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Background: Despite significant progress in orthopaedic surgery, the prevalence of periprosthetic joint infections (PJIs) remains persistent, and future increases are expected due to the increasing number of joint arthroplasties. PJIs are intricately connected to biofilm-producing bacteria, which encase infected prostheses, impairing the effectiveness of antibiotics and the immune system. Acute PJIs with immature biofilms are traditionally managed with debridement, antibiotics, and implant retention (DAIR). However, to date, there has not been a conclusive direct clinical comparison (in vivo) demonstrating the superiority of one irrigation solution over others. Recently, there has been a growing interest in irrigation solutions with antibiofilm properties demonstrated in in vitro studies, exemplified by the preformulated Bactisure® irrigation solution, which contains ethanol, acetic acid, sodium acetate, benzalkonium chloride, and sterile water. The main objective of this study was to evaluate the effectiveness (infection cure rate) of preformulated Bactisure® irrigation solution in vivo compared with saline solution in a control group of patients with acute knee and/or hip periprosthetic infections treated with DAIR., Methods: Prospective single-centre randomized controlled trial involving patients with acute haematogenous PJI who received standard DAIR surgery from December 2022 to December 2024. The type of irrigation solution used during surgery will include two groups allocated at a 1:1 ratio: a control group (n = 25) with saline solution and an experimental group (n = 25) receiving the Bactisure® preformulated solution. The sample size was calculated based on an expected reduction in reinfection rates from 45% in the control group to 10% in the experimental group. Data on baseline patient characteristics, clinical and radiological information, and healthcare questionnaires will be recorded. All patients will be followed for minimum of 12 months. The infection cure rate at 1 year will be the primary outcome., Discussion: This study is the first to compare the effectiveness of preformulated Bactisure® irrigation solution with that of saline solution in real clinical practice (in vivo) in patients with acute knee and/or hip periprosthetic infections treated with DAIR. Our main hypothesis is that, compared with saline solution, Bactisure® provides a better infection cure rate at 1 year post-DAIR., Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN10873696 . Registered on December 19, 2023., Competing Interests: Declarations Ethics approval and consent to participate Ethical approval was obtained on 25/11/2022 from the Clinical Research Ethics Committee (CEIm) of Vall d’Hebron University Hospital (Pg. Vall d’Hebron, 119–129, Barcelona, 08035, Spain; (+ 34) 934893891; ceic@vhir.org) under reference number PR(AT)192/2022. Written consent from patients will be obtained before their participation in the study. The study is registered with the International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN10873696 (registered on 19/12/2023). Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests., (© 2024. The Author(s).)

Introduction: Fibrinolytic agents (FA) activate the fibrinolytic system, converting plasminogen into plasmin to break down fibrin. Their use for irrigation of abdominal abscesses is debated, and this meta-analysis evaluates their efficacy., Methods: We searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing FA and saline in percutaneous drainage of abdominal abscesses. Outcomes included length of hospitalization, duration of drainage, and drainage volume. We pooled mean differences (MD) and 95% confidence intervals (CI) using a random-effects model. We also performed a trial sequential analysis (TSA)., Results: We included six RCTs encompassing 299 patients. In the overall analysis, FA increased drainage volume (MD 104.25 mL; 95% CI 35.72-172.77 mL; p = 0.003; I 2  = 0%). In children, saline reduced hospitalization duration (MD -1.26 days; 95% CI -1.98 to -0.55 days; p = 0.0006; I 2  = 0%), whereas FA increased drainage volume (MD 84.66 mL; 95% CI 5.77-153.54 mL; p = 0.04; I 2  = 0%). In adults, FA significantly reduced hospitalization duration (MD -11.12 days; 95% CI -15.16 to -7.08 days; p < 0.00001; I 2  = 0%) and duration of drainage (MD -6.53 days; 95% CI -9.25 to -3.81 days; p < 0.00001; I 2  = 0%) while increasing drainage volume (MD 164.47 mL; 95% CI 26.16-302.78 mL; p = 0.02; I 2  = 0%). On TSA, the required information size was achieved only for the adult subgroup's hospitalization and drainage duration., Conclusion: In adults, FA reduce hospitalization and drainage duration and increase drainage volume. In children, saline seems more effective in reducing hospitalization duration, while FA increase drainage volume. These findings underscore the need for age-specific treatments and further research, especially in the pediatric population., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Intramuscular administration is a commonly used method for delivering sedatives and anesthetics in veterinary medicine. Previous studies have reported inflammation at the intramuscular injection site in laboratory animals and observed signal changes on MRI following intramuscular injections in humans. We hypothesized that following intramuscular injection, the site would exhibit T2 hyperintensity and contrast enhancement on MRI. To investigate this, this prospective study evaluated the pattern of signal changes and grade of T2 signal intensity and contrast enhancement over time after the intramuscular injection of medetomidine at a premedication dosage, comparing it to saline. MRI scans were performed immediately postinjection into the biceps femoris and quadriceps femoris muscles, as well as at 2, 8, 24, and 72 h, and 7 days postinjection. A semiquantitative scale was utilized to grade signal intensity and contrast enhancement. Both medetomidine and saline injections showed T2 hyperintensity immediately after injection and contrast enhancement from 2 h postinjection, manifesting as flame-shaped. These signal changes decreased up to 24 h postinjection (p < .05). The signal changes induced by medetomidine showed higher T2 hyperintense change and stronger contrast enhancement compared with saline at most time points, with the signal changes persisting for a longer duration (p < .05). These findings suggest that intramuscular administration of medetomidine induces a more severe tissue reaction compared with saline, and the results are expected to aid in the differentiation of various muscle diseases that present with similar MRI findings., (© 2024 American College of Veterinary Radiology.)

Importance: Sickle cell disease (SCD), a clinically heterogenous genetic hemoglobinopathy, is characterized by painful vaso-occlusive episodes (VOEs) that can require hospitalization. Patients admitted with VOEs are often initially resuscitated with normal saline (NS) to improve concurrent hypovolemia, despite preclinical evidence that NS may promote erythrocyte sickling. The comparative effectiveness of alternative volume-expanding fluids (eg, lactated Ringer [LR]) for resuscitation during VOEs is unclear., Objective: To compare the effectiveness of LR to NS fluid resuscitation in patients with SCD and VOEs., Design, Setting, and Participants: This multicenter cohort study and target trial emulation included inpatient adults with SCD VOEs who received either LR or NS on hospital day 1. The Premier PINC AI database (2016-2022), a multicenter clinical database including approximately 25% of US hospitalizations was used. The analysis took place between October 6, 2023, and June 20, 2024., Exposure: Receipt of LR (intervention) or NS (control) on hospital day 1., Main Outcome and Measures: The primary outcome was hospital-free days (HFDs) by day 30. Targeted maximum likelihood estimation was used to calculate marginal effect estimates. Heterogeneity of treatment effect was explored in subgroups., Results: A total of 55 574 patient encounters where LR (n = 3495) or NS (n = 52 079) was administered on hospital day 1 were included; the median (IQR) age was 30 (25-37) years. Patients who received LR had more HFDs compared with those who received NS (marginal mean difference, 0.4; 95% CI, 0.1-0.6 days). Patients who received LR also had shorter hospital lengths of stay (marginal mean difference, -0.4; 95% CI, -0.7 to -0.1 days) and lower risk of 30-day readmission (marginal risk difference, -5.8%; 95% CI, -9.8% to -1.8%). Differences in HFDs between LR and NS were heterogenous based on fluid volume received: among patients who received less than 2 L, there was no difference in LR vs NS; among those who received 2 or more L, LR was superior to NS., Conclusion and Relevance: This cohort study found that, compared with NS, LR had a small but significant improvement in HFDs and secondary outcomes including 30-day readmission. These results suggest that, among patients with VOEs in whom clinicians plan to give volume resuscitation fluids on hospital admission, LR should be preferred over NS.

Purpose: To discern whether reduced infection rates were attributed to antiseptic solutions or mechanical rectal irrigation., Patients and Methods: After receiving ethical approval, the study included patients who underwent transrectal prostate biopsy due to elevated PSA or abnormal digital rectal examination findings, and prostate cancer under active surveillance, at Tepecik Training and Research Hospital between April 2022 and June 2023. Standard antibiotic prophylaxis was administered. Patients were randomized into three equal groups according to the rectal irrigation strategy., Results: Overall complications occurred in 4%. Despite distinct cleaning agents, there was no significant difference in infection rates ( p  = 0.780) or fever incidence ( p  = 0.776). Pathological analyses revealed comparable outcomes ( p  = 0.764)., Conclusion: The study challenges the prevailing belief that antiseptic solutions are indispensable for infection prevention, as saline demonstrated similar efficacy. Limitations include data gaps from potential external hospital visits and absent rectal microorganism swab culture. While TRUS-PB remains the gold standard, this study suggests that mechanically cleansing the rectal mucosa with saline-a cost-effective, side-effect-free alternative-may be a viable infection prevention method, particularly beneficial for patients with antiseptic allergies. The findings prompt a reconsideration of the necessity of antiseptic solutions in TRUS-PB, offering an alternative approach to mitigate infectious complications., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Recently, enhanced recovery after surgery (ERAS) protocols have attracted attention; they emphasize on avoiding intraoperative hypothermia while performing lumbar fusion surgery. However, none of the studies have reported the protocol for determining the temperature of saline irrigation during biportal endoscopic spine surgery (BESS) procedure. This study evaluated the effectiveness of warm saline irrigation during BESS in acute postoperative pain and inflammatory reactions., Materials and Methods: Fifty-five patients who underwent BESS procedure were retrospectively analyzed for the incidence of perioperative hypothermia (< 36 o C), postoperative inflammatory factors (white blood cells (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), serum amyloid A (SAA)), and clinical outcomes (back visual analog scale (VAS) score, postoperative shivering). The patients were divided into the warm and cold saline irrigation groups., Results: Hemoglobin, WBC, ESR, creatine kinase, and creatine kinase-muscle brain levels did not significantly differ between the warm and cold saline groups. The mean CRP, IL-6, and SAA levels were significantly higher in the cold saline group than in the warm saline group (p = 0.0058, 0.0028, and 0.0246, respectively); back VAS scores were also higher with a statistically significant difference until two days postoperatively (p < 0.001). During the entire procedure, the body temperature was significantly lower in the cold saline irrigation group, but the hypothermia incidence rate significantly differed 30 min after the operation was started., Conclusions: Using warm saline irrigation during BESS is beneficial for early recovery after surgery, as it is associated with reduced postoperative pain and complication rates., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The implications of saline flushing of the radial sheath have not been studied in terms of radial artery occlusion. We aimed to investigate radial artery patency outcomes after the saline flush of the radial sheath., Methods: In this prospective observational study, patients were selected to receive either radial sheath flushing with 10 mL of saline after pulling the sheath to one-third of its length (Group 1) or standard care (Group 2) after removal of the catheter sheath as per physician discretion. Radial artery patency was assessed by Doppler ultrasound at 24 h and 30 days after the procedure., Results: A total of 2877 patients were enrolled in the study, with 1340 receiving radial sheath flushing and 1537 receiving standard care. At 24 h after the procedure, the incidence of radial artery occlusion was significantly lower in the radial sheath flushing group compared to the standard care group (4.4% vs 12.6%, p  = 0.027). This difference persisted 30 days after the procedure (6.1% vs 15.8%, p  = 0.015). Radial sheath flushing was independently associated with a lower risk of radial artery occlusion 30 days after the procedure, after adjusting for potential confounders (OR 0.375, 95% CI 0.18-0.77, p  = 0.008)., Conclusion: In conclusion, this prospective study provides evidence to support the use of radial sheath flushing after coronary intervention via the radial artery as a simple and effective strategy for reducing the risk of radial artery occlusion without increasing the risk of other adverse outcomes., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Venous access devices are used in health care. To prevent occlusions the evidence confirmed the need for routine catheter flushing before and after infusion as well as at the end of use. To date, the efficacy of heparin has not been demonstrated. The aim of this study was to evaluate the effectiveness of the locking of central venous catheters with heparin versus normal saline in adults to prevent occlusion, catheter-related infections and thrombosis in adults. A literature search using Medline, Embase, Cochrane Library and Cinahl was performed to identify all meta-analyses addressing the effectiveness of heparin versus normal saline in locking central venous catheters in adults. Four reviewers independently selected publications assessed quality and extracted data. Parameter estimates regarding occlusion, catheter- related infections and thrombosis were pooled using an umbrella review. We identified 6356 references. Seven systematic reviews were included in the study. Most of the studies included in the systematic reviews were conducted in oncohaematology departments, intensive care and cardiac surgery units among patients with multiple diseases and chronicity. Most studies report a heparin concentration of 10 to 5000 IU/ml versus normal saline and other solutions. There was no evidence that heparin was more effective than normal saline in reducing complications such as occlusion, catheter-related infections and thrombosis. No statistically significant difference was found between heparin and normal saline in reducing catheter occlusion. Heparin is not superior compared to normal saline., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To compare the effectiveness of 2 track sealing techniques following computed tomography (CT)-guided lung biopsy using either gelatin sponge slurry (GSS) or saline to reduce the rate of postbiopsy pneumothorax., Materials and Methods: In this prospective study, a total of 266 patients (median age, 66.2 years; range, 25.5-89.2 years; 150 men) were included between July 2019 and January 2023. The patients referred for a CT-guided lung biopsy, in whom the needle would pass through aerated lung, were randomly assigned to either the GSS sealing technique group (n = 132) or the saline track sealing technique (n = 134) in a 1:1 ratio. All biopsies were performed using a 19-gauge coaxial needle in a tertiary hospital by 1 of 4 interventional radiologists with varying levels of experience (F.C., L.G., P.L., C.V.). The outcomes were pneumothorax occurrence, pneumothorax-related intervention (simple aspiration and/or drainage), and biopsy-related hospital stay length., Results: Pneumothorax rates were 12.1% in the GSS group and 24.6% in the saline group (P = .008). Hospital length of stay was significantly shorter in the GSS group (P = .003). The need for pneumothorax-related intervention did not reach statistical significance between the groups (6.8% vs 12.7%; P = .107). In the multiple logistic regression analysis, track sealing with GSS was a protective factor for pneumothorax (odds ratio [OR], 0.44; 95% CI, 0.22-0.87; P = .019), and emphysema was associated with higher risk of pneumothorax (OR, 2.67; 95% CI, 1.31-5.44; P = .007)., Conclusions: Track sealing with GSS following a CT-guided lung biopsy is significantly more effective than saline in reducing postbiopsy pneumothorax and results in shorter hospital stay., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Some evidence suggests that fluid resuscitation with lactated Ringer's solution (LR) may have an anti-inflammatory effect on acute pancreatitis (AP) when compared to normal saline (NS) and may be associated with a decrease in severity, but existing single-center randomized controlled trials showed conflicting results. The WATERLAND trial aims to investigate the efficacy and safety of fluid resuscitation using LR compared to NS in patients with AP., Methods: The WATERLAND trial is an international multicenter, open-label, parallel-group, randomized, controlled, superiority trial. Patients will be randomly assigned in a 1:1 ratio to receive LR versus NS-based fluid resuscitation for at least 48 h. The primary outcome will be moderately severe or severe AP, according to the revision of the Atlanta classification. The secondary objectives of the WATERLAND trial are to determine the effect of LR versus NS fluid resuscitation on several efficacy and safety outcomes in patients with AP. A total sample of 720 patients, 360 in the LR group and 360 in the NS group, will achieve 90% power to detect a difference between the group proportions of 10%, assuming that the frequency of moderately severe or severe AP in the LR group will be 17%. A loss to follow-up of 10% of patients is expected, so the total sample size will be 396 patients in each treatment arm (792 patients overall). The test statistic used is the two-sided Z test with pooled variance set at a 0.05 significance level., Discussion: The WATERLAND study aims to improve the early management of AP. Fluid resuscitation is an inexpensive treatment available in any hospital center worldwide. If a better evolution of pancreatitis is demonstrated in one of the treatment arms, it would have important repercussions in the management of this frequent disease., Trial Registration: ClinicalTrials.gov, NCT05781243. Registration date on January 4, 2023. EudraCT number 2023-000010-18, first posted March 23, 2023., (© 2024. The Author(s).)

Background: Computed tomography (CT)-guided lung biopsy is a widely used technique for the diagnosis of pulmonary lesions and with a high technical success rate and diagnostic accuracy. On the other hand, it is associated with a high risk of complications, especially pneumothorax. Various methods have been tried to reduce the incidence of pneumothorax, but no established method exists. The purpose of this study was to evaluate whether the combination of tract sealing with normal saline and rapid rollover can reduce the rate of pneumothorax and chest tube insertion after CT-guided lung biopsy., Methods: We reviewed all CT-guided lung biopsies performed at a single institution between October 2016 and December 2021. Before August 2019, no specific additional techniques were employed to mitigate complications (Group 1). In contrast, after September 2019, normal saline for tract sealing was injected during needle removal, and if pneumothorax was observed during the intervention, the patient was rolled over into the puncture-site down position immediately after needle removal (Group 2). The rate of complications was compared between the two groups., Results: 130 patients in Group 1 and 173 in Group 2 were evaluated. There was no significant difference in pneumothorax rate between the two groups (30.0% vs. 23.1%, P = .177). A chest tube was inserted in 10 of 130 patients in Group 1 and only in 1 of 173 in Group 2 (P = .001). There were no complications associated with this combinational technique., Conclusions: The combination of normal saline injection and rapid rollover significantly reduced the incidence of pneumothorax requiring chest tube insertion after CT-guided lung biopsy. Therefore, normal saline injection and rapid rollover can serve as a preventive method for severe pneumothorax in CT-guided lung biopsy., (© 2024. The Author(s).)

Fluid resuscitation is an important way in the treatment of acute pancreatitis (AP). This meta-analysis aimed to compare the safety and efficacy of Lactate Ringer's solution (LR) and Normal Saline (NS) in the treatment of patients with acute pancreatitis. Searched in PubMed, Web of Science Core Collection (Clarivate), Embase, Cochrane Library, CNKI, China Wanfang, and China VIP database. All randomized controlled clinical trials (RCTs) were identified. Six studies with 431 patients were included. Compared with NS, LR can significantly reduce the incidence of SIRS at 24h, reduce the length of hospitalization, moderate-severe AP, ICU admission and local complications, especially pancreatic necrosis. It is safe and effective to choose LR for fluid resuscitation in AP, but due to the small number of included studies, multi-center and large-sample RCTs are still needed for further verification. PROSPERO registration number: CRD42022322788., (Copyright © 2023 Elsevier España, S.L.U. All rights reserved.)

Purpose: Full-endoscopic spine surgery (FESS) is associated with specific complications, possibly linked to increased intracranial pressure (ICP) resulting from continuous saline infusion into the epidural space. This study aimed to assess the impact of saline irrigation and its correlation with noninvasively obtained ICP waveform changes., Methods: Patients undergoing FESS between January 2019 and November 2020 were included. Noninvasive ICP (n-ICP) monitoring utilized an extracranial strain sensor generating ICP waveforms, from which parameters P2/P1 ratio and time to peak (TTP) values were derived and correlated to irrigation and vital parameters. Documentation occurred at specific surgical intervals (M0-preoperatively; M1 to M4-intraoperatively; M5-postoperatively). Mixed-model analysis of variance and multiple comparisons tests were applied, with M0 as the baseline., Results: Among 31 enrolled patients, three experienced headaches unrelated to increased ICP at M5. The P2/P1 ratio and TTP decreased during surgery (p < 0.001 and p < 0.004, respectively). Compared to baseline, P2/P1 ratio and vital parameters remained significantly lower at M5. No significant differences were observed for fluid parameters throughout surgery., Conclusions: This study demonstrated a decline in the n-ICP parameters after anesthetic induction despite the anticipated increase in ICP due to constant epidural irrigation. The n-ICP parameters behaved independently of fluid parameters, suggesting a potential protective effect of anesthesia.

Background: Mucus plugging is a common complication of airway stenting. There is no data or guidance on the best airway hygiene regimen and consequently wide practice variation exists., Methods: This single-center, nonblinded, randomized, pilot study aims to evaluate the effectiveness and safety of nebulized 3% saline (3%S) versus normal saline (NS) in reducing the incidence of mucus plugging in adult patients that undergo central airway stent placement. Patients were enrolled immediately after stent placement and randomized to nebulized 3%S or NS (3 mL) 3 times a day. Patients were scheduled for surveillance bronchoscopy in 4 to 6 weeks. Unscheduled bronchoscopies due to symptomatic mucus plugging were recorded., Results: From December 2022 to March 2024, 37 patients were screened, and 35 were enrolled. Four in the 3%S and 8 in the NS group did not undergo a surveillance bronchoscopy and were excluded from the final analysis. During surveillance bronchoscopy for the 3%S (n=13) and NS (n=10) groups, obstructive mucus plugging was noted in 7.7% versus 40%, granulation requiring intervention in 7.7% versus 10%, and >25% circumferential biofilm in 0% versus 30%, respectively. In the 3%S versus NS groups, 0% versus 20% of patients required an unscheduled bronchoscopy due to mucus plugging. There were no side effects reported with the daily use of 3%S or NS., Conclusion: Nebulized 3%S is safe and may be equally or more effective than NS in preventing obstructive mucus plugging in patients who undergo airway stenting. A larger blinded randomized controlled trial is necessary to confirm this finding., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the performance of transpulmonary thermodilution (TPTD) using room-temperature saline (CORT) and waveform-derived continuous CO (CCO) compared with TPTD using iced saline (COICED) as the indicator for measurements of CO in isoflurane-anesthetized dogs., Methods: 8 Beagles aged 1 to 2 years (7.4 to 11.2 kg) were enrolled in this experimental study from March 21 to 31, 2023. Dogs were anesthetized with 0.01 mg/kg acepromazine, 5 to 6 mg/kg propofol, and isoflurane and were mechanically ventilated. Dogs were instrumented with a central venous catheter and a femoral arterial catheter equipped with a thermistor. The COICED, CORT, and pulse wave-derived CCO values were obtained at baseline, during infusions of phenylephrine and norepinephrine, and during blood withdrawal and replacement. Data were analyzed with a mixed effect model, Bland-Altman plots, and concordance. Percent error was calculated. P < .05 was used for significance., Results: Data were collected from 8 dogs. Significant effects of time and the interaction of time and method were found. Bland-Altman plots showed negligible bias with limits of agreement between -0.35 and 0.25 L/min for CORT versus COICED and -1.23 and 1.15 L/min for CCO versus COICED. Percent errors were 17.7% and 66.6%, respectively. In the 4-quadrant plots, the concordance rate was 95% and 68% for measurements obtained with CORT and for CCO, respectively., Conclusions: Transpulmonary thermodilution using room temperature saline was accurate and able to track changes in CO. Continuous CO had a large percent error and low tracking ability., Clinical Relevance: Transpulmonary thermodilution using room temperature saline is reliable for monitoring CO and obviates the need for iced preparations in clinical scenarios.

Objective: Dilution of concentrated epinephrine prior to intravenous use during clinical emergencies can delay urgent interventions. The objective of this study was to determine whether diluted epinephrine remains stable and sterile over time in common hospital settings., Methods: Epinephrine samples were prepared by clinically relevant double dilution techniques. Samples were stored in 10-mL syringes and incubated under 1 of 4 simulated hospital environments with a mixture of lighting and temperature settings: 4°C/20°C, with or without fluorescent lighting. Samples were incubated for 0, 15, 30, 60, or 90 days. Capillary zonal electrophoresis was used to quantify the concentration of epinephrine and/or presence of any degradation products. All samples were tested for the presence of bacterial growth using blood agar cultures., Results: Diluted epinephrine samples remained stable for up to 90 days in all 4 simulated clinical storage conditions. No bacterial colony-forming units were detected in any of the environmental samples regardless of incubation duration, light, or temperature conditions., Conclusion: Diluted epinephrine for anticipated clinical emergencies may remain clinically useful for up to 90 days, thus improving patient safety, access to medications, and overhead costs by reducing waste.

Endodontic irrigation protocols are not only used to clean and disinfect the root canal system, but also to condition the canal wall dentine for subsequent root filling. In this study we tested whether a final irrigation step with saline solution or 80% ethanol improved root canal sealabilty by two popular sealers, an epoxy resin (AH Plus) and a hydraulic calcium silicate cement-based product (BioRoot RCS). Root canals in extracted single-rooted human teeth were instrumented and filled with a matched gutta-percha cone and sealer. During instrumentation and prior to root filling, sealer-specific irrigation protocols were applied. These involved a combined sodium hypochlorite/1-hydroxyethylidene-1,1-diphosphonic acid application, which was followed by irrigation with ethylenediaminetetraacetic acid (EDTA) for AH Plus. Protocols were followed by a 5-ml ultimate rinse with saline solution or 80% ethanol. No such final rinse was the control (N = 9). Canals were then dried with matched paper points. One week after root filling and storage of the teeth at 37°C in a humid environment, Rhodamine B was used to trace leakage. Two-way ANOVA revealed that the type of sealer had a significant (P < 0.05) impact on apical dye penetration while the final rinse did not (P > 0.05). AH Plus provided the slightly better seal (P < 0.05). Leakage occurred between the sealer and the dentin with AH Plus, and between the sealer-to-dentin as well as the sealer-to-gutta-percha interface with BioRoot RCS. In summary and under current conditions, there was no benefit from applying saline or ethanol as an ultimate rinsing solution prior to drying the canal with matched paper points., (Copyright 2024 Nidambur Vasudev Ballal, Rajkumar Narkedamalli, Josette Camilleri, Vasileios Kapralos, Matthias Zehnder. License: This work is licensed under a Creative Commons Attribution 4.0 International License.)

Objective. In neural electrical stimulation, safe stimulation guidelines are essential to deliver efficient treatment while avoiding neural damage and electrode degradation. The widely used Shannon's limit, k , gives conditions on the stimulation parameters to avoid neural damage, however, underlying damage mechanisms are not fully understood. Moreover, the translation from bench testing to in vivo experiments still presents some challenges, including the increased polarisation observed, which may influence charge-injection mechanisms. In this work, we studied the influence on damage mechanisms of two electrolyte parameters that are different in vivo compared to usual bench tests: solution pH and electrolyte gelation. Approach. The potential of a platinum macroelectrode was monitored in a three-electrode setup during current-controlled biphasic charge-balanced cathodic-first pulse trains. Maximum anodic and cathodic potential excursions during pulse trains were projected on cyclic voltammograms to infer possible electrochemical reactions. Main results. In unbuffered saline of pH ranging from 1 to 12, the maximum anodic potential was systematically located in the oxide formation region, while the cathodic potential was located the molecular oxygen and oxide reduction region when k approached Shannon's damage limit, independent of solution pH. The results support the hypothesis that Shannon's limit corresponds to the beginning of platinum dissolution following repeated cycles of platinum oxidation and reduction, for which the cathodic excursion is a key tipping point. Despite similar potential excursions between solution and gel electrolytes, we found a joint influence of pH and gelation on the cathodic potential alone, while we observed no effect on the anodic potential. We hypothesise that gelation creates a positive feedback loop exacerbating the effects of pH ; however, the extent of that influence needs to be examined further. Significance. This work supports the hypothesis of charge injection mechanisms associated with stimulation-induced damage at platinum electrodes. The validity of a major hypothesis explaining stimulation-induced damage was tested and supported on a range of electrolytes representing potential electrode environments, calling for further characterisation of platinum dissolution during electrical stimulation in various testing conditions., (Creative Commons Attribution license.)

Background: Contact lens discomfort is a symptom-based clinical diagnosis that affects 13% to 75% of contact lens wearers. The Tear Film and Ocular Surface Society defines contact lens discomfort as "a condition characterized by episodic or persistent adverse ocular sensations related to lens wear either with or without visual disturbance, resulting from reduced compatibility between the lens and ocular environment, which can lead to decreased wearing time and discontinuation from lens wear." Signs of the condition include conjunctival hyperemia, corneal and conjunctival staining, altered blinking patterns, lid wiper epitheliopathy, and meibomian gland dysfunction. Eye care specialists often treat contact lens discomfort with lubricating drops, including saline, although there is no clear evidence showing this treatment is effective and safe., Objectives: To evaluate the efficacy and safety of lubricating drops for ocular discomfort associated with contact lens wear in adults., Search Methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase.com, two other databases, and two trials registries to May 2024, without date or language restrictions., Selection Criteria: We included parallel-group randomized controlled trials (RCTs) that evaluated lubricating drops, including saline, versus no treatment, or that evaluated lubricating drops versus saline, in adult contact lens wearers. We included studies regardless of publication status, language, or year of publication., Data Collection and Analysis: We applied standard Cochrane methodology. The critical outcome was contact lens discomfort. Important outcomes were corneal fluorescein staining and conjunctival redness. Adverse outcomes were incident microbial keratitis, inflammatory corneal infiltrates, and participant discontinuation. We assessed risk of bias for outcomes reported in the summary of findings table using the Cochrane risk of bias tool RoB 2, and we rated the certainty of the evidence using GRADE., Main Results: We included seven RCTs conducted in the USA, Canada, Italy, and France. They randomized a total of 463 participants to lubricating drops, saline, or no treatment. Four trials evaluated lubricating drops and saline versus no treatment, but one of them provided no usable outcome data. Three trials evaluated lubricating drops versus saline. Study characteristics All trial participants were adults, and the mean age ranged from 25.7 years to 36.7 years. The proportion of women varied from 15% to 82%. The trials lasted between one and four weeks. Of the five trials that reported contact lens discomfort, we judged three at high risk of bias, and considered the other two had some risk of bias concerns. Lubricating drops (including saline) versus no treatment Lubricating drops compared with no treatment may reduce contact lens discomfort, measured on a 37-point scale (lower is better), but the evidence is very uncertain (mean difference [MD] -5.9 points, 95% confidence interval [CI] -3.74 to -8.05; 2 RCTs; 119 participants). One trial found no difference between lubricating drops and no treatment in "end-of-day" comfort. The trial that compared saline with no treatment provided no results for the control group. Two studies measured corneal fluorescein staining on a scale of 0 to 20 (lower is better). We found low-certainty evidence of little to no difference between lubricating drops and no treatment in changes in the extent (MD -0.15 points, 95% CI -0.86 to 0.56; 2 RCTs; 119 participants), depth (MD -0.01 points, 95% CI -0.44 to 0.42; 2 RCTs; 119 participants), or type (MD 0.04 points, 95% CI -0.38 to 0.46; 2 RCTs; 119 participants) of corneal fluorescein staining scores. Regarding conjunctival redness, measured on a scale of 0 to 4 (lower is better), there was low-certainty evidence of little to no difference between lubricating drops and no treatment in nasal region scores (MD 0.10, 95% CI -0.29 to 0.49; 1 RCT; 73 participants) and temporal region scores (MD 0.00, 95% CI -0.39 to 0.39; 1 RCT; 73 participants). No studies reported microbial keratitis or inflammatory corneal infiltrates, and no trials reported vision-threatening adverse events up to four weeks of treatment. All trials reported the proportion of participants who discontinued participation. In two trials, no participants left any treatment group. Our meta-analysis of another two studies suggests little difference in the number of people who dropped out of the lubricating treatment group versus the no treatment group (risk ratio [RR] 1.42, 95% CI 0.19 to 10.94; 138 participants; low-certainty evidence). Lubricating drops versus saline Lubricating drops may have little to no effect compared with saline on contact lens discomfort measured on a visual analog scale of 0 to 100 (lower is better), but the evidence is very uncertain (MD 9.5 points, 95% CI -4.65 to 23.65; 1 RCT; 39 participants). No studies reported corneal fluorescein staining or conjunctival redness. No studies reported microbial keratitis or inflammatory corneal infiltrates, and no trials reported vision-threatening adverse events up to four weeks of treatment. Our meta-analysis of three studies suggests little difference in the number of people who dropped out of the lubricating treatment group versus the saline group (RR 1.56, 95% CI 0.47 to 5.12; 269 participants; low-certainty evidence)., Authors' Conclusions: Very low-certainty evidence suggests that lubricating drops may improve contact lens discomfort compared with no treatment, but may have little or no effect on contact lens discomfort compared with saline. Low-certainty evidence also suggests that lubricating drops may have no unwanted effects that would lead to discontinuation over one to four weeks. Current evidence suggests that prescribing lubricating drops (including saline) to people with contact lens discomfort is a viable option. However, most studies did not assess patient-reported contact lens (dis)comfort using a validated instrument. Therefore, further well-designed trials are needed to generate high-certainty evidence on patient-reported outcomes as well as on longer-term safety outcomes., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Endotracheal intubation is a frequently performed procedure in anesthesia practice, and ensuring the correct inflation of the cuff is essential for maintaining the airway seal. Overinflation of endotracheal tube (ETT) cuffs can lead to complications, such as postoperative sore throat. This study aimed to compare the incidence of elevated ETT cuff pressure between saline and air inflation in elective laparoscopic abdominal surgery., Methods: The study involved 60 participants ranging in age from 18 to 65, with American Society of Anesthesiologists physical status levels 1-2, who underwent laparoscopic abdominal surgery. We randomly assigned patients to two groups: Group A (air-filled ETT cuffs, N.=30) and Group S (saline-filled ETT cuffs, N.=30). Intra-cuff pressure was recorded before and after CO2 insufflation, as well as during changes in patient position. The number of interventions to restore intra-cuff pressure to 18 mmHg was documented. Peak airway pressure, plateau pressure, and positive end-expiratory pressure (PEEP) were measured at 15-minute intervals., Results: The number of interventions needed to maintain intra-cuff pressure was significantly lower in the saline group compared to the air group. All patients started with initial cuff pressures above 20 mmHg. After insufflation, the first-minute cuff pressures were higher in the air group (P=0.001). Both groups experienced a significant increase in intra-cuff pressure with the Trendelenburg position, and after moving to the reverse Trendelenburg position (saline and air groups, P=0.001 and 0.012, respectively), the air group had higher intra-cuff pressure than the saline group (P=0.002). There were no significant differences between groups in peak airway pressure, plateau pressure, and PEEP., Conclusions: Inflating ETT cuffs with saline instead of air during laparoscopic abdominal surgeries led to a reduced requirement for interventions in maintaining pressure. This indicates that the use of saline inflation may significantly lower the risk of high cuff pressure and related complications.

Objective: To compare the ability of bioreactance noninvasive cardiac output (BR-NICO) with thermodilution cardiac output (TDCO) for the measurement of cardiac output (CO) in healthy adult horses receiving 2 different IV volume replacement solutions., Design: Prospective randomized crossover study from September to November 2021., Setting: University teaching hospital., Animals: Six university-owned adult horses., Interventions: Horses were randomly assigned to receive 7.2% hypertonic saline solution (HSS) or 6% hydroxyethyl starch (130/0.4) solution (HETA). BR-NICO and TDCO were measured simultaneously at baseline, 10, 20, 30, 40, 50, 60, 90, and 120 minutes before fluid administration and again at the same times after starting a bolus infusion of IV volume replacers. All solutions were administered within 10 minutes., Measurements and Main Results: BR-NICO and TDCO were strongly correlated (Pearson r 2  = 0.93; P < 0.01). Regression analysis showed the relationship between TDCO and BR-NICO was BR-NICO = 0.48 × TDCO + 0.6. For the corrected BR-NICO values, the Bland-Altman agreement mean bias and lower/upper limits of agreement were -0.62 and -5.3 to 3.9 L/min, respectively. Lin's concordance (95% confidence interval) between methods was 0.894 (0.825-1.097). Compared with baseline, HSS increased the CO at 10 and 20 minutes (TDCO and BR-NICO). Compared with baseline, HETA decreased the CO at 10 and 20 minutes (TDCO and BR-NICO) and increased the CO at 90 (TDCO only) and 120 minutes (TDCO and BR-NICO)., Conclusions: BR-NICO strongly agreed with TDCO in the measurement of CO in healthy unsedated adult horses. HSS administration significantly increased CO in the first 30 minutes, while HETA initially decreased CO at 10 minutes but increased CO to above baseline values by 90 minutes., (© Veterinary Emergency and Critical Care Society 2024.)

Objectives: To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline., Design: Randomized controlled trial., Setting: Single tertiary care center., Participants: Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020., Interventions: Balanced solution-based chloride-restrictive intravenous fluid strategy., Measurements and Main Results: 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., Conclusions: 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., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This study aimed to evaluate the current evidence on various aspects of fluid therapy such as type, volume, and timing of fluid bolus administration in children with septic shock. Systematic review and meta-analysis of clinical trials including children less than 18 years of age admitted to the pediatric emergency and intensive care unit with severe infection and shock requiring fluid resuscitation. The intervention included balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The primary outcome was mortality rate. Of the 219 citations retrieved, 12 trials (3526 children with severe infection with or without malaria and shock) were included. The pooled results found no significant difference in the mortality rate between groups comparing balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The risk of acute kidney injury (AKI) was significantly less in the BC group compared to the NS group. The certainty of evidence for mortality was of "moderate certainty" in the BC vs NS group, and was of "very low certainty" for the other two groups., Conclusions: The current meta-analysis found no significant difference in the mortality rate between the types of resuscitation fluid, and their speed or volume of administration. However, a significantly decreased risk of AKI was found in the BC group. More evidence is needed regarding the speed and volume of administration of fluid boluses in critically ill children.Prospero registration: CRD42020209066., What Is Known: • Balanced crystalloids (BC) may be better than normal saline (NS) for fluid resuscitation in critically ill children., What Is New: • BC are better than NS for fluid resuscitation in critically ill children as they decrease AKI and hyperchloremia., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Delayed graft function after kidney transplantation is linked to poor graft survival and increased chronic allograft injury. Recent guidelines suggest using balanced crystalloids over 0.9% saline owing to better metabolic profiles, but their impact on DGF remains unclear., Methods: We searched PubMed, Embase, and Cochrane Central Registry of Clinical Trials from inception until February 29, 2024, and included RCTs that randomised adult participants to receive either intravenous balanced fluids or 0.9% saline intraoperatively. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool and certainty of evidence using GRADE. Outcomes analysed were delayed graft function incidence, vasopressor requirements, length of hospital stay, and postoperative metabolic profiles., Results: Of 106 publications identified, we included 11 RCTs (n=1717). Pooled analysis showed that the use of balanced fluids was associated with a lower incidence of delayed graft function compared with 0.9% saline (RR 0.82, 95% CI: 0.69 to 0.98, P=0.01, moderate certainty). Balanced crystalloids were associated with higher postoperative serum pH, higher serum bicarbonate, and lower serum chloride concentration, but effects on vasopressor requirements, length of hospital stay, and serum creatinine were uncertain., Conclusions: Balanced crystalloid intravenous fluid therapy reduced delayed graft function incidence and maintained more favourable serum chemistry profiles compared with 0.9% saline in patients undergoing kidney transplantation. However, crystalloid type did not significantly influence vasopressor requirements and length of hospital stay., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Depression, considered the most prevalent neuropsychiatric disorder, is multifactorial and complex. Oxidative stress and inflammation significantly contribute to its etiology. Conversely, methane, a novel therapeutic gas, has demonstrated efficacy in enhancing tissue resilience against ischemic injuries and inflammation. In this study, we investigated the effect of methane-rich saline (MRS) on depression using the chronic unpredictable mild stress (CUMS) model. Depressed rats received MRS treatment, and depression-like behaviors and cognitive function were assessed through sucrose preference, open field, forced swimming, and Morris water maze tests. Additionally, we measured serum corticosterone levels, antioxidant enzyme activity, hippocampal malondialdehyde (MDA), and TNFα levels, and investigated histological changes in the hippocampus. Our findings revealed that MRS significantly ameliorated Depressive-like behaviors and cognitive impairment. Furthermore, MRS administration regulated serum corticosterone levels and also MRS reduced hippocampal lipid peroxidation, TNFα, and hippocampus tissue damage. MRS likely exerts its effects by reducing oxidative stress and inflammatory factors and modulating the function of the hypothalamus-pituitary-adrenal (HPA) axis. These results demonstrate the protective effects of MRS on the hippocampus in CUMS animals., Competing Interests: Declarations. Ethics approval: All stages of work in this study were approved by the Ethics Committee of Yazd University of Medical Sciences which is in accordance with the US National Institutes of Health Publication guide for the care and use of laboratory animals with ethical code: IR.SSU.MEDICINE.REC.1398.209. Competing interests: The authors declare that there are no conflicts of interest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: A. Capogreco is a consultant for ERBE. R. Maselli is a consultant for ERBE, Fujifilm, 3DMatrix and Boston Scientific. C. Hassan is a consultant for Alpha-Sigma, Fujifilm, Medtronic, Norgine, Olympus and Pentax. A. Repici is a consultant for Medtronic, ERBE, Fujifilm and Olympus.

Background: Presently, the efficacy of neonatal resuscitation techniques via interventions such as oral, nasal, and endotracheal suction for preventing meconium aspiration syndrome (MAS) after delivery has not been satisfactory., Objective: This study aimed to investigate the role of intratracheal instillation of budesonide on oxidative stress in MAS., Methods: Sixty-two neonates with MAS admitted to Huai'an Maternity and Child Healthcare Hospital from January 2018 to June 2020 were divided into a study group (intratracheal instillation of 2 ml budesonide suspension; n  = 31) and a control group (intratracheal instillation of 2 ml normal saline; n  = 31). Collect data from two groups of patients and evaluate clinical outcomes, including oxygenation index (OI), as well as serum total oxidant status (TOS), total antioxidant capacity (TAC), oxidative stress index (OSI) and 8-Isoprostane before treatment and 72h after admission., Results: We found no statistical differences in mortality, complication rate, total oxygen inhalation time, OI before treatment and 72h after admission between the two groups of neonates with MAS, while the duration of invasive respiratory support in the study group was significantly shorter than in the control group. Also, serum TAC, TOS, OSI and 8-isoprostane levels were not statistically different before treatment between the two groups. After 72h of admission, OSI and 8-Isoprostane in neonates with MAS in the study group were much lower than those in the control group. TOS, OSI, 8-Isoprostane in the control group and 8-Isoprostane in the study group were significantly higher than those before treatment. As for TAC and TOS, no significant differences were observed between the two groups., Conclusion: Intratracheal instillation of budesonide was shown to alleviate oxidative stress and shorten invasive ventilation time in neonates with MAS.

(1) Background and Objectives : Catheter-related bladder discomfort (CRBD), a common and distressing consequence of indwelling urinary catheters, can significantly impact postoperative recovery. This study aimed to determine the effectiveness of bladder irrigation with a 0.05% lidocaine normal saline solution for the prevention of CRBD following transurethral surgery. (2) Materials and Methods : In this randomized, double-blind, placebo-controlled trial, patients were assigned to either a control group receiving normal saline or a treatment group receiving 0.05% lidocaine (2% lidocaine 25 mL in 1000 mL saline) for bladder irrigation. Both groups were administered fentanyl (1 μg/kg) for analgesia at the end of the procedure. The primary endpoint was the assessment of the incidence and severity of CRBD upon awakening within the first 6 h postoperatively, using a four-grade scale based on the patients' reports of discomfort. (3) Results : Out of 79 patients completing the study, the incidence of moderate to severe CRBD was significantly lower in the lidocaine group (5.1%, 2/39) compared to the control group (25%, 10/40) at 10 min after waking from anesthesia ( p = 0.014). Furthermore, the lidocaine group experienced significantly less CRBD at 1 and 2 h postoperative (2.6% and 0%, respectively) compared to the control group (20% and 10%, respectively) ( p = 0.015, p = 0.043), with no significant differences at 6 h ( p = 0.317). (4) Conclusions : The results suggest that bladder irrigation with 0.05% lidocaine reduces the occurrence of moderate to severe CRBD by nearly 80% in the initial 2 h postoperative period after transurethral surgery.

criteria were randomized to each irrigant, 65 in the NaOCl and 60 in the NSS groups. ProRoot® MTA was used as a pulp dressing material in both groups and teeth were followed for 12 months. The primary outcome was the success of VPT; requiring both clinical and radiographic success to be considered as success. The hypothesis was that the absolute difference of VPT success in the NSS group was not worse than that in the NaOCl group, by a margin of 5%. The secondary outcome was discoloration; percentages of discolorations between both groups were compared. Results: Using a per protocol analysis, the absolute difference of VPT success between the NSS and NaOCl groups was 2.08% (95% CI: -1.95, 6.1). Perceptible gray discolorations were 80% and 63% in NaOCl and NSS groups (difference -17%; 95% CI: -40.0, 6.2; p=0.15). Conclusions: For MTA-VPT procedure, irrigation with NSS was not worse than that with NaOCl. However, both irrigants caused discoloration. (EEJ-2023-05-065).

Background: In treating post-traumatic scars, this study compared the safety and effectiveness of combined subcision with saline and microneedling versus combined subcision with platelet-rich plasma and microneedling. Combined subcision with saline and microneedling or combined subcision with platelet-rich plasma and microneedling were used to treat 36 consecutive individuals with post-traumatic scarring. The Modified Manchester score was used to assess texture change, pigmentation, and surface distortion changes. Each change was given a score between 1 and 4. A lower score (range: 3-12) indicates a better result. The mean of the three individual scores was determined. For best outcomes, each patient needed four treatment sessions for each scar, with a one-month follow-up period following the final treatment. The three variables in group B had mean scores of 1.4 ± 0.5, 2 ± 0.8, and 2.2 ± 0.9, respectively, for texture change, pigmentation, and surface distortion. With a mean score of 1.4 ± 0.5, texture change had the best response out of the three variables we evaluated. The investigator determined that the mean improvement score for patients in group B's overall appearance was 5.61 ± 1.19. The study has shown that the combination of subcision with platelet-rich plasma, and microneedling appears to be a promising treatment for posttraumatic scars due to its low risk and high efficacy. Our findings suggest that this is a safe method for treating posttraumatic scars, with few side effects and a low chance of recurrence., Irb Local Approval Number: 04-2023-300279., Clinical Trial Registry: NCT06135480., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Extracellular calcium critically regulates physiologic aldosterone production. Moreover, abnormal calcium flux and signaling are involved in the pathogenesis of the majority of primary aldosteronism cases., Methods: We investigated the influence of the saline suppression test (SST) on calcium homeostasis in prospectively recruited participants (n = 86)., Results: During SST, 100% of participants had decreases in serum calcium, with 48% developing frank hypocalcemia. Serum calcium declined from 2.30 ± 0.08 mmol/L to 2.13 ± 0.08 mmol/L (P < .001) with parallel increases in parathyroid hormone from 6.06 ± 2.39 pmol/L to 8.13 ± 2.42 pmol/L (P < .001). In contrast, serum potassium and bicarbonate did not change, whereas eGFR increased and serum glucose decreased (P < .001). Lower body surface area (translating to greater effective circulating volume expansion during SST) was associated with greater reductions in (β = .33, P = .001), and absolutely lower, serum calcium levels (β = .25, P = .001). When evaluating clinically-relevant diagnostic thresholds, participants with post-SST aldosterone levels <138 pmol/L had lower post-SST calcium and 25-hydroxyvitamin D levels (P < .05), and higher post-SST parathyroid hormone levels (P < .05) compared with those with post-SST aldosterone levels >277 pmol/L., Conclusion: SST uniformly decreases serum calcium, which is likely to be due to the combination of variable dilution, increased renal clearance, and vitamin D status. These acute reductions in bioavailable calcium are associated with lower post-SST aldosterone. Given the critical role of extracellular calcium in regulating aldosterone production, these findings warrant renewed inquiry into the validity of SST interpretations for excluding primary aldosteronism., Competing Interests: Conflict of interest: JMB reports consulting fees unrelated to the contents of this work from Bayer and Astra Zeneca. AV reports consulting fees unrelated to the contents of this work from Corcept Therapeutics, Mineralys, HRA Pharma., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Endocrinology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: This study aimed to compare the effect of two methods of maintenance intravenous fluid therapy on hyponatremia in hospitalized infants with sepsis., Methods: In a double-blinded randomized clinical trial, 60 term infants with sepsis were enrolled. Blood samples were taken to determine sodium, potassium, Creatinine, and BUN levels before the initiation of treatment. Urine samples were taken to assess specific gravity and urinary output. Infants in the intervention group received half saline in 10% dextrose and infants in the control group were assigned to receive the conventional solution as maintenance. The above indicators were re-evaluated 24 and 48 h after the initiation of treatment. Two groups were compared concerning the incidence of hyponatremia, and other criteria such as urinary output and urinary specific gravity, blood urea nitrogen (BUN), and creatinine levels., Results: Hyponatremia was more common in the control group. Sodium levels were significantly higher in half saline recipients 24 h (137.83 ± 2.86 vs. 134.37 ± 1.91 mmol/L), and 48 h (138.10 ± 2.41 vs. 133.66 ± 1.98 mmol/L) after treatment (P < 0.001). Although BUN in the intervention group was significantly higher in comparison to the control group, the difference in urinary output, urine specific gravity, potassium, and Creatinine levels were not significant in the two groups., Conclusions: The use of a half-saline solution as maintenance fluid reduces the risk of hyponatremia after 48 h when compared to 0.18%NaCl., Trial Registration: This has been registered at Iranian Registry of Clinical Trials (Retrospectively registered, Registration date: 2017-10-12, identifier: IRCT2017053034223N1, https://irct.behdasht.gov.ir/trial/26204 )., (© 2024. The Author(s).)

Nonclinical studies of test articles (TAs) in nonhuman primates are often designed to assess both biodistribution and toxicity. For this purpose, studies commonly use intravenous perfusion of ice-cold (2°C-8°C) saline to facilitate measurements of TA-associated nucleic acids and proteins, after which tissues undergo later fixation by immersion for histological processing and microscopic evaluation. Intriguingly, minimal apoptosis/single cell necrosis (A/SCN) of randomly distributed neural cells is evident in the cerebral cortex and less often the hippocampus in animals from all groups, including vehicle-treated controls. Affected cells exhibit end-stage features such as cytoplasmic hypereosinophilia, nuclear condensation or fragmentation, and shape distortions, so their lineage(s) generally cannot be defined; classical apoptotic bodies are exceedingly rare. In addition, A/SCN is not accompanied by glial reactions, leukocyte infiltration/inflammation, or other parenchymal changes. The severity is minimal in controls but may be slightly exacerbated (to mild) by TA that accumulate in neural cells. One plausible hypothesis explaining this A/SCN exacerbation is that cold shock (perhaps complicated by concurrent tissue acidity and hypoxia) drives still-viable but TA-stressed cells to launch a self-directed death program. Taken together, these observations indicate that A/SCN in brain processed by cold saline perfusion with delayed immersion fixation represents a procedural artifact and not a TA-related lesion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The aim of the present study is to determine the effect of the pushing technique with saline on the success of peripheral IV catheter placement in a paediatric haematology and oncology sample., Methods: The randomized controlled trial was conducted among 60 paediatric haematology and oncology patients aged between 0 and 17. The participants were randomly assigned to two peripheral intravenous catheter placement groups (intervention group, n:30, control group, n:30). Each patient was evaluated with the Difficult Intravenous Access (DIVA) score before being included in the study. Each patient was assessed using the Personal Information Form for Children and Catheter Registration Form., Results: The average age of the children was 86.4 months (SD = 60.0); 36.7% were female. The pushing technique with saline significantly increased the success of placing a peripheral IV catheter on the first attempt in the intervention group compared to the control group (F = 42.391, p = 0.000). The number of attempts during peripheral IV catheter placement significantly decreased in the intervention group compared with the control group (t = -5.676, p = 0.000). Complications were less in the intervention group compared with the control group (χ2 = 24.438, p = 0.000). The procedure time was significantly shorter in the intervention group compared with the control group (t = -4.026, p = 0.000)., Conclusion: The pushing technique with saline is an effective method to increase the first attempt success rate, decrease the number of attempts, reduce the procedure time, and reduce the complications during peripheral intravenous catheter placement procedures in paediatric haematology and oncology patients with difficult intravenous access., Trial Registration: This study was registered at ClinicalTrials.gov (NCT05685290 & date of first recruitment: January 3, 2023) https://clinicaltrials.gov/ct2/show/NCT05685290., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Aim: Saline contrast-enhanced electrical impedance tomography (EIT) has been used to identify the respiratory failure etiologies through assessment of regional lung perfusion at the bedside. In this study, we introduce a novel approach to detect right-to-left intracardiac shunt based on the center of heart (CoH) parameter determined from the early phase of impedance-time curve after saline bolus injection., Methods and Result: The timepoints when the saline bolus enter the heart (T0) and the lung regions (T1) are identified at first. A moving time window from T0 to T1 is then generated with steps of 0.5 s and the slope of the impedance-time curve in each pixel within the window calculated. CoH is calculated as the geometric center of pixel slope values in the right-to-left image direction. To illustrate how this method works in practice, we calculated the CoH values at T0 to T1 in 10 control hypoxic patients with no right-to-left shunt. In addition, we examined two critically ill patients with right-to-left intracardiac shunt. One was postcardiac surgery patient who had a residual atrial septal defect by color doppler of transesophageal echocardiograph. The other patient had a congenital heart disease of ventricular septal defect by color doppler of trans-thoracic echocardiography. A large difference in CoH between T0 to T1 was observed in the two patients with intracardiac shunt than in the control patients (11.06 ± 3.17% vs. 1.99 ± 1.43%, P = 0.030)., Conclusion: Saline bolus EIT for lung perfusion might be used as ventriculography to identify the right-to-left intracardiac shunt at the bedside., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: J waves may be augmented by coronary angiography (CAG) or intracoronary drug administration but the underlying mechanism is unknown., Purpose: The effect of intracoronary normal saline (NS) on J waves were investigated., Patients and Methods: After the standard CAG using iopamidol (Iopamiro R Inj), NS was injected into the right coronary artery in 10 patients with and eight patients without J waves at the baseline. The 12-lead ECG was monitored, stored on a computer and retrieved later for measurement of the J wave amplitude before or during the coronary interventions., Results: J waves in leads II, III and aVF at baseline increased significantly in each lead during the right CAG and NS injection into the right coronary artery. The J wave changes were similar between the two interventions and distinct similar alterations were observed in the QRS complex. We postulated that the ischemic myocardium that was induced during CAG or intracoronary NS administration slowed the conduction velocity of depolarization in the perfusion territory and delayed the timing of J waves to appear. Then, the delayed appearance of J waves would be less opposed by electromotive force from other areas resulting in augmentation., Conclusion: J wave augmentation was observed during CAG and intracoronary NS administration. As a mechanism of augmentation, we postulated that contrast media and NS induce myocardial ischemia and delay the timing of J waves to a point of less opposition by electromotive force from other areas., Highlights: J wave augmentation has been reported during intracoronary injection of contrast media or drugs. The present study confirmed that normal saline alone was able to augment J waves. Mechanistically, coronary interventions using anoxic solutions can cause regional myocardial ischemia and reduce the conduction velocity of depolarization. Then, delayed J waves are less opposed by the electromotive force from remote areas which leads to augmentation. When a drug is diluted in normal saline and given intracoronarily, changes in J waves can be due to normal saline. The pathophysiological and clinical significance of J waves augmented during coronary interventions need to be established., (© 2024 Wiley Periodicals LLC.)

Introduction: A mainstay in the acute management of diabetic ketoacidosis (DKA) is fluid resuscitation. Normal saline is recommended by the American Diabetes Association; however, it has been associated with hyperchloremic metabolic acidosis and acute kidney injury. Limited literature is available to determine the most appropriate crystalloid fluid to treat patients with DKA., Objective: The purpose of this study was to compare lactated Ringer's (LR) to normal saline (NS) in the acute management of DKA., Methods: This was a retrospective, multicenter single health system cohort study. The primary outcome was to evaluate the time to high anion gap metabolic acidosis (HAGMA) resolution using LR compared to NS. Secondary outcomes included the incidence of nongap metabolic acidosis, hyperchloremia, acute kidney injury, and new renal replacement therapy. Other secondary outcomes included insulin infusion duration and hospital and intensive care unit length of stay. The Cox proportional hazards model was used for the primary outcome., Results: A total of 771 patient encounters were included. Lactated Ringer's was associated with faster time to HAGMA resolution compared to NS (adjusted hazard ratio 1.325; 95% confidence interval 1.121-1.566; p < 0.001). No difference was found in complications such as incidence of nongap metabolic acidosis, hyperchloremia, acute kidney injury, and new renal replacement therapy between the LR and NS groups. Additionally, there was no difference in insulin infusion duration and hospital or intensive care unit length of stay., Conclusion: Treatment with LR as the primary crystalloid for acute DKA management was associated with faster HAGMA resolution compared with NS. Similar incidence in complications and length of stay was observed between the two groups. The findings of this study add to the accumulating literature suggesting that balanced crystalloids may offer an advantage over NS for the treatment of patients with DKA., (© 2024 Pharmacotherapy Publications, Inc.)

Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient., (© 2024. The Author(s), under exclusive licence to International Pediatric Nephrology Association.)

Normal saline (NS) is recommended for the treatment of chloride-depletion alkalosis (CDA). However, its use in patients with drinking water restrictions or fluid volume deficiencies may lead to hypernatremia. We report the case of a 42-year-old Japanese man with ileus due to sigmoidal volvulus, who presented with CDA. After endoscopic decompression, NS was administered to treat the CDA. Despite the administration of NS, CDA persisted and hypernatremia developed. The infusion was then changed to high cation-gap amino acids (HCG-AA), which improved both metabolic alkalosis and hypernatremia. Thus, HCG-AA may be useful for the treatment of hypernatremia in patients with CDA., (© 2023. The Author(s), under exclusive licence to Japanese Society of Nephrology.)

Objective: To investigate the impact of different infusion media on the flow rate of infusion pumps., Methods: Ten infusion pumps were randomly selected and tested for infusion rates using deionized water, saline solution, glucose solution, and parenteral nutrition solution. The infusion flow rate was set at 30 mL/h, and the testing methodology conformed to the standards for the calibration and quality control of syringe pumps and infusion pumps., Results: For infusion set A, the infusion rate was unaffected by the infusion media, remaining within the acceptable quality control standards. For infusion set B, when infused with deionized water, saline solution, and glucose solution, the infusion errors were within the quality control standards. However, when using parenteral nutrition solution as the infusion medium, the infusion error exceeded the acceptable quality control standards., Conclusion: Both the infusion set and the infusion medium can affect the flow rate of infusion pumps. It is crucial to calibrate the flow rate according to the specific infusion medium to reduce medical risks associated with infusion pumps during clinical use.

Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced Electrolyte Solutions (BES) may prove a more physiological alternative, but convincing evidence is missing. We aimed to compare the efficacy of 0.9% saline to BES in DKA management. MEDLINE, Cochrane Library, and Embase databases were searched for relevant studies using predefined keywords (from inception to 27 November 2021). Relevant studies were those in which 0.9% saline (Saline-group) was compared to BES (BES-group) in adults admitted with DKA. Two reviewers independently extracted data and assessed the risk of bias. The primary outcome was time to DKA resolution (defined by each study individually), while the main secondary outcomes were changes in laboratory values, duration of insulin infusion, and mortality. We included seven randomized controlled trials and three observational studies with 1006 participants. The primary outcome was reported for 316 patients, and we found that BES resolves DKA faster than 0.9% saline with a mean difference (MD) of -5.36 [95% CI: -10.46, -0.26] hours. Post-resuscitation chloride (MD: -4.26 [-6.97, -1.54] mmoL/L) and sodium (MD: -1.38 [-2.14, -0.62] mmoL/L) levels were significantly lower. In contrast, levels of post-resuscitation bicarbonate (MD: 1.82 [0.75, 2.89] mmoL/L) were significantly elevated in the BES-group compared to the Saline-group. There was no statistically significant difference between the groups regarding the duration of parenteral insulin administration (MD: 0.16 [-3.03, 3.35] hours) or mortality (OR: -0.67 [0.12, 3.68]). Studies showed some concern or a high risk of bias, and the level of evidence for most outcomes was low. This meta-analysis indicates that the use of BES resolves DKA faster than 0.9% saline. Therefore, DKA guidelines should consider BES instead of 0.9% saline as the first choice during fluid resuscitation., (© 2024 The Author(s). Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

Rationale: Saline nasal sprays are frequently used in the management of seasonal allergic rhinitis (SAR) for the cleansing and clearing of aeroallergens from the nasal cavity. Also using a drug-free approach, AM-301 nasal spray is forming a thin film barrier on the nasal mucosa to prevent contact with allergens, trap them, and facilitate their discharge. A clinical trial compared the efficacy, safety, and tolerability of AM-301 and saline spray in SAR., Methods: A total of 100 patients were randomized 1:1 to self-administer AM-301 or saline 3 × daily for 2 weeks. Primary efficacy endpoint: reduction in mean daily reflective Total Nasal Symptom Score (rTNSS). Secondary efficacy endpoints: reduction in mean instantaneous TNSS and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), global impression of efficacy. Safety and tolerability: adverse events, relief medication use, symptom-free days, global impression of tolerability., Results: AM-301-treated patients achieved a significantly lower rTNSS than the saline group (LS square means difference -1.1, 95% CI -1.959 to -0.241, p = .013) with improvement observed across all individual nasal symptoms. Likewise, all secondary endpoints showed statistical significance in favor of AM-301; for example, quality of life was significantly improved overall (p < .001) as well as for each individual RQLQ domain. Both treatments showed similarly good safety and tolerability. With AM-301, fewer patients used relief medication and more enjoyed symptom-free days compared to saline treatment., Conclusions: AM-301 was more effective than saline in improving SAR nasal symptoms and related quality of life while offering similar tolerability, demonstrating the benefits of a barrier approach., (© 2024 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Abstract: To compare the effect of ultrasound guided saline enema (USGSE) and x-ray fluoroscopic air enema in the reduction of intussusception in children, 80 children with intussusception were randomly divided into ultrasonic-guided saline enema reduction in 40 cases (USGSE group) and x-ray air enema reduction in 40 cases (air enema group). The enema pressure, success rate, average time, and cost of the 2 methods were compared. The average operation time of the USGSE group was lower than that of the air group ([5.35 ± 1.79] min vs [6.03 ± 2.41] min, P = 0.159), the average pressure of the air group was higher than that of the air group ([10.95 ± 1.54] kPa vs [9.6 ± 1.26] kPa; P < 0.001), the success rate of resetting was higher than that of the air group (87.5% vs 85.0%; P = 0.745), and the cost of USGSE was lower than that of the air group ([339.23 ± 10.73] yuan vs [378.23 ± 18.20] yuan, P < 0.001). Subgroup analysis showed that the success rate of enema treatment in children with onset time <48 hours was significantly higher than that in children with onset time ≥48 hours (98.30% vs 54.50%, continuous correction χ 2 = 22.16; P < 0.001). The success rate and operation time of USGSE in pediatric intussusception reduction are similar to that of air enema, and the advantages of low cost and no radiation are worthy of popularization. For children with onset time ≥48 hours, enema reduction is safe and effective, but the conversion rate to open is high. It is necessary to carefully identify the symptoms of intestinal perforation and necrosis on the basis of strictly following the indications to avoid delayed treatment., Competing Interests: Disclosure: The author declares no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Transforaminal epidural steroid injections (TFESI) are commonly employed to treat lumbosacral radiculopathy. Despite anti-inflammatory properties, the addition of 3% hypertonic saline has not been studied., Objective: Compare the effectiveness of adding 0.9% NaCl (N-group) vs. 3% NaCl (H-group) in TFESI performed for lumbosacral radiculopathy., Methods: This retrospective study compared TFESI performed with lidocaine, triamcinolone and 0.9% NaCl vs. lidocaine, triamcinolone and 3% NaCl. The primary outcome was the proportion of patients who experienced a ≥ 30% reduction in pain on a verbal rating scale (VRS; 0-100) at 3 months. Secondary outcome measures included the proportion of patients who improved by at least 30% for pain at 1 and 6 months, and who experienced ≥15% from baseline on the Oswestry disability index (ODI) at follow-up., Results: The H-group experienced more successful pain outcomes than the N-group at 3 months (59.09% vs. 41.51%; P = .002) but not at 1 month (67.53% vs. 64.78%; P = .61) or 6 months (27.13% vs 21.55%: P = .31). For functional outcome, there was a higher proportion of responders in the H-group than the N-group at 3 months (70.31% vs. 53.46%; P = .002). Female, age ≤ 60 years, and duration of pain ≤ 6 months were associated with superior outcomes at the 3-month endpoint. Although those with a herniated disc experienced better outcomes in general with TFESI, the only difference favoring the H-group was for spondylolisthesis patients., Conclusions: 3% hypertonic saline is a viable alternative to normal saline as an adjunct for TFESI, with randomized studies needed to compare its effectiveness to steroids as a possible alternative., Registration: Thai Clinical Trials Registry ID TCTR 20231110006., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Background: Reliable assessment of coronary microvascular function is essential. Techniques to measure absolute coronary blood flow are promising but need validation. The objectives of this study were: first, to validate the potential of saline infusion to generate maximum hyperemia in vivo. Second, to validate absolute coronary blood flow measured with continuous coronary thermodilution at high (40-50 mL/min) infusion speeds and asses its safety., Methods: Fourteen closed-chest sheep underwent absolute coronary blood flow measurements with increasing saline infusion speeds at different dosages under general anesthesia. An additional 7 open-chest sheep underwent these measurements with epicardial Doppler flow probes. Coronary flows were compared with reactive hyperemia after 45 s of coronary occlusion., Results: Twenty milliliters per minute of saline infusion induced a significantly lower hyperemic coronary flow (140 versus 191 mL/min; P =0.0165), lower coronary flow reserve (1.82 versus 3.21; P ≤0.0001), and higher coronary resistance (655 versus 422 woods units; P =0.0053) than coronary occlusion. On the other hand, 30 mL/min of saline infusion resulted in hyperemic coronary flow (196 versus 192 mL/min; P =0.8292), coronary flow reserve (2.77 versus 3.21; P =0.1107), and coronary resistance (415 versus 422 woods units; P =0.9181) that were not different from coronary occlusion. Hyperemic coronary flow was 40.7% with 5 mL/min, 40.8% with 10 mL/min, 73.1% with 20 mL/min, 102.3% with 30 mL/min, 99.0% with 40 mL/min, and 98.0% with 50 mL/min of saline infusion when compared with postocclusive hyperemic flow. There was a significant bias toward flow overestimation (Bland-Altman: bias±SD, -73.09±30.52; 95% limits of agreement, -132.9 to -13.27) with 40 to 50 mL/min of saline. Occasionally, ischemic changes resulted in ventricular fibrillation (9.5% with 50 mL/min) at higher infusion rates., Conclusions: Continuous saline infusion of 30 mL/min but not 20 mL/min induced maximal hyperemia. Absolute coronary blood flow measured with saline infusion speeds of 40 to 50 mL/min was not accurate and not safe., Competing Interests: Dr Fearon receives institutional research support from Abbott Vascular, Medtronic, and the National Institutes of Health has consulted with CathWorks, and has stock options with HeartFlow. The other authors report no conflicts.

Background: Tracheal tube cuff pressure will increase after pneumoperitoneum when the cuff is inflated with air, high pressure can cause tracheal mucosal damage. This prospective trial aimed to assess if inflating with normal saline or lidocaine can prevent increase of tracheal tube cuff pressure and tracheal mucosal damage in laparoscopic surgeries with general anesthesia. Whether changes of tracheal tube cuff transverse diameter (CD) can predict changes of tracheal tube cuff pressure., Methods: Ninety patients scheduled for laparoscopic resection of colorectal neoplasms under general anesthesia were randomly assigned to groups air (A), saline (S) or lidocaine (L). Endotracheal tube cuff was inflated with room-temperature air in group A (n = 30), normal saline in group S (n = 30), 2% lidocaine hydrochloride injection in group L (n = 30). After intubation, tracheal tube cuff pressure was monitored by a calibrated pressure transducers, cuff pressure was adjusted to 25 cmH 2 O (T 0.5 ). Tracheal tube cuff pressure at 15 min after pneumoperitoneum (T 1 ) and 15 min after exsufflation (T 2 ) were accessed. CD were measured by ultrasound at T 0.5 and T 1 , the ability of ΔCD (T 1-0.5 ) to predict cuff pressure was accessed. Tracheal mucous injury at the end of surgery were also recorded., Results: Tracheal tube cuff pressure had no significant difference among the three groups at T 1 and T 2 . ΔCD had prediction value (AUC: 0.92 [95% CI: 0.81-1.02]; sensitivity: 0.99; specificity: 0.82) for cuff pressure. Tracheal mucous injury at the end of surgery were 0 (0, 1.0) in group A, 0 (0, 1.0) in group S, 0 (0, 0) in group L (p = 0.02, group L was lower than group A and S, p = 0.03 and p = 0.04)., Conclusions: Compared to inflation with air, normal saline and 2% lidocaine cannot ameliorate the increase of tracheal tube cuff pressure during the pneumoperitoneum period under general anesthesia, but lidocaine can decrease postoperative tracheal mucosa injury. ΔCD measured by ultrasound is a predictor for changes of tracheal tube cuff pressure., Trial Registration: Chinese Clinical Trial Registry, identifier: ChiCTR2100054089, Date: 08/12/2021., (© 2024. The Author(s).)

Background: The use of balanced crystalloids over normal saline for perioperative fluid management during kidney transplantation and its benefits on acid-base and electrolyte balance along with its influence on postoperative clinical outcomes remains a topic of controversy. Therefore, we conducted this review to assess the impact of balanced solutions compared to normal saline on outcomes for kidney transplant patients., Methods: We searched MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing balanced lower-chloride solutions to normal saline in renal transplant patients. Our main outcome of interest was delayed graft function (DGF). Additionally, we examined acid-base and electrolyte measurements, along with postoperative renal function. We computed relative risk (RR) using the Mantel-Haenszel test for binary outcomes, and mean difference (MD) for continuous data, and applied DerSimonian and Laird random-effects models to address heterogeneity. Furthermore, we performed a trial sequential analysis (TSA) for all outcomes., Results: Twelve RCTs comprising a total of 1668 patients were included; 832 (49.9%) were assigned to receive balanced solutions. Balanced crystalloids reduced the occurrence of DGF compared to normal saline, with RR of 0.82 (95% confidence interval [CI], 0.71-0.94), P = .005; I² = 0%. The occurrence was 25% (194 of 787) in the balanced crystalloids group and 34% (240 of 701) in the normal saline group. Moreover, our TSA supported the primary outcome result and suggests that the sample size was sufficient for our conclusion. End-of-surgery chloride (MD, -8.80 mEq·L -1 ; 95% CI, -13.98 to -3.63 mEq.L -1 ; P < .001), bicarbonate (MD, 2.12 mEq·L -1 ; 95% CI, 1.02-3.21 mEq·L -1 ; P < .001), pH (MD, 0.06; 95% CI, 0.04-0.07; P < .001), and base excess (BE) (MD, 2.41 mEq·L -1 ; 95% CI, 0.88-3.95 mEq·L -1 ; P = .002) significantly favored the balanced crystalloids groups and the end of surgery potassium (MD, -0.17 mEq·L -1 ; 95% CI, -0.36 to 0.02 mEq·L -1 ; P = .07) did not differ between groups. However, creatinine did not differ in the first (MD, -0.06 mg·dL -1 ; 95% CI, -0.38 to 0.26 mg·dL -1 ; P = .71) and seventh (MD, -0.06 mg·dL -1 ; 95% CI, -0.18 to 0.06 mg·dL -1 ; P = .30) postoperative days nor urine output in the first (MD, -1.12 L; 95% CI, -3.67 to 1.43 L; P = .39) and seventh (MD, -0.01 L; 95% CI, -0.45 to 0.42 L; P = .95) postoperative days., Conclusions: Balanced lower-chloride solutions significantly reduce the occurrence of DGF and provide an improved acid-base and electrolyte control in patients undergoing kidney transplantation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background and Aims: The safety and efficacy of solutions for submucosal injection are critical for endoscopic resection of gastric adenomas or early gastric cancers. Although several injectable solutions have been introduced for endoscopic resection, they have some limitations. We aimed to compare the efficacy of the new sodium alginate-based solution MC-003 with that of normal saline (NS; 0.9% sodium chloride)., Methods: In this randomized, triple-blind study, 70 patients were initially enrolled for EMR or endoscopic submucosal dissection (ESD). The main outcomes included the need for additional injections, completion of en bloc resection, and occurrence of adverse events., Results: Each group ultimately included 34 patients. Complete en bloc resections were achieved in all patients (P = 1.000). The MC-003 group had more peri-neoplasm tissue fibrosis (P = .056) and needed fewer additional injections for lesions >15 mm (P = .037), located in the distal portion of the stomach (P = .007), and during ESD procedures (P = .001). The adverse event rate was comparable in both groups., Conclusions: MC-003 outperformed NS in reducing the need for additional injections during en bloc resection, particularly in larger lesions located in the distal portion of the stomach (where most lesions were found) during ESD procedures, without increasing the incidence of serious adverse events. MC-003 is a promising submucosal injectable solution in real-world clinical settings., Competing Interests: Disclosure All authors disclosed no financial relationships. This study was financially supported by McNulty Pharmaceuticals and was related to the company’s interests., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)