Adequate Urine Output Research Articles

Pain Management Practice Patterns for Common Pediatric Urology Procedures

To characterize practice patterns among members of the Society for Pediatric Urology. A survey instrument assessing pain management was e-mailed to all members of the Society for Pediatric Urology. Five hundred fifteen invitations were sent, 134 were included, for a 26% response rate. Pain management strategies were assessed for 7 case scenarios. Surveys were included if the responder answered a minimum of 2 case scenarios. Question Pro survey engine was used to process the survey. Local/regional block was the most frequent intraoperative anesthesia (54%-90%). Epidural/caudal use varied from 19% to 42%. For postop opioids, a dichotomy exists between those without age restriction and those who wait until the patient is 6months old. Sixty three percent responded that ketorolac was prescribed only if the patient had normal renal function, 20% after confirmation of adequate urine output for bilateral procedures, 3% when postoperative creatinine was normal, and 14% did not use ketorolac at all. In regards to age limitations, most did not indicate a limit (53%), whereas a large number required the child to be older than 6months (26%). Regarding local blocks, most urologists perform the block themselves (61%) for simple/complex penile surgery or inguinal surgery. Of this group, only 33% actually bill for the administration of the block. After a caudal block, a minority (26%) of respondents require the patient to void before discharge for ambulatory procedures. There is no clear consensus in pain management for common pediatric urologic procedures. These disparities should be the aim of future studies.

Association between renal replacement therapy in critically ill patients with severe acute kidney injury and mortality

PurposeTo evaluate the characteristics and outcomes of critically ill patients with severe acute kidney injury (AKI) treated and not treated with renal replacement therapy (RRT). MethodsSecondary analysis of a multi-centre cohort study. Primary exposure was RRT. Primary outcome was propensity and multi-variable adjusted-hospital mortality. ResultsWe studied 1250 patients (71.3%) who received and 502 (28.7%) who did not receive RRT. Reasons for not starting RRT (not mutually exclusive) were limitations of support (33.6%, n = 169), adequate urine output (46.2%; n = 232), plan to observe (56.4%; n = 283), and advanced age (12.6%; n = 63). Mortality was higher in those not receiving RRT due to limitations and advanced age but lower for adequate urine output and plan to observe. Propensity and multi-variable adjusted analysis showed no statistical difference in hospital mortality (adj-OR 1.47; 95% CI, 0.93-2.24) in patients receiving RRT. Results were similar in a sensitivity analysis restricted to patients fulfilling risk, injury, failure, loss, end-stage kidney disease-FAILURE criteria (37.0%; n = 446) (adj-OR 1.36; 95% CI, 0.70-2.66). ConclusionIn this cohort, reasons for not starting RRT included limitations of support and perception of impending renal recovery. Despite similar risk of mortality after adjusting for selection bias and confounders, RRT-treated patients were fundamentally different from non-treated patients across a spectrum of variables that precludes valid comparison in observational data.

Multi-Organ and Complex Full Facial Segment Procurement from a Brain Dead Donor

The procurement of facial vascularized composite allografts (VCA) is complicated by highly variable recipient defects, in contrast to more standardized recovery of solid organ and hand VCA. In donors undergoing facial VCA recovery, coordination with multi-organ recovery is essential to preserve functional outcomes of solid organ allografts. Methods: We performed coordinated procurement of a full facial VCA with abdominal organ recovery for transplantation from a brain dead donor. The facial VCA included all facial skin, mimetic muscles, multiple sensory and motor nerve branches, the anterior tongue and segments of the maxilla and mandible. Abdominal organ recovery included liver and kidneys. Close monitoring of arterial blood gases, urine output, transfusion requirements, and key steps of facial VCA dissection guided timing of abdominal organ recovery. Results: Recovery of the facial VCA required ˜10.5 hours, with tracheostomy and silicone mask impression performed prior to procurement. Transfusion of 9 units packed red blood cells, 6 units fresh frozen plasma, 1 pooled unit platelets, and 7 L crystalloid were required to maintain stable hemodynamics (MAP 70.1±8.4mmHg) and adequate urine output (0.7 mL/kg/Hr). Donor coagulopathy increased transfusion requirements and the majority of blood loss occurred after mid-face dissection and the initiation of abdominal organ recovery. Oxygenation (192-254 mmHg) and blood pH (7.30-7.35) were normal throughout recovery. Abdominal organ recovery was initiated 6.5 hours into the procedure and prior to performing facial VCA osteotomies; abdominal and facial recovery teams were able to operate concurrently thereafter. After heparinization, the facial VCA was explanted for backtable flushing with University of Wisconsin solution. Abdominal organ recovery immediately followed without complication and good recipient graft function. Conclusions: Facial VCA procurement entails additional blood loss and substantial extension of donor recovery operations. Close monitoring of the donor allows for delayed solid-organ recovery after facial skeletal dissection and potential greatest blood loss. Coordinated care between anesthesia, solid-organ, and facial VCA teams allows for procurement of a complicated facial VCA while preserving solid organ outcomes.

A Study of Renal Transplant for Patients with Neurogenic Bladder

In our hospital, we performed renal transplants on 12 patients with neurogenic bladder between 1992 and 2010. Three patients with bladder dysfunction had undergone pre-operative cystoplasties for the improvement of their bladder compliance. Patients were divided into high-risk and low-risk groups according to risk of urinary tract complications and infections after renal transplants. The levels of risk were determined on the basis the patients' pre-operative bladder functions and urination states, and the two groups were compared with respect to the incidence of post-operative UTIs (urinary tract infections) and level of renal function. All patients, except a female who could not perform regular CIC (clean intermittent catheterizations) to maintain adequate urine output, were able to maintain renal function. A recipient was able to deliver a baby safely. In addition, we were able to treat post-operative UTIs by increasing the frequency of CICs and by adding a night balloon.

Environmental Hypothermia in Porcine Polytrauma and Hemorrhagic Shock is Safe

We have previously demonstrated survival benefit to induced hypothermia in a porcine model of controlled hemorrhagic shock simulating an associated delay to definitive care. In the current study, we wished to evaluate the effects of environmental hypothermia in a porcine model of hemorrhagic shock with the addition of polytrauma. Sixteen pigs were randomized to normothermic (39°C, n = 7) or hypothermic (34°C, n = 9) groups. The model included instrumentation, chest injury (captive bolt device), hemorrhage to systolic blood pressure (SBP) of ∼50 mmHg, and crush liver injury. Animals received limited fluid resuscitation for a 1-h period with goal SBP of greater than 80 mmHg and ice packs or warming blankets to achieve goal temperatures, followed by full resuscitation with goal SBP of greater than 90 mmHg, adequate urine output, and hemoglobin by protocol for 20 h. Survivors were observed for an additional 24 h with end points including mortality, markers of organ injury, and neurologic function. There were no differences in survival between the groups (mortality = 1/9, hypothermia group vs. 2/7, normothermia group, P = 0.39). Markers of organ injury were elevated in the hypothermia group at 24 h after injury but were identical between groups at the end of the experimental protocol (48 h after injury). There were no noted differences in neurologic function between the two groups. Environmental hypothermia in a model of polytrauma and hemorrhagic shock was not associated with worse outcomes.

Colloids in the intensive care unit

The most recent published evidence on the use of colloids versus crystalloids in critical care is reviewed, with a focus on population-dependent differences in safety and efficacy. Colloids offer a number of theoretical advantages over crystalloids for fluid resuscitation, but some colloids (e.g., hydroxyethyl starch solutions, dextrans) can have serious adverse effects, and albumin products entail higher costs. The results of the influential Saline Versus Albumin Fluid Evaluation (SAFE) trial and a subsequent SAFE subgroup analysis indicated that colloid therapy should not be used in patients with traumatic brain injury and other forms of trauma due to an increased mortality risk relative to crystalloid therapy. With regard to patients with severe sepsis, two meta-analyses published in 2011, which collectively evaluated 82 trials involving nearly 10,000 patients, indicated comparable outcomes with the use of either crystalloids or albumins. For patients requiring extracorporeal cardiopulmonary bypass (CPB) during heart surgery, the available evidence supports the use of a colloid, particularly albumin, for CPB circuit priming and postoperative volume expansion. In select patients with burn injury, the published evidence supports the use of supplemental colloids if adequate urine output cannot be maintained with a crystalloid-only rescue strategy. The results of the SAFE trial and a subgroup analysis of SAFE data suggest that colloids should be avoided in patients with trauma and traumatic brain injury. There are minimal differences in outcome between crystalloids and hypo-oncotic or iso-oncotic albumin for fluid resuscitation in severe sepsis; in select populations, such as patients undergoing cardiac surgery, the use of iso-oncotic albumin may confer a survival advantage and should be considered a first-line alternative.

Rhabdomyolysis in the Intensive Care Unit

Rhabdomyolysis is a clinical syndrome defined by muscle breakdown and subsequent release of intracellular contents. There are many etiologies of rhabdomyolysis, classified here as congenital and acquired; compartment syndrome secondary to trauma with reperfusion injury is one common precipitating factor. Regardless of the underlying etiology, the pathophysiology follows a similar pathway via myocyte destruction and release of myoglobin into the systemic circulation. Rhabdomyolysis-induced renal failure is caused by the precipitation of myoglobin in the renal tubules which is enhanced under acidic conditions. A high index of clinical suspicion is required to promptly recognize rhabdomyolysis, especially in the unconscious patient. Presenting symptoms include tea-colored urine and muscle weakness or fatigue. The diagnosis is confirmed most reliably with the finding of elevated serum creatine kinase levels. Early, aggressive resuscitation with either normal saline or lactated Ringer's solution to maintain an adequate urine output is the most important intervention in preventing the development of acute renal failure. There is insufficient clinical evidence supporting the routine administration of diuretics and bicarbonate to protect against the development of acute renal failure.

Resuscitation After Severe Burn Injury Using High-Dose Ascorbic Acid: A Retrospective Review

Resuscitation of burn victims with high-dose ascorbic acid (vitamin C [VC]) was reported in Japan in the year 2000. Benefits of VC include reduction in fluid requirements, resulting in less tissue edema and body weight gain. In turn, these patients suffer less respiratory impairment and reduced requirement for mechanical ventilation. Despite these results, few burn centers resuscitate patients with VC in fear that it may increase the risk of renal failure. A retrospective review of 40 patients with greater than 20% TBSA between 2007 and 2009 was performed. Patients were divided into two groups: one received only lactated Ringer's (LR) solution and another received LR solution plus 66 mg/kg/hr VC. Both groups were resuscitated with the Parkland formula to maintain stable hemodynamics and adequate urine output (>0.5 ml/kg/hr). Patients with >10-hour delay in transfer to the burn center were excluded. Data collected included age, gender, weight, %TBSA, fluid administered in the first 24 hours, urine output in the first 24 hours, and Acute Physiology and Chronic Health Evaluation II score. PaO2 in millimeters mercury:%FIO2 ratio and positive end-expiratory pressure were measured at 12-hour intervals, and hematocrit was measured at 6-hour intervals. Comorbidities, mortality, pneumonia, fasciotomies, and renal failure were also noted. After 7 patients were excluded, 17 patients were included in the VC group and 16 in the LR group. VC and LR were matched for age (42 ± 16 years vs 50 ± 20 years, P = .2), burn size (45 ± 21%TBSA vs 39 ± 15%TBSA, P = .45), Acute Physiology and Chronic Health Evaluation II (17 ± 7 vs 18 ± 8, P = .8), and gender. Fluid requirements in the first 24 hours were 5.3 ± 1 ml/kg/%TBSA for VC and 7.1 ± 1 ml/kg/%TBSA for LR (P < .05). Urine output was 1.5 ± 0.4 ml/kg/hr for VC and 1 ± 0.5 ml/kg/hr for LR (P < .05). Vasopressors were needed in four VC patients and nine LR patients (P = .07). VC patients required vasopressors to maintain mean arterial pressure for a mean of 6 hours, but LR needed vasopressors for 11 hours (P = .2). No significant differences in PaO2 in millimeters mercury:%FIO2 ratio, positive end-expiratory pressure, frequency of pneumonia, renal failure, or inhalation injury were found. VC group had four mortalities, and LR group had three mortalities (P = 1). VC is associated with a decrease in fluid requirements and an increase in urine output during resuscitation after thermal injury. Although this study did not find a difference in outcomes with VC administration, it demonstrates that VC can be safely used without an increased risk of renal failure. The effects of VC should be further studied in a large-scale, prospective, randomized trial.

Effects of Profuse Sweating Induced by Exercise on Urinary Uric Acid Excretion in a Hot Environment

In order to determine whether exercise-induced profuse sweating could reduce urinary uric acid excretion, we simulated badminton players training and measured their uric acid in urine, sweat and blood during the training period. Thirteen male volunteers who were well-trained badminton players were recruited in this study. On the first 2 days and the last 2 days of the study period none of the subjects engaged in any intense exercise- or activity-inducing profuse sweat, but they accepted routine training 2 h per day during the middle 3 days. The results show that mean serum urate levels of thirteen volunteers rose significantly on day 4, when the concentrations increased by 18.2% over day 2 (P < 0.05). The mean ten-hour urinary uric acid excretion of seven volunteers on the 3 training days was significantly less at 178.5 micromol/day and 118.3 micromol/day than those on the preceding and subsequent days of the training days, respectively (P < 0.05). Furthermore, for six volunteers, the mean ratio of clearance of uric acid to creatinine was 6.6% on day 2, which significantly decreased to 5.4% on day 4 (P < 0.05). It is concluded profuse sweating exercise results in a decrease of urinary uric acid excretion amounts and leads to increased serum uric acid after the exercise. We suggest that persons who take vigorous exercise or are exposed to hot environments need drinking enough fluids to prevent dehydration and maintain adequate urinary output. People with profuse sweat after rigorous exercise are recommended taking sports drinks containing abundant sodium in order to decrease serum uric acid.

What Are the Fluid Requirements in Toxic Epidermal Necrolysis?

Acute fluid requirements in toxic epidermal necrolysis (TEN) have neither been quantified nor reported. The purpose of this study was to examine acute fluid administration in TEN patients. A consecutive series of criteria and biopsy-confirmed cases of TEN admitted to our burn centre were selected for retrospective analysis. Charts were reviewed for demographic and resuscitation variables for the first (D0), second (D1), and third (D2) 24-hour periods after burn center admission. Twenty-one TEN cases were available for study, with a mean epidermal detachment of 53 +/- 24% TBSA. Mortality was 29%, with all deaths occurring after the study period. Average crystalloid volumes decreased from D0 (2.2 +/- 1.5 ml/kg/%TBSA) through D1 (1.6 +/- 1.1 ml/kg/%TBSA) and D2 (1.4 +/- 1.0 ml/kg/%TBSA), whereas urine output increased from D0 (1.3 +/- 0.9 ml/kg/hr) through D1 (1.4 +/- 0.9 ml/kg/hr) and D2 (1.8 +/- 1.1 ml/kg/hr). Worst base deficit (BD) corrected significantly from D0 to D1 (P = .01) and from D1 to D2 (P = .002). There was no correlation between daily crystalloid volumes and %TBSA detachment. Nonsurvivors had significantly higher severity-of-illness score for TEN and 24-hour mean and worst BDs than survivors, but did not require significantly more crystalloid or display lower urine outputs. Initial provision of approximately 2 ml/kg/%TBSA epidermal detachment to patients with TEN resulted in more than adequate urine output and significant correction of the BD. We emphasize that these data do not represent a resuscitation formula but rather a guideline for initial fluid administration, which should then be titrated to the patient's response.

Hypernatremia

Hypernatremia

Der beatmete Patient nach kardiopulmonaler Reanimation - Milde Hypothermiebehandlung verbessert neurologisches Outcome

Leider ist die völlige neurologische Erholung nach einem Herz-Kreislauf-Stillstand noch immer ein seltenes Ereignis. Ein standardisiertes Vorgehen - beruhend auf der Behandlung der zugrunde liegenden Ursachen, der frühen Revaskularisierung (wenn indiziert), einem optimierten Blutdruckmanagement zur Aufrechterhaltung der Nierenfunktion und einer optimalen Glukosekontrolle - ist das grundlegende Prinzip der Intensivtherapie nach einem Herzstillstand. Darüber hinaus kann durch die Anwendung der milden therapeutischen Hypothermie bei bewusstlosen Patienten nach einem Herz-Kreislauf-Stillstand das neurologische Ergebnis erheblich verbessert werden. Dabei sollte die Köperkerntemperatur der Patienten über zwölf bis 24 Stunden auf 32-34°C abgesenkt werden. Nur sechs Patienten müssen auf diese Weise behandelt werden, um bei einem zusätzlichen Patienten die neurologischen Ergebnisse zu verbessern.

THE 24-HOUR URINE CREATININE CLEARANCE PREDICTS SUCCESSFUL DISCONTINUATION OF CONTINUOUS RENAL REPLACEMENT THERAPY IN ACUTE RENAL FAILURE.

Purpose Continuous renal replacement therapy (CRRT) is increasingly used to manage acute renal failure (ARF) in the intensive care unit (ICU). There are no specific guidelines to help determine the optimal time for discontinuation of CRRT. The decision to stop CRRT has traditionally been based on an increase in the urine output in conjunction with an improving hemodynamic profile; however, an adequate urine output is not always accompanied by improved solute clearance. Ideally, CRRT should be discontinued when sufficient intrinsic renal recovery has occurred. Unwarranted CRRT increases the cost of ICU care and risk for complications, including bleeding, hypotension, and catheter-related sepsis. We evaluated the utility of a 24-hour urine collection for creatinine clearance (CrCl), obtained while on CRRT, as a means to guide discontinuation of therapy. Methods We retrospectively evaluated ICU patients who had a 24-hour urine CrCl performed when they became nonoliguric while on CRRT. CRRT discontinuation was deemed successful if patients maintained adequate metabolic and volume status for at least 2 weeks following removal of CRRT. Results A total of 23 patients were identified. All patients had a baseline creatinine of 15 mL/min prior to CRRT discontinuation, whereas 14 had a 24-hour urine CrCl 15 mL/min and CrCl 15 mL/min group successfully remained off RRT for at least 2 weeks following CRRT discontinuation, whereas only 4 of 14 (29%) patients in the CrCl 15 mL/min for remaining off CRRT is 89%; the negative predictive value of a 24-hour urine CrCl 15 mL/min predicts successful discontinuation of CRRT. Conclusion Our data suggest that a 24-hour urine CrCl > 15 mL/min, collected while on CRRT, predicts renal recovery and may help guide cessation of CRRT.

Use of fenoldopam to increase urine output in a patient with renal insufficiency secondary to septic shock: A case report

We describe the use of fenoldopam to increase urine output in a pediatric patient with sepsis, heart failure, oliguria, and volume overload. Case report. A tertiary pediatric intensive care unit. A 17-year-old male who was being treated for acute lymphoblastic leukemia and was admitted from outside the hospital to the pediatric intensive care unit, in septic shock, after a course of chemotherapy. A continuous fenoldopam infusion of 0.03 microg/kg/min was added to a regimen of multiple inotropic and vasopressor agents and a furosemide continuous infusion. Urine output increased 586% 12 hrs after starting the fenoldopam infusion and 775% from baseline 24 hrs after starting the infusion. Diuretics were decreased while maintaining adequate urine output. No hypotension was noted. Fenoldopam increased urine output in a pediatric patient who was in septic shock and oliguria. The mechanism for this effect is unclear, and further trials are necessary to determine the role of fenoldopam in this patient population.

Back to the Future: Intraoperative Fluid Restriction in Gastrointestinal Surgery—A New Practice to the West, but an Old One to Sub-Sahara Africa

In his article, Joshi (1) suggests benefits of intraoperative fluid restriction in gastrointestinal surgery. We would like to report our own experience with perioperative fluid management in abdominal surgery in a referral hospital in Goma, the Democratic Republic of Congo in Africa. During the period from January to June 2005, a total of 69 abdominal surgeries were performed. Full data sets were available of 45 patients (65.2%) older than 16 yr who were enrolled into the analysis. Thirty-four patients (75.6%) were female. Mean age was 33 11 yr. Table 1 presents details on intraoperative data and postoperative complications. Although most patients were dehydrated before surgery as a result of nonexistent prehospital medical care, the amount of fluids given during surgery was low. Although lower amounts of fluids during abdominal surgery have been reported (2), intraoperative fluid balance in our analysis was comparable to that reported by Kita et al. (3). When compared with studies evaluating restrictive intraoperative fluid strategies in abdominal surgery (4,5), hourly fluid administration was substantially lower in our patient population, even though intraoperative blood loss was higher than reported in other studies (2–5). This is likely because electrocoagulation was not available for most surgical procedures. Despite restricted use of intraoperative fluids, all patients had adequate urine output, and postoperative complications were rare. In view of highly limited logistical and infrastructural resources, the hospital mortality of our abdominal surgical patient population (2.2%) is very low for a sub-Sahara African setting (6). Perioperative fluid restriction is a common practice in most subSaharan countries. Important reasons include limited hospital resources, patient inability to pay for hospital supplies, disruption of hospital services by war, and the demands placed by occasional epidemics. Because the presented hospital is supported by a Western organization and can therefore compensate for limited financial resources of individual patients, it is likely that intraoperative fluid therapy is even more restrictive in other sub-Saharan hospitals that do not receive external support.

Maximizing Organ Donation Opportunities Through Donation After Cardiac Death

John Edwards is the clinical administrator for Gift of Life Donor Program in Philadelphia, Pa, overseeing all clinical aspects of organ and tissue recovery, and a faculty member for the Gift of Life Institute, Philadelphia, providing training and mentoring for healthcare organizations nationally. Patti Mulvania oversees the clinical education program for the Gift of Life Donor Program in Philadelphia and is a faculty member of the Gift of Life Institute, specializing in consent and clinical communication. Virginia Robertson is the associate director of the Gift of Life Institute in Philadelphia. Formerly, she was the director of hospital services for the Gift of Life Donor Program. Gweneth George is the director of hospital services for the Gift of Life Donor Program in Philadelphia. She directs a team of nearly 20 hospital development staff accountable for donation performance in 150 acute care hospitals. Richard Hasz is vice president of clinical services for the Gift of Life Donor Program in Philadelphia. He oversees the day-to-day clinical operations, including transplant coordination, hospital development, organ preservation, and tissue recovery. Howard Nathan is president and chief executive officer of the Gift of Life Donor Program in Philadelphia. The program has been involved in coordinating more than 22 000 organ transplantations and tens of thousands of tissue transplantations since 1974.

Early Catheter Removal following Transurethral Prostatectomy: A Study of 431 Patients

Objectives: To assess and review catheter removal on the first day after transurethral prostatectomy. Subjects and Methods: The study included 431 consecutive patients who underwent transurethral prostatectomy between 2000 and 2003 at a Scarborough General Hospital, Toronto, Canada. The equipment used was a standard resectoscope with a regular loop. No roller ball or other gadget was used. The cutting and coagulation electrical variables were standard at 160 and 60 W for the generator used. The decision to remove the catheters was based on normal vital signs, adequate urine output, absence of clots and acceptable color of the catheter effluent. Results: Catheters were removed in 415 (96.3%) patients on postoperative day 1. Of the 415 patients 332 (80.0%) were discharged on the same day. The criteria for catheter removal on postoperative day 1 were not met in 16 (3.7%) patients and the mean indwelling catheter time was 4.8 ± 2.4 days and the mean length of hospital stay after surgery was 6.2 ± 3.3 days. For the entire group, the mean indwelling catheter time was 1.1 ± 0.8 days and the mean length of hospital stay after surgery was 1.6 ± 1.5 days. Risk factors which predicted delayed removal were age, postoperative bleeding and several comorbidities, that is coronary heart disease, renal insufficiency and Alzheimer’s disease. Conclusions: Removal of the catheter on the first postoperative day after transurethral prostatectomy seems to be feasible, safe and cost-effective without increasing significant morbidity in selected patients.

Hypertonic Lactated Saline Resuscitation Reduces the Risk of Abdominal Compartment Syndrome in Severely Burned Patients

Secondary abdominal compartment syndrome is a lethal complication after resuscitation from burn shock. Hypertonic lactated saline (HLS) infusion reduces early fluid requirements in burn shock, but the effects of HLS on intraabdominal pressure have not been clarified. Patients admitted to our burn unit between 2002 and 2004 with burns > or =40% of the total body surface area without severe inhalation injury were entered into a fluid resuscitation protocol using HLS (n = 14) or lactated Ringer's solution (n = 22). Urine output was monitored hourly with a goal of 0.5 to 1.0 mL/kg per hour. Hemodynamic parameters, blood gas analysis, intrabladder pressure as an indicator of intraabdominal pressure (IAP), and the peak inspiratory pressure were recorded. Pulmonary compliance and the abdominal perfusion pressure were also calculated. In the HLS group, the amount of intravenous fluid volume needed to maintain adequate urine output was less at 3.1 +/- 0.9 versus 5.2 +/- 1.2 mL/24 h per kg per percentage of total body surface area, and the peak IAP and peak inspiratory pressure at 24 hours after injury were significantly lower than those in the lactated Ringer's group. Two of 14 patients (14%) in the HLS group and 11 of 22 patients (50%) developed IAH within 20.8 +/- 7.2 hours after injury. In patients with severe burn injury, a large intravenous fluid volume decreases abdominal perfusion during the resuscitative period because of increased IAP. Our data suggest that HLS resuscitation could reduce the risk of secondary abdominal compartment syndrome with lower fluid load in burn shock patients.

Evaluation of furosemide regimens in neonates treated with extracorporeal membrane oxygenation

IntroductionLoop diuretics are the most frequently used diuretics in patients treated with extracorporeal membrane oxygenation (ECMO). In patients after cardiopulmonary bypass (CPB) surgery, the use of continuous furosemide infusion is increasingly documented. Because ECMO and CPB are 'comparable' procedures, continuous furosemide infusion is used in newborns on ECMO. We report on the use of continuous intravenous furosemide in neonates treated with ECMO.MethodsThis was a retrospective observational study in neonates treated with continuous intravenous furosemide during ECMO.ResultsThirty-one patients were included in the study. A median of 25 (9–149) hours after the start of ECMO, continuous furosemide therapy was started at a median rate of 0.08 (0.02–0.17) mg/kg per hour. The continuous furosemide dose was not changed in the individual patient. Seven patients received a furosemide bolus prior to, and five patients received additional loop diuretics during, the continuous infusion. Urine production before continuous furosemide therapy was not significantly different between patients who received a furosemide bolus prior to the infusion and those who did not receive this bolus (P = 0.2879). Although a positive effect of the 'loading' bolus was observed in urine output in the first 24 hours, there was no statistically significant difference in urine output (P = 0.0961) or in time (P = 0.1976) to reach a urine output of 6 ml/kg per hour between patients. After 24 hours, urine production remained a median of 6.2 ml/kg per hour irrespective of furosemide boluses. The forced diuresis was well tolerated as illustrated by stable haemodynamic parameters and a decrease in ECMO flow and vasopressor score over the observation period.ConclusionThis is the first report on continuous intravenous furosemide therapy in newborns treated with ECMO. The furosemide regimens used in this study varied widely in continuous and intermittent doses. However, all regimens achieved adequate urine output. An advantage of continuous, over intermittent, intravenous furosemide could not be documented. Furosemide dosing regimens should be developed for neonates treated with ECMO. In addition, therapeutic drug-monitoring studies are required to prevent furosemide toxicity because so far no data are available on serum furosemide levels in neonates treated with ECMO.

Intentional Self-Poisoning With the Chlorophenoxy Herbicide 4-Chloro-2-Methylphenoxyacetic Acid (MCPA)

Data on poisoning with MCPA (4-chloro-2-methyl-phenoxyacetic acid) are limited to 6 case reports. Our objective is to describe outcomes from intentional self-poisoning with MCPA in a prospective case series of 181 patients presenting to hospitals in Sri Lanka. Patient information was collected by on-site study physicians as part of an ongoing prospective cohort study of poisoned patients. Medical history, clinical details, and blood samples were obtained prospectively. Overall clinical toxicity was minimal in 85% of patients, including mild gastrointestinal symptoms in 44% of patients. More severe clinical signs of chlorophenoxy poisoning reported previously, such as rhabdomyolysis, renal dysfunction, and coma, also occurred but were uncommon. Eight patients died (4.4%). Most deaths occurred suddenly from cardiorespiratory arrest within 48 hours of poisoning; the pathophysiological mechanism of death was not apparent. The correlation between admission plasma MCPA concentration and clinical markers of severity of toxicity (physical signs, symptoms, and increased creatine kinase level) was poor. Intentional self-poisoning with MCPA generally causes mild toxicity, but cardiorespiratory arrest and death may occur. All patients should receive routine resuscitation and supportive care. It seems reasonable to correct acidosis and maintain an adequate urine output, but there is insufficient evidence to support other specific interventions. Our data do not support a clinical role for measurement of plasma MCPA in the acute management of poisoning, and insufficient data were available to fully examine the utility of measured electrolytes and creatine kinase levels.