant associations between the development of any adverse event (including a new oxygen requirement, acute chest syndrome, aspiration event, other hospital-acquired infection, acute kidney injury, and intensive care unit transfer) and the following variables: intravenous fluid administered in the first 24 h (p = 0.001, OR 1.899, 95% CI 1.319-2.733), total amount of intravenous fluid administered (p = 0.005, OR 1.081, 95% CI 1.023-1.141), and total amount of fluid intake including oral fluids, blood transfusions, and intravenous fluids (p = 0.009, OR 1.046, 95% CI 1.011-1.081). Other factors found to be significantly associated with any adverse event were dialysis dependence prior to admission (p < 0.001, OR 12.984, 95% CI 3.660-46.056) and admission to an inpatient service versus an emergency room or observation unit (p = 0.008, OR 3.201, 95% CI 1.346-7.612). While fluid administration may theoretically slow the sickling process, this data suggests that fluid administration during a vaso-occlusive episode, and especially total volume given in the first 24 h, may also lead to adverse events.

Background: Contrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). Patients with chronic kidney disease (CKD) have an elevated risk for developing this complication. Although CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization., Methods: We assessed the prevalence and variability of CA-AKI prophylaxis among CKD patients undergoing PCI between October 2007 and September 2015 in any cardiac catheterization laboratory in the VA Healthcare System. Prophylaxis included periprocedural hydration with normal saline or sodium bicarbonate, NAC, and contrast minimization (contrast volume to glomerular filtration rate ratio ≤ 3). Multivariable hierarchical logistic regression models quantified site-specific prophylaxis variability. As secondary analyses, we also assessed CA-AKI prophylaxis measures in all PCI patients regardless of kidney function, periprocedural hydration in patients with comorbid CHF, and temporal trends in CA-AKI prophylaxis., Results: From 2007 to 2015, 15,729 patients with CKD underwent PCI. 6928 (44.0%) received periprocedural hydration (practice-level median rate 45.3%, interquartile range (IQR) 35.5-56.7), 5107 (32.5%) received NAC (practice-level median rate 28.3%, IQR 22.8-36.9), and 4656 (36.0%) received contrast minimization (practice-level median rate 34.5, IQR 22.6-53.9). After adjustment for patient characteristics, there was significant site variability with a median odds ratio (MOR) of 1.80 (CI 1.56-2.08) for periprocedural hydration, 1.95 (CI 1.66-2.29) for periprocedural hydration or NAC, and 2.68 (CI 2.23-3.15) for contrast minimization. These trends were similar among all patients (with and without CKD) undergoing PCI. Among patients with comorbid CHF (n = 5893), 2629 (44.6%) received periprocedural hydration, and overall had less variability in hydration (MOR of 1.56 (CI 1.38-1.76)) compared to patients without comorbid CHF (1.89 (CI 1.65-2.18)). Temporal trend analysis showed a significant and clinically relevant decrease in NAC use (64.1% of cases in 2008 (N = 1059), 6.2% of cases in 2015 (N = 128, p = < 0.0001)) and no significant change in contrast-minimization (p = 0.3907)., Conclusions: Among patients with CKD undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, however, was also present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed.

Introduction: 'Fluid creep' or excessive fluid delivered to burn patients during early resuscitation has been suggested by several studies from individual burn centers., Methods: We performed a Medline search from 1980 to 2015 in order to identify studies of burn patients predominantly resuscitated with lactated Ringers with infusion adjusted per urinary output. Data was abstracted for 48 publications (3196 patients) that met entry criteria., Results: Higher resuscitation volumes compared to Parkland estimates were reported, but the trend of increasing resuscitation volumes over the last 30 years is not supported by regression of total fluid infused versus year of study. Mean 24h fluid infused for all studies was 5.2±1.1mL/kg per %TBSA. The mean 24h urinary output reported in 30 studies was 1.2±0.5mL/kg per hr. Burns with inhalation injuries (5 studies) received significantly more fluid than non-inhalation injured burn patients (5.0±1.3 versus 3.9±0.9mL/kg per %TBSA). Fluid infused and urinary outputs were similar for adults and pediatric patients. The most striking finding of our analyses was the great ranges of the means and high standard deviations of volumes infused compared to the original Baxter publication that introduced the Parkland formula CONCLUSIONS: These analyses suggest that burn units currently administer volumes larger than Parkland formula with great patient variability. Individual patient hourly data is needed to better understand the record of burn resuscitation and Fluid Creep., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Background: Acute respiratory distress syndrome (ARDS), a complex response to various insults, has a high mortality rate. As pulmonary edema resulting from increased vascular permeability is a hallmark of ARDS, management of the fluid status, including the urine output (UO) and fluid intake (FI), is essential. However, the relationships between UO, FI, and mortality in ARDS remain unclear. This retrospective study aimed to investigate the interactive associations among UO, FI, and mortality in ARDS., Methods: This was a secondary analysis of a prospective randomized controlled trial performed at 10 centers within the ARDS Network of the National Heart, Lung, and Blood Institute research network. The total UO and FI volumes within the 24-h period preceding the trial, the UO to FI ratio (UO/FI), demographic data, biochemical measurements, and other variables from 835 patients with ARDS, 539 survivors, and 296 non-survivors, were analyzed. The associations among UO, FI, the UO/FI, and mortality were assessed using a multivariable logistic regression., Results: In all 835 patients, an increased UO was significantly associated with decreased mortality when used as a continuous variable (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.98-0.99, P = 0.002) and as a quartile variable (OR of Q2 to Q4: 0.69-0.46, with Q1 as reference). To explore the interaction between UO and FI, the UO/FI was calculated, and a cut-off value of 0.5 was detected for the association with mortality. For patients with a UO/FI ≤0.5, an increased UO/FI was significantly associated with decreased mortality (OR: 0.09, 95% CI: 0.03-0.253, P <  0.001); this association was not significant for patients with UO/FI ratios > 0.5 (OR: 1.04, 95% CI: 0.96-1.14, P = 0.281). A significant interaction was observed between UO and the UO/FI. The association between UO and mortality was significant in the subgroup with a UO/FI ≤0.5 (OR: 0.97, 95% CI: 0.96-0.99, P = 0.006), but not in the subgroup with a UO/FI > 0.5., Conclusions: The association between UO and mortality was mediated by the UO/FI status, as only patients with low UO/FI ratios benefitted from a higher UO.

This retrospective observational case series conducted at 2 large academic centers over a 4-year period consists of 15 cases of profound hypotension in surgical patients immediately after initiation of the Belmont Fluid Management System for rapid transfusion of blood products. Halting the infusion and administering vasoactive agents led to resolution of hypotension. Repeat transfusion with the Belmont system resulted in repeat hypotension unless counteracted with vasopressors. No etiology was elucidated. This represents the largest documented association of acute hypotensive transfusion reaction with any rapid infusion system in surgical patients.

Objective: Identifying fluid responsiveness is critical to optimizing perfusion while preventing fluid overload. An experimental study of hypovolemic shock resuscitation showed the importance of ventricular compliance and peripheral venous pressure (PVP) on fluid responsiveness. The authors tested the hypothesis that reduced ventricular compliance measured using transesophageal echocardiography results in decreased fluid responsiveness after a fluid bolus., Design: Prospective observational study., Setting: Two-center, university hospital study., Participants: The study comprised 29 patients undergoing elective coronary revascularization., Intervention: Albumin 5%, 7 mL/kg, was infused over 10 minutes to characterize fluid responders (>15% increase in stroke volume) from nonresponders., Measurements and Main Results: Invasive hemodynamics and the ratio of mitral inflow velocity (E-wave)/annular relaxation (e'), or E/e' ratio, were measured using transesophageal echocardiography to assess left ventricular (LV) compliance at baseline and after albumin infusion. Fifteen patients were classified as responders and 14 as nonresponders. The E/e' ratio in responders was 7.4 ± 1.9 at baseline and 7.1 ± 1.8 after bolus. In contrast, E/e' was significantly higher in nonresponders at baseline (10.7 ± 4.6; p = 0.04) and further increased after bolus (12.6 ± 5.5; p = 0.002). PVP was significantly greater in the nonresponders at baseline (14 ± 4 mmHg v 11 ± 3 mmHg; p = 0.02) and increased in both groups after albumin infusion. Fluid responsiveness was tested using the area under the receiver operating characteristic curve and was 0.74 for the E/e' ratio (95% confidence interval 0.55-0.93; p = 0.029) and 0.72 for the PVP (95% confidence interval 0.52-0.92; p = 0.058)., Conclusion: Fluid responders had normal LV compliance and lower PVP at baseline. In contrast, nonresponders had reduced LV compliance, which worsened after fluid bolus. E/e,' more than PVP, may be a useful clinical index to predict fluid responsiveness., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The 7th National Infusion and Vascular Access Society (NIVAS) conference was held in Manchester, 12-13 June 2019.

Background: Brain injury (BI) induces a state of immunodepression leading to pneumonia. We investigated the invariant natural killer T (iNKT) cell compartment., Methods: This is an observational study in two surgical intensive care units (ICUs) of a single institution and a research laboratory. Clinical data and samples from a prospective cohort were extracted. Severe brain-injured patients (n = 33) and sex- and age-matched healthy donors (n = 40) were studied., Results: We observed the presence of IL-10 in serum, a loss of IFN-γ and IL-13 production by peripheral blood mononuclear cells (PBMCs) following IL-2 stimulation, and downregulation of HLA-DR expression on both monocytes and B cells early after BI. Inversely, CD1d, the HLA class I-like molecule involved in antigen presentation to iNKT cells, was over-expressed on patients' monocytes and B cells. The antigen-presenting activity to iNKT cells of PBMCs was increased in the patients who developed pneumonia, but not in those who remained free of infection. Frequencies of iNKT cells among PBMCs were dramatically decreased in patients regardless of their infection status. Following amplification, an increased frequency of CD4+ iNKT cells producing IL-4 was noticed in the group of patients free of infection compared with those who became infected and with healthy donors. Finally, serum from BI patients inhibited the iNKT cells' specific response as well as the non-specific IL-2 stimulation of PBMCs, and the expression of the beta-2 adrenergic receptor was elevated at the surface of patients T lymphocytes., Conclusions: We observed severe alterations of the iNKT cell compartment, including the presence of inhibitory serum factors. We demonstrate for the first time that the decreased capacity to present antigens is not a generalized phenomenon because whereas the expression of HLA-DR molecules is decreased, the capacity for presenting glycolipids through CD1d expression is higher in patients.

Purpose of Review: Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics., Recent Findings: Traditional therapies such as type of crystalloid fluid administration and steroid therapy for sepsis are currently under re-evaluation. Angiotensin II is investigated for reversing vasodilatory shock. The role of capillary endothelium leak and cellular metabolism can be affected by vitamin C and thiamine levels. Biomarker level trends, specifically PCT, can aid clinical suspicion of infection., Summary: Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.

Background: Asymptomatic or mildly symptomatic exercise-associated hyponatremia (EAH) can be exacerbated by aggressive hydration., Objective: This work predicts the percentage of athletes at risk for exacerbation of EAH from indiscriminate hydration after an ultramarathon., Methods: Postrace serum sodium, creatinine, creatine kinase (CK), and urea nitrogen concentrations were determined for 161-km ultramarathon participants. Body mass was measured prior to and immediately after the race. Incidents when serum CK was > 20,000 U/L or creatinine ≥ 1.5 times estimated baseline were considered to be "at risk for receiving I.V. hydration" if presenting to a hospital. Those with EAH without body mass loss during the race were considered "overhydrated" and "at risk for EAH exacerbation.", Results: Among 627 finishers, 16 (2.6%) were at risk for EAH exacerbation. Considering 421 observations at risk for receiving I.V. hydration, 16 (47.1%) of the 34 observations with EAH were at risk for EAH exacerbation. Among those at risk for receiving I.V. hydration and with EAH, serum urea nitrogen and creatine concentration as a multiple of estimated baseline were lower (p < 0.05) for those at risk for EAH exacerbation, compared with those without overhydration, but there were no clinically useful laboratory findings to distinguish these two groups due to considerable overlap of values., Conclusions: Whether in the field or hospital setting, I.V. hydration of an athlete after an ultramarathon carries a notable risk for exacerbating EAH, so clinicians should use caution when hydrating athletes after endurance events., (Published by Elsevier Inc.)

Background: In response to marked concern regarding inadequate fluid intake recording in care homes, an innovative mobile hydration app was collaboratively developed. "Hydr8" aimed to facilitate accurate recording and communication of residents' fluid intake and ultimately increase care quality and patient safety., Objective: The aim of this study was to examine the implementation of Hydr8 in a sample of care homes in one area in England., Methods: The principles of Realist Evaluation and Action research were drawn upon throughout the study. Overall, 5 care homes participated in this study, 3 interview-only sites and 2 case-study sites, where interviews and observations were conducted at 3 time-points. Furthermore, 28 staff members participated, including care staff, management, a registered nurse, and administrative staff., Results: Findings suggest that Hydr8 benefits practice, enhancing the understanding of hydration and person-centered care and improving staff communication. However, technical glitches hindered the seamless embedding of Hydr8 into everyday practice, and enthusiasm for long-term use was dependent on the resolution of issues. In addition, Hydr8 heightened perceptions of personal accountability, and while managers viewed this as positive, some staff members were apprehensive. However, individuals were enthusiastic about the long-term use and potential of Hydr8., Conclusions: Utilizing the findings of this study to further develop and adapt Hydr8 indicates the long-term use of Hydr8 as promising. Although perceptions of Hydr8 were primarily positive, setbacks in its implementation and use created difficulties in normalizing the solution into everyday practice. This study highlights the need for education related to hydration practice and a change of infrastructure in care home settings to implement technical solutions and changes to care., (©Alison Steven, Gemma Wilson, Lesley Young-Murphy. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 29.01.2019.)

An international team of experts in the field of fluid resuscitation was invited by the ESICM to form a task force to systematically review the evidence concerning fluid administration using basic monitoring. The work included a particular emphasis on pre-ICU hospital settings and resource-limited settings. The work focused on four main questions: (1) What is the role of clinical assessment to guide fluid resuscitation in shock? (2) What basic monitoring is required to perform and interpret a fluid challenge? (3) What defines a fluid challenge in terms of fluid type, ranges of volume, and rate of administration? (4) What are the safety endpoints during a fluid challenge? The expert panel found insufficient evidence to provide recommendations according to the GRADE system, and was only able to make recommendations for basic interventions, based on the available evidence and expert opinion. The panel identified significant gaps in the scientific evidence on fluid administration outside the ICU (excluding the operating theater). Globally, scientific communities and health care systems should address these critical gaps in evidence through research on how basic fluid administration in resource-rich and resource-limited settings can be improved for the benefit of patients and societies worldwide.

Background: Hyponatraemia is the most common electrolyte disturbance amongst hospitalised patients. Both American and European guidelines recommend fluid restriction as first line treatment for SIADH, however differ on second line recommendations. The objective of this study was to examine investigation and management of hyponatraemia in hospitalised patients in an Australian tertiary hospital., Methods: A retrospective audit was conducted of electronic medical records and laboratory data of inpatients with serum sodium (Na) ≤125 mmol/L, admitted over a 3 month period to the Princess Alexandra Hospital, Brisbane, Australia. The main outcomes measured included: demographic characteristics, investigations, accuracy of diagnosis, management strategy, change in Na and patient outcomes., Results: The working clinical diagnosis was considered accurate in only 37.5% of cases. Urine Na and osmolality were requested in 72 of 152 patients (47.4%) and in 43 of 70 euvolaemic patients (61.4%). Thyroid function tests (67.1%) and morning cortisol (45.7%) were underutilized in the euvolaemic group. In the SIADH cohort, fluid restriction resulted in a median (IQR) 7.5 mmol/L (4-10.5) increase in Na after 3 days; no treatment resulted in a median 0 mmol/L (- 0.5-1.5) change. Oral urea was utilized in 5 SIADH patients where Na failed to increase with fluid restriction alone. This resulted in a median 10.5 mmol/L (3.5-13) increase in Na from baseline to day 3. There were no cases of osmotic demyelination. The median length of stay was 8 days (4-18.5). Mortality was 11.2% (17 patients). There was a weak but significant correlation between nadir serum Na and mortality (R = 0.18, P = 0.031)., Conclusion: Inpatient hyponatraemia is often inadequately investigated, causing errors in diagnosis. Treatment is heterogeneous and often incorrect. In cases with hyponatraemia refractory to fluid restriction, oral urea presents an effective alternative treatment.

Purpose: A new postcardiac surgery fluid resuscitation strategy was implemented in our cardiovascular intensive care unit (CVICU) to implement evidence-based practice. We transitioned from a primarily albumin fluid-based strategy to a lactated Ringer's fluid-based strategy. We sought to determine whether a new postoperative fluid resuscitation strategy significantly altered the fluid composition for postcardiac surgery patients and what effect that would have on fluid resuscitation costs. Secondary outcomes included various clinical parameters., Methods: This was a retrospective, before-and-after cohort study of postcardiac surgery patients in an academic quaternary care intensive care unit (ICU) during two different 3-month time intervals. A total of 192 patients were studied: 108 pre-intervention and 84 post intervention. The intervention consisted of surveying stakeholders regarding potential concerns of reducing albumin use, an educational intervention addressing those concerns, and removing albumin from the routine postcardiac surgery ICU admission order set., Results: In the post intervention time period, albumin use decreased significantly compared to pre-invention (p<0.01), and lactated Ringer's volume increased significantly (p<0.01). However, total volume administered for resuscitation was not significantly different pre- and post intervention (1129 ml vs. 1369 ml, p=0.136). There were a net-cost savings between the pre-intervention and post intervention period (3 mo) of $30,549.20, with the albumin reduction accounting for most of those savings. Secondary outcomes were not significantly different between groups., Conclusions: An albumin fluid reduction strategy was successful in reducing the amount of albumin fluid used for postcardiac surgery patients and resulted in substantial cost savings., (© 2018 Pharmacotherapy Publications, Inc.)

Background: Whether goal-directed fluid therapy based on dynamic predictors of fluid responsiveness (GDFTdyn) alone improves clinical outcomes in comparison with standard fluid therapy among patients undergoing surgery remains unclear., Methods: PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched for relevant studies. Studies comparing the effects of GDFTdyn with that of standard fluid therapy on clinical outcomes among adult patients undergoing surgery were considered eligible. Two analyses were performed separately: GDFTdyn alone versus standard fluid therapy and GDFTdyn with other optimization goals versus standard fluid therapy. The primary outcomes were short-term mortality and overall morbidity, while the secondary outcomes were serum lactate concentration, organ-specific morbidity, and length of stay in the intensive care unit (ICU) and in hospital., Results: We included 37 studies with 2910 patients. Although GDFTdyn alone lowered serum lactate concentration (mean difference (MD) - 0.21 mmol/L, 95% confidence interval (CI) (- 0.39, - 0.03), P = 0.02), no significant difference was found between groups in short-term mortality (odds ratio (OR) 0.85, 95% CI (0.32, 2.24), P = 0.74), overall morbidity (OR 1.03, 95% CI (0.31, 3.37), P = 0.97), organ-specific morbidity, or length of stay in the ICU and in hospital. Analysis of trials involving the combination of GDFTdyn and other optimization goals (mainly cardiac output (CO) or cardiac index (CIx)) showed a significant reduction in short-term mortality (OR 0.45, 95% CI (0.24, 0.85), P = 0.01), overall morbidity (OR 0.41, 95% CI (0.28, 0.58), P < 0.00001), serum lactate concentration (MD - 0.60 mmol/L, 95% CI (- 1.04, - 0.15), P = 0.009), cardiopulmonary complications (cardiac arrhythmia (OR 0.58, 95% CI (0.37, 0.92), P = 0.02), myocardial infarction (OR 0.35, 95% CI (0.16, 0.76), P = 0.008), heart failure/cardiovascular dysfunction (OR 0.31, 95% CI (0.14, 0.67), P = 0.003), acute lung injury/acute respiratory distress syndrome (OR 0.13, 95% CI (0.02, 0.74), P = 0.02), pneumonia (OR 0.4, 95% CI (0.24, 0.65), P = 0.0002)), length of stay in the ICU (MD - 0.77 days, 95% CI (- 1.07, - 0.46), P < 0.00001) and in hospital (MD - 1.18 days, 95% CI (- 1.90, - 0.46), P = 0.001)., Conclusions: It was not the optimization of fluid responsiveness by GDFTdyn alone but rather the optimization of tissue and organ perfusion by GDFTdyn and other optimization goals that benefited patients undergoing surgery. Patients managed with the combination of GDFTdyn and CO/CI goals might derive most benefit.

Background: Fluid overloading is detrimental to organ function and results in a poor prognosis. It is necessary to evaluate fluid responsiveness before fluid loading. We performed a systematic meta-analysis to evaluate the diagnostic value of the respiratory variation in peripheral arterial blood flow peak velocity (△Vpeak PA) in predicting fluid responsiveness in mechanically ventilated patients., Methods: PubMed, Embase and The Cochrane Library databases were searched for studies that used △Vpeak PA to predict fluid responsiveness in mechanically ventilated patients. We calculated the pooled values of sensitivity, specificity and the area of the summary receiver operating characteristic curve by Meta-Disc 14.0 software., Results: Nine studies with a total of 402 patients were included. Two low quality studies were deleted in further analysis. Moreover, because of different locations of peripheral artery, the rest included studies were divided into brachial site group and carotid site group for meta-analysis individually. The pooled sensitivity, specificity and area under curve were 0.85 (95% confidence interval (CI) 0.77-0.92), 0.86 (95% CI 0.77-0.92) and 0.9268 in carotid site group. The pooled sensitivity, specificity and area under curve were 0.72 (95% CI 0.60-0.81), 0.85 (95% CI 0.74-0.93) and 0.8587 in brachial site group., Conclusions: △Vpeak of carotid and brachial artery had a diagnostic value in predicting fluid responsiveness respectively. Moreover, △Vpeak of carotid artery had more value than brachial artery in predicting fluid responsiveness. However, there was some clinical heterogeneity; therefore, further studies are needed to confirm diagnostic accuracy.

Background: Previous studies have shown that, compared with non-stone formers, stone formers have a higher papillary density measured with computer tomography (CT) scan. The effect of increased hydration on such papillary density in idiopathic calcium stone formers is not known., Methods: Patients with recurrent calcium oxalate stones undergoing endourological procedures for renal stones at our Institution from June 2013 to June 2014 were considered eligible for enrolment. Enrolled patients underwent a baseline unenhanced CT scan before the urological procedure; after endoscopic removal of their stones, the patients were instructed to drink at least 2 L/day of a hypotonic, oligomineral water low in sodium and minerals (fixed residue at 180 °C < 200 mg/L) for at least 12 months. Finally, the patients underwent a follow-up unenhanced CT scan during hydration regimen., Results: Twenty-five patients were prospectively enrolled and underwent baseline and follow-up CT scans. At baseline, mean papillary density was 43.2 ± 6.6 Hounsfield Units (HU) (43.2 ± 6.7 for the left kidney and 42.8 ± 7.1 HU for the right kidney). At follow-up and after at least 12 months of hydration regimen, mean papillary density was significantly reduced at 35.4 ± 4.2 HU (35.8 ± 5.0 for the left kidney and 35.1 ± 4.2 HU for the right kidney); the mean difference between baseline and follow-up was - 7.8 HU (95% confidence interval - 10.6 to - 5.1 HU, p < 0.001)., Conclusions: Increased fluid intake in patients with recurrent calcium oxalate stones was associated with a significant reduction in renal papillary density., Trial Registration: NCT03343743 , 15/11/2017 (Retrospectively registered).

Background: The accuracy of respiratory variation of the inferior vena cava (rvIVC) in predicting fluid responsiveness, particularly in spontaneously breathing patients is unclear., Objectives: To consider the evidence to support the accuracy of rvIVC in identifying patients who are unlikely to benefit from fluid administration., Design: Systematic review and meta-analysis., Data Source: We searched MEDLINE, EMBASE, Cochrane Library, KoreaMed, LILCAS and WHO Clinical Trial Registry from inception to June 2017., Eligibility Criteria: Case-control or cohort studies that evaluated the accuracy of rvIVC in living adult humans were included. A study was included in the meta-analysis if data enabling construction of 2 × 2 tables were reported, calculated or could be obtained from authors and met the above cited criteria., Result: A total of 23 studies including 1574 patients were included in qualitative analysis. The meta-analysis involved 20 studies and 761 patients. Pooled sensitivity and specificity of rvIVC in 330 spontaneously breathing patients were 0.80 [95% confidence interval (CI) 0.68 to 0.89] and 0.79 (95% CI 0.60 to 0.90). Pooled sensitivity and specificity of rvIVC in 431 mechanically ventilated patients were 0.79 (95% CI 0.67 to 0.86) and 0.70 (95% CI 0.63 to 0.76)., Conclusion: Decreased inferior vena caval respiratory variation is moderately accurate in predicting fluid unresponsiveness both in spontaneous and mechanically ventilated patients. The findings of this review should be used in the appropriate clinical context and in conjunction with other clinical assessments of fluid status., Identifier: CRD 42017068028.

Sepsis is a common and life-threatening condition that requires early recognition and swift initial management. Diagnosis and treatment of sepsis and septic shock are fundamental for emergency clinicians, and include knowledge of clinical and laboratory indicators of subtle and overt organ dysfunction, infection source control, and protocols for prompt identification of the early signs of septic shock. This issue is a structured review of the literature on the management of sepsis, focusing on the current evidence, guidelines, and protocols.

Introduction: Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of traumatic death worldwide and particularly on the battlefield. They are especially challenging when present simultaneously (polytrauma), and clear blood pressure end points during fluid resuscitation are not well described for this situation. The goal of this study is to evaluate for any benefit of increasing blood pressure using a vasopressor on brain blood flow during initial fluid resuscitation in a swine polytrauma model., Materials and Methods: We used a swine polytrauma model with simultaneous TBI, femur fracture, and HS with uncontrolled noncompressible internal bleeding from an aortic tear injury. Five animals were assigned to each of three experimental groups (hydroxyethyl starch only [HES], HES + 0.4 U/kg vasopressin, and no fluid resuscitation [No Fluids]). Fluids were given as two 10 mL/kg boluses according to tactical field care guidelines. Primary outcomes were mean arterial blood pressure (MAP) and brain blood flow at 60 min. Secondary outcomes were blood flows in the heart, intestine, and kidney; arterial blood lactate level; and survival at 6 hr. Organ blood flow was measured using injection of colored microspheres., Results: Five animals were tested in each of the three groups. There was a statistically significant increase in MAP with vasopressin compared with other experimental groups, but no significant increase in brain blood flow during the first 60 min of resuscitation. The vasopressin group also exhibited greater total internal hemorrhage volume and rate. There was no difference in survival at 6 hours., Conclusion: In this experimental swine polytrauma model, increasing blood pressure with vasopressin did not improve brain perfusion, likely due to increased internal hemorrhage. Effective hemostasis should remain the top priority for field treatment of the polytrauma casualty with TBI., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Fluid intake during military training is prescribed based on the interactions among work rates, environmental conditions, and uniform configurations. The efficacy of this guidance has not been empirically assessed in over a decade. To determine the acceptability of the fluid intake guidance, sweat losses were measured in a variety of conditions with modern uniform/body armor configurations and were then compared to prescribed fluid intakes for each condition (workload, environment, clothing)., Methods: Whole body sweat losses of 324 Soldiers and 14 model simulations were measured under a variety of work intensities ((Watts) easy, moderate, hard), work durations (2-25 h), environmental conditions (White-Black flag), and uniform configurations (including Army Combat Uniform and body armor). Whole body sweat losses were then calculated relative to 4 h drinking guidance and in accordance with TB MED 507 recommended work/rest ratios. The differences between the prescribed fluid intake and sweat loss were calculated and expressed as a percent loss or gain of body weight. Values within a threshold of ±2% body water flux (BWF) were deemed an acceptable conservative starting point for performance and health concerns., Findings: Values within ±2% BWF numbered 309/338; 25 of 338 observations exceeded the +2% BWF while 4 of 338 observations exceeded the -2% BWF. When total fluid restriction was simulated, all experienced body weight loss with 151 of 338 observations exceeding the -2% BWF., Discussion: When calculated using actual measured sweating rates from the laboratory and model simulations, current fluid intake guidance appears to predict with 91.4% accuracy the volume of fluid required to maintain a proper euhydrated state (±2%) during 4 h of exercise. Simulations of total fluid restriction support the necessity for fluid intake guidance so that the Warfighter's performance does not degrade. It is recommended that the current military fluid intake guidance focuses on methods for accurately tracking fluid intakes., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018.)

After exposure to microgravity, or head-down bed rest (HDBR), fluid loading is often used with the intent of increasing plasma volume and maintaining mean arterial pressure during orthostatic stress. Nine men (aged 18-32 years) underwent three randomized trials with lower body negative pressure (LBNP) before and after: (1) 4-h of sitting with fluid loading (1 g sodium chloride/125 mL of water starting 2.5-h before LBNP), (2) 28-h of 6-degree HDBR without fluid loading, and (3) 28-h of 6-degree HDBR with fluid loading. LBNP was progressive from 0 to -40 mmHg. After 28-h HDBR, fluid loading did not protect against the loss of plasma volume (-280 ± 64 mL without fluid loading, -207 ± 86 with fluid loading, P = 0.472) nor did it protect against a drop of mean arterial pressure (P = 0.017) during LBNP (Post-28 h HDBR response from 0 to -40 mmHg LBNP: 88 ± 4 to 85 ± 4 mmHg without fluid loading and 93 ± 4 to 88 ± 5 mmHg with fluid loading, P = 0.557 between trials). However, fluid loading did protect against the loss of stroke volume index and central venous pressure observed after 28-h HDBR. Fluid loading also attenuated the increase of angiotensin II seen after 28-h HDBR and throughout the LBNP protocol (Post-28 h HDBR response from 0 to -40 mmHg LBNP: 16.6 ± 3.4 to 23.7 ± 5.0 pg/mL without fluid loading and 6.1 ± 0.8 to 12.2 ± 2.3 pg/mL with fluid loading, P < 0.001 between trials). Our results indicate that fluid loading did not protect against plasma volume loss due to HDBR or change blood pressure responses to LBNP. However, changes in central venous pressure, stroke volume and fluid regulatory hormones could potentially influence longer duration studies and those with more severe orthostatic stress., (© 2018 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of The Physiological Society and the American Physiological Society.)

Elucidation of the structural basis of endothelial barrier function and the study of transcapillary fluid exchange dynamics are areas of active research. There has been significant enhancement in our understanding of the ultrastructural basis of endothelial barrier function. The role of glycocalyx has received special attention. Experimental evidence has called for a revision in the classic Starling principle of transcapillary exchange. The glycocalyx model provides a potential structural mechanism for the revised Starling principle. This knowledge can provide the framework for understanding the volume expansion effect of fluid therapy and the physiological basis of fluid therapy., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care., Objective: We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality., Methods: We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered., Results: There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08)., Conclusions: We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma., (Published by Elsevier Inc.)

Perioperative fluid management impacts outcomes and plays a pivotal role in enhanced recovery pathways (ERPs). There have been major advances in understanding the effects of fluid therapy and administration during the perioperative period. Improving fluid management during this period leads to a decrease in complications, decrease in length of stay (LOS), and enhanced patient outcomes. It is important to consider preoperative and postoperative fluid management to be just as critical as intraoperative management given multiple associated benefits to the patients. Preoperative hydration with (complex) carbohydrate drinks up until 2 h before surgery is safe and should be encouraged, as this helps improve metabolism, decrease insulin resistance, reduce anxiety, and reduce nausea and vomiting. During the intraoperative period, the goals of fluid management are to maintain euvolemia using an individualized plan for fluid and haemodynamic management, matching the needs for monitoring with patient and surgical risk through goal-directed therapy (GDT). By combining the use of fluids and inotropes, GDT uses measurements and indicators of cardiac output and stroke volume to improve blood flow intraoperatively, and ultimately reduce LOS and complications. In the postoperative period, an early transition to oral hydration helps to enhance the conditions for healing and recovery from surgery. I.V. fluid therapy should be kept at a minimum, and urine output should not be the driving force for fluid administration. The optimization of perioperative fluid management is critical to ERPs as it helps improve pulmonary function, tissue oxygenation, gastrointestinal motility, and wound healing., (Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objectives: To describe tissue oxygen saturation (StO 2 ) in response to a vascular occlusion test using thenar eminence and forearm near-infrared spectroscopy (NIRS) and the association with volume responsiveness after cardiac surgery., Design: Single-center, prospective, observational cohort study., Setting: Cardiothoracic intensive care unit., Participants: Seventy-six post-cardiac surgical adults., Interventions: Immediately before and 10 minutes after a 250-to-500 mL fluid bolus, StO 2 was measured in response to a vascular occlusion test to calculate tissue deoxygenation (R des ) and reoxygenation (R res ) rates. Concurrently, systemic hemodynamic, metabolic, and blood gas variables were collected., Measurements and Main Results: A total of 203 boluses were captured using thenar NIRS and 141 boluses using forearm NIRS. Approximately 25% of boluses increased cardiac output by ≥15% (volume responders). Thenar and forearm R des decreased in responders, but increased (thenar) or remained unchanged (forearm) in nonresponders. A logistic regression model of the association among StO 2 , R des and R res , and volume responsiveness was significant for thenar measurements (p = 0.001) with an area under the receiver operating characteristic of 0.69 (95% confidence interval: 0.62-0.75). It also was significant (p = 0.02) for forearm measurements, with an area under the receiver operating characteristic of 0.71 (0.62-0.79). R des was an independent variable in both instances (odds ratio 0.31 [0.14-0.69], thenar; odds ratio 0.60 [0.45-0.80], forearm). Thenar and forearm NIRS variables were correlated poorly with cardiac output, stroke volume, systemic oxygen delivery and consumption index, mixed venous, and central venous oxygen saturation (Spearman׳s coefficients, r = 0.17-0.46, p < 0.002)., Conclusion: In post-cardiac surgical patients, thenar and forearm NIRS variables were associated with volume responsiveness although not achieving precision necessary for clinical management., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The Paediatric Research in Emergency Departments International Collaborative (PREDICT) performs multicentre research in Australia and New Zealand. Research priorities are difficult to determine, often relying on individual interests or prior work., Objective: To identify the research priorities of paediatric emergency medicine (PEM) specialists working in Australia and New Zealand., Methods: Online surveys were administered in a two-stage, modified Delphi study. Eligible participants were PEM specialists (consultants and senior advanced trainees in PEM from 14 PREDICT sites). Participants submitted up to 3 of their most important research questions (survey 1). Responses were collated and refined, then a shortlist of refined questions was returned to participants for prioritisation (survey 2). A further prioritisation exercise was carried out at a PREDICT meeting using the Hanlon Process of Prioritisation. This determined the priorities of active researchers in PEM including an emphasis on the feasibility of a research question., Results: One hundred and six of 254 (42%) eligible participants responded to survey 1 and 142/245 (58%) to survey 2. One hundred and sixty-eight (66%) took part in either or both surveys. Two hundred forty-six individual research questions were submitted in survey 1. Survey 2 established a prioritised list of 35 research questions. Priority topics from both the Delphi and Hanlon process included high flow oxygenation in intubation, fluid volume resuscitation in sepsis, imaging in cervical spine injury, intravenous therapy for asthma and vasopressor use in sepsis., Conclusion: This prioritisation process has established a list of research questions, which will inform multicentre PEM research in Australia and New Zealand. It has also emphasised the importance of the translation of new knowledge., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Signs of hypovolaemia are frequent in the postoperative period, but not all patients need or respond to fluid administration. An increase in cardiac output (CO) after passive leg raising (PLR) has been demonstrated to be useful as a volume response predictor in non-surgical, spontaneously breathing patients., Objective: The objective of this study was to evaluate the accuracy of transthoracic echocardiography after PLR to predict fluid responsiveness in post-surgical patients., Design: A prospective observational study., Setting: A tertiary hospital between January and July 2015., Patients: Fifty-one spontaneously breathing postoperative patients with suspected hypovolaemia (arterial hypotension, oliguria, tachycardia or delayed capillary refill) were considered for the study., Intervention: Demographic and personal data were collected, as well as heart rate variations, mean arterial pressure during PLR and after administering 500 ml of Ringer's lactate solution. CO was measured by transthoracic echocardiography., Main Outcome Measures: The primary outcome was measurement of CO before and after PLR and Ringer's lactate administration., Results: Forty-one patients were included in the study (six patients were excluded because of a poor echocardiographic window and four because of misalignment of the Doppler and outflow tract of the left ventricle). Twenty-two patients (54%) were considered responders to fluid therapy, with an increase of stroke volume greater than or equal to 15% after 500 ml lactated Ringer's infusion. The highest area under the curve was found for an increase in CO (0.91 ± 0.05; 95% confidence interval 0.78 to 0.97). An increase in CO greater than 11% after the PLR manoeuvre predicts a volume response with 68% sensitivity and 100% specificity., Conclusion: This is the first study showing that measurement of CO after PLR can predict volume response in spontaneously breathing postoperative patients.

Background: During a fluid challenge, the changes in cardiac performance and peripheral circulatory tone are closely related to the position of the ventricle on the Frank-Starling curve. Some patients have a good haemodynamic response to a fluid challenge, others hardly any response. The early haemodynamic effects of a fluid challenge could predict the final response before the entire fluid volume has been administered., Objective: To assess whether a multivariate logistic regression model, including pulse pressure variation (PPV), cardiac cycle efficiency (CCE), arterial elastance and the difference between the dicrotic pressure and both systolic and mean arterial pressure (SAP - Pdic and MAP - Pdic) can predict cardiac responsiveness early during a fluid challenge in comparison with the standard procedure described elsewhere., Design: Observational study., Setting: Elective surgical patients undergoing laparotomy, enrolled in two Italian University Hospitals., Patients: Fifty adult surgical patients, ventilated with a lung protective strategy, were enrolled and data from 46 were analysed., Interventions: A fluid challenge consisting of 500 ml of crystalloid infused over 10 min., Main Outcome Measures and Analysis: The changes in CCE, arterial elastance, SAP - Pdic and MAP - Pdic were compared using analysis of variance. A multivariate logistic regression analysis utilising baseline values and the first minute measuring a variation statistically significant for the considered variables., Results: At baseline, PPV correctly identified 70% of patients (89% of non-responders; 42% of responders). The model, including baseline PPV, ΔCCE and ΔSAP - Pdic, correctly identified the efficiency of fluid challenge in 87% of patients (84.2% of responders; 92.5 of non-responders) after 5 min from fluid challenge infusion., Conclusion: In this pilot study conducted in a population of surgical patients mechanically ventilated with a VT less than 8 ml kg, a dynamic model of fluid challenge assessment, including PPV, ΔCCE and ΔSAP - Pdic, enhances the prediction of fluid challenge response after 5 min of a 10-min administration., Trial Registration: ACTRN12616001479493.

Initiation or continuation of artificial hydration (AH) at the end of life requires unique considerations. A combination of ethical precedents and medical literature may provide clinical guidance on how to use AH at the end of life. The purpose of this review is to describe the ethical framework for and review current literature relating to the indications, benefits, and risks of AH at the end of life. Provider, patient, and family perspectives will also be discussed.

Introduction: Previous work has shown poisoning-related emergency department (ED) visits are increasing, and these visits are resource-intensive. Little is known, however, about how resource utilization for patients with known or suspected poisoning differs from that of general ED patients., Methods: We reviewed 4 years of operational data at a single ED. We identified visits due to known or suspected poisoning (index cases), and paired them with time-matched controls. In the primary analysis, we compared the groups with respect to a broad array of resource utilization characteristics. In a secondary analysis, we performed the same comparison after excluding patients ultimately transferred to a psychiatric facility., Results: There were 405 index cases and 802 controls in the primary analysis, and 374 index cases and 741 controls in the secondary analysis. In the primary/secondary analyses, patients with known or suspected poisoning had longer ED lengths of stay in minutes (370 vs. 232/295 vs. 234), higher rates of laboratory results per patient (40.4 vs. 26.8/39.6 vs. 26.8), greater administration of intravenous medications and fluids per patient (2.0 vs. 1.6/2.1 vs. 1.6), higher rates of transfer to a psychiatric facility (7.7 vs. 0.2%/not applicable), and higher rates of both admission (40.2 vs. 32.8/43.6 vs. 33.1%) and admission to an advanced care bed (21.5 vs. 7.6/23.3 vs. 7.8%). Patients with known or suspected poisoning had lower rates of imaging per patient, for both plain radiographs (0.4 vs. 0.5/0.4 vs. 0.5) and advanced imaging studies (0.3 vs. 0.5/0.4 vs. 0.5)., Conclusions: ED patients with known or suspected poisoning are more resource intensive than general ED patients. These results may have implications for both resource allocation (particularly for departments that might see a high volume of such patients) and ED operations management.

Purpose of Review: Fluid responsiveness prediction is not always possible with well established dynamic approaches such as passive leg raising or pulse pressure variation in the ICU. The purpose of the present review is to summarize emerging alternative techniques for fluid responsiveness prediction in adult critically ill patients and discuss their methodology and applicability. In addition, the future role of fluid responsiveness prediction in the ICU is discussed., Recent Findings: Several new dynamic techniques have been investigated and they all contribute to the applicability of fluid responsiveness techniques. Although increasing the applicability, most of the emerging techniques still rely on ventilator setting changes in patients that are fully or almost fully adapted to the ventilator or require reliable flow monitoring, which prevents broad applicability. Yet, the mini/micro fluid challenges and the use of extrasystolic preload changes have the potential of being more applicable but all reviewed methods need further validation and methodological refinement., Summary: Emerging techniques are encouraging for broader applicability of fluid responsiveness prediction. Still, the clinical impact of correctly predicting fluid responsiveness remains to be investigated in the critically ill and the research community should have a clear aim of moving toward that type of studies.

To survive the transition to extrauterine life, newborn infants must have lungs that provide an adequate surface area and volume to allow for gas exchange. The dynamic activities of fetal breathing movements and accumulation of lung luminal fluid are key to fetal lung development throughout the various phases of lung development and growth, first by branching morphogenesis, and later by septation. Because effective gas exchange is essential to survival, pulmonary hypoplasia is among the leading findings on autopsies of children dying in the newborn period. Management of infants born prematurely who had disrupted lung development, especially at the pre-glandular or canalicular periods, may be challenging, but limited success has been reported. Growing understanding of stem cell biology and mechanical development of the lung, and how to apply them clinically, may lead to new approaches that will lead to better outcomes for these patients., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Diarrhea remains to be a main cause of childhood mortality. Diarrhea case management indicators reflect the effectiveness of child survival interventions. We aimed to assess time trends and country-wise changes in diarrhea case management indicators among under-5 children in low-and-middle-income countries., Methods: We analyzed aggregate data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys done from 1986 to 2012 in low-and-middle-income countries. Two-week prevalence rates of diarrhea, caregiver's care seeking behavior and three case management indicators were analyzed. We assessed overall time trends across the countries using panel data analyses and country-level changes between two sequential surveys., Results: Overall, yearly increase in case management indicators ranged from 1 · 3 to 2 · 5%. In the year 2012, <50% of the children were given correct treatment (received oral rehydration and increased fluids) for diarrhea. Annually, an estimated 300 to 350 million children were not given oral rehydration solutions, or recommended home fluids or 'increased fluids' and 304 million children not taken to a healthcare provider during an episode of diarrhea. Overall, care seeking for diarrhea, increased from pre-2000 to post-2000, i.e. from 35 to 45%; oral rehydration rates increased by about 7% but the rate of 'increased fluids' decreased by 14%. Country-level trends showed that care seeking had decreased in 15 countries but increased in 33 countries. Care seeking from a healthcare provider increased by ≥10% in about 23 countries. Oral rehydration rates had increased by ≥10% in 15 countries and in 30 countries oral rehydration rates increased by <10%., Conclusions: Very limited progress has been made in the case management of childhood diarrhea. A better understanding of caregiver's care seeking behavior and health care provider's case management practices is needed to improve diarrhea case management in low- and-middle-income countries.