Fluid Administration Research Articles

Understanding Heen Yog, Mithya Yog, and Ati Yog in IV Fluid Administration: A Comparative Analysis from Ayurveda, Karma Yog, and Modern Medical Science

Ayurveda offers a holistic framework for understanding the causes of disease, particularly through the concept of Asatmendriyartha Samyoga, involving Heen Yog (underuse), Mithya Yog (improper use), and Ati Yog (overuse). These can also be understood within the scope of Karma Yog, the philosophy that proper, timely action leads to positive outcomes. This paper explores how the administration of IV fluids, a critical medical intervention for correcting electrolyte imbalances, is a form of Karma, and when performed correctly, aligns with Karma Yog principles. Improper IV fluid use - whether through Heen Yog, Mithya Yog, or Ati Yog - can lead to adverse outcomes, thus emphasising the need for balance, skill, and timing in this therapeutic action. A synthesis of Ayurvedic texts and contemporary medical literature is presented to explore this concept.

Vasopressor Therapy.

Vasopressor therapy represents a key part of intensive care patient management, used to increase and maintain vascular tone and thus adequate tissue perfusion in patients with shock. Norepinephrine is the preferred first-line agent because of its reliable vasoconstrictor effects, with minimal impact on heart rate, and its mild inotropic effects, helping to maintain cardiac output. Whichever vasopressor is used, its effects on blood flow must be considered and excessive vasoconstriction avoided. Other vasoactive agents include vasopressin, which may be considered in vasodilatory states, and angiotensin II, which may be beneficial in patients with high renin levels, although more data are required to confirm this. Dobutamine should be considered, along with continued fluid administration, to help maintain adequate tissue perfusion in patients with reduced oxygen delivery. In this narrative review, we consider the different vasopressor agents, focusing on the importance of tailoring therapy to the individual patient and their hemodynamic response.

Impact of Fluid Balance on the Development of Lung Injury.

The pathophysiological relationship between fluid administration, fluid balance, and mechanical ventilation in the development of lung injury is unclear. To quantify the relative contribution of mechanical power and fluid balance in the development of lung injury. Thirty-nine healthy female pigs, divided into four groups, were ventilated for 48 hours with high (~18J/min) or low (~6J/min) mechanical power; and high (~4L) or low (~1L) targeted fluid balance. We measured physiological variables e.g., end-expiratory lung gas volume, respiratory-system mechanics, gas-exchange and hemodynamics, and pathological variables, i.e., lung weight, wet-to-dry ratio, and histology score of lung injury. End-expiratory lung gas volume, respiratory system elastance, strain and oxygenation significantly worsened in the two groups assigned to receive high fluid balance, irrespective of the mechanical power received. All four groups had similar lung weight (i.e., lung edema), lung wet-to-dry ratio and pathological variables. Animals with higher fluid balance developed more ascites, which was associated with a decrease in end-expiratory lung gas volume. In conclusion, our study did not detect a significant difference in lung injury between high and low mechanical power. Some damage is directly attributable to mechanical power, while additional injury appears to result indirectly from high fluid balance, which reduces end-expiratory lung gas volume, with ascites playing an important role in this process.

Impact of Enhanced Recovery After Surgery Protocol Compliance on Outcome After Pancreatic Surgery: Results From a Certified ERAS Center

Objective: The aim was to evaluate the sustainability of the pancreatic Enhanced Recovery After Surgery (ERAS) program and the effect of ERAS items on patient morbidity and hospital stay. Background: The current ERAS guideline recommendations encompass 27 items to improve recovery after pancreatoduodenectomy (PD). Methods: Patients who underwent pancreatic resection at the University Hospital Hamburg-Eppendorf between February 2016 and June 2023 were included. The datasets were retrospectively collected from a central database. The effects of individual ERAS items and compliance on morbidity and hospital stay were assessed by uni- and multivariable analyses. Results: In total, 594 patients who underwent PD (44.8%), distal pancreatectomy (14.6%), total pancreatectomy (17.8%), or other pancreatic resections (22.7%) were included. Of these, 90 patients (15.2%) achieved a high overall ERAS compliance of ≥70%. High compliance was associated with significantly less complications (Clavien–Dindo ≥ 3a), reduced 30-day mortality, and a shorter hospital stay. Early mobilization on the first postoperative day (POD1), restrictive intravenous fluid administration, and timely removal of urinary catheters were significant multivariable predictors for lower morbidity. Early mobilization on POD1 also correlated with reduced morbidity in the subcohort of PD cases. Conclusions: The pancreatic ERAS protocol can be sustainably implemented and applied to both, PD and non-PD cases. A high level of compliance with the ERAS protocol after pancreatic resections correlated with improved outcomes but was achieved by less than one-fifth of patients. Early mobilization on POD1 and restrictive fluid management were key indicators for optimized short-term outcomes.

Needs Assessment and Tailored Training Pilot for Emergency Care Clinicians in the Prehospital Setting in Rwanda

Background: In low- and middle-income countries (LMIC), 45% of deaths could be addressed by implementation of an emergency medical services (EMS) system. Prehospital care is a critical component of EMS worldwide, and basic, affordable training has been shown to improve EMS systems. However, patient outcome impact is unclear. In this study we aimed to assess the current state of prehospital care in Kigali, Rwanda, through a needs assessment, focused training intervention, and analysis of current practices and patient outcomes. Methods: We identified 30 clinicians through the prehospital medical command office and included them in the study. A prospective, nonrandomized, interrupted time-series approach was used. Data collected through closed- and open-ended questionnaires included age, sex, training, and knowledge assessment. We used the data to create a tailored, 18-hour training after which immediate and 11-month post-tests were administered. Linked prehospital and hospital care datasets allowed for evaluation of patient outcomes and prehospital process indicators that included training skill application, airway intervention, intravenous fluid administration, and glucose administration. Results: Of 30 clinicians, 18 (60%) were female, 19 were nurses, and 11 were nurse anaesthetists. Median age was 36, and median years providing care was 10 (IQR 7–11). Twenty-four (80%) participants completed immediate and post-test assessments. Mean knowledge across 12 core skills significantly improved from a pre-test mean of 59.7% (95% confidence interval [CI] 42.2–77.20) to a post-test mean of 87.8% (95% CI 74.7–100). At 11 months post-training, the score improvement maintained, with a mean score of 77.6%(95% CI 59.2–96.8). For patient outcomes, the total sample size was 572 patients; 324 of these patients were transported to the ED during the pre-training period (56.4%), while 248 were transported post-training. Prehospital oxygen administration for patients with a saturation level of <95% significantly increased pre- to post-training (66.7% to 71.7%; Δ = 5.0%; Δ95% CI 1.9,−8.1%). No significant changes were noted in patient treatment outcomes or other process indicators due to small sample sizes. Conclusion: This study provides insights on Rwandan EMS and demonstrates that a tailored intervention targeting education on prehospital process indicators has positive impacts on clinician knowledge and practice.

Management Practices for Hemodynamic Impairment in Neonates Born Prematurely: A Quality Improvement Project.

Background: No consensus exists on the management of hemodynamic impairment in very premature neonates. At level 3 NICU, the protocol involves an initial infusion of crystalloids, followed by a cardiac ultrasound if the infusion fails to restore appropriate hemodynamics. Based on the ultrasound findings, a decision is then made regarding a second infusion or the prescription of vasopressor amines. The aim of the present study was to assess the effect of and compliance with this management practice in neonates born prematurely between 26 and 31 completed weeks of gestation following a plan-do-study-act design. Methods: Data were collected retrospectively from patient records for all neonates who were managed for hemodynamic impairment within the first 24 h of life. Results: Of 604 neonates born during the study period, 68 were included in this study, but only eight cases followed the protocol. Reasons for non-compliance were the absence of cardiac ultrasound and variations in the duration and dosage of fluid administration. There was a significant relationship between blood pressure and positive inspiratory pressure levels at the time of management and compliance with the protocol. Conclusions: A revision of the protocol will emphasize the importance of echocardiography assessment, as all neonates responded to the ultrasound-guided therapy. As a quality improvement measure, attending neonatologists will be trained to thoroughly adhere to the protocol before the next evaluation.

Impact of Interhospital Transfer on Outcomes in Acute Pancreatitis: Implications for Healthcare Quality.

Background/Objectives: Effective management of acute pancreatitis (AP) hinges on prompt volume resuscitation and is adversely affected by delays in diagnosis. Given diverse clinical settings (tertiary care vs. community hospitals), further investigation is needed to understand the impact of the initial setting to which patients presented on clinical outcomes and quality of care. This study aimed to compare outcomes and quality indicators between AP patients who first presented to the emergency department (ED) of a tertiary care center and AP patients transferred from community hospitals. Methods: This study included AP patients managed at our tertiary care hospital between 2008 and 2018. We compared demographics and outcomes, including length of stay (LOS), intensive care unit (ICU) admission, rates of local and systemic complications, re-admission rates, and one-year mortality in transferred patients and those admitted from the ED. Quality indicators of interest included duration of volume resuscitation, time until advancement to enteral feeding, pain requiring opioid medication [measured in morphine milliequivalent (MME) dosing], and surgical referrals for cholecystectomy. Categorical variables were analyzed by chi-square or Fisher's exact test; continuous variables were compared using Kruskal-Wallis tests. Regression was performed to assess the impact of transfer status on our outcomes of interest. Results: Our cohort of 882 AP patients comprised 648 patients admitted from the ED and 234 patients transferred from a community hospital. Transferred patients were older (54.6 vs. 51.0 years old, p < 0.01) and had less frequent alcohol use (28% vs. 39%, p < 0.01). Transferred patients had a significantly greater frequency of gallstone AP (40% vs. 23%), but a lower frequency of alcohol AP (16% vs. 22%) and idiopathic AP (29% vs. 41%) (p < 0.001). Regarding clinical outcomes, transferred patients had significantly higher rates of severe AP (revised Atlanta classification) (10% vs. 2% severe, p < 0.001) and ICU admission (8% vs. 2%, p < 0.001) and longer median LOS (5 vs. 4 days, p < 0.001). Regarding quality indicators, there was no significant difference in the number of days of intravenous fluid administration, or days until advancement to enteral feeding, pain requiring opioid pain medication, or rates of surgical referral for cholecystectomy. Conclusions: Though the quality of care was similar in both groups, transferred patients had more severe AP with higher rates of systemic complications and ICU admissions and longer LOS, with no difference in quality indicators between groups.

Abstract 4136159: Determinants of Exercise Intolerance in Postural Orthostatic Tachycardia Syndrome: a Systematic Review

Background: Postural Orthostatic Tachycardia Syndrome (POTS) is a syndrome of an exaggerated heart rate (HR) response with standing, disproportionately affecting young women associated with exercise intolerance due to dizziness, palpitations, and/or chest pain. Research question: How does the exaggerated increase in HR with standing translate into impaired exercise tolerance in subjects with POTS? Aims: To systematically analyze determinants of exercise intolerance in subjects with POTS. Methods: We searched the National Library of Science and identifed 11 cohorts with a diagnosis of POTS and an assessment of exercise capacity. We abstracted the information including type of exercise testing, hemodynamics and gas exchange parameters (peak oxygen consumption [VO 2 ]) with exercise, and effect of interventions (if present). Results: We identified 849 subjects with POTS, female:male ratio of 8.5:1, 25±8 years, and 365 age-and sex-matched controls. A cycle ergometer was used in 8 studies (574 subjects, 68%) and a treadmill in 3 (275 subjects, 32%). Peak VO 2 was measured in 10 studies (836 subjects, 98%), and exercise hemodynamics in 9 (593 subjects, 70%). All 11 (100%) studies described a higher HR at rest and during submaximal exercise in subjects with POTS, with a similar slope of HR/load, and shorter time to peak HR. Of the 9 studies with hemodynamics, 6 (67%) reported a reduction in stroke volume (SV) with standing and with exercise, but only 1 (11%) documented a reduction in cardiac output (CO). Two studies (22%) enrolling teenagers showed a variable increase in SV and CO in POTS. Peak VO 2 was reduced in 8 (80%) studies when compared with predicted values, but only in 4 (40%) when compared with controls matched for deconditioning. Intravenous fluid administration in two studies did not affect HR, SV, CO or peak VO 2 . Exercise training in one study (19 subjects) and propranolol 20 mg in another study (11 subjects) led to improving peak VO 2 . Conclusions: An exaggerated HR response with standing and with exercise is a hallmark of POTS, a mechanism by which subjects reach a higher HR at lower workloads. While the increase in HR is associated with a reduction in SV, CO is typically maintained and occasionally increased, therefore making it an unlikely mechanism responsible for the peculiar exertional symptoms of POTS. Strategies that result in a reduction in HR may, on the other hand, translate in improved exercise capacity in subjects with POTS.

Abstract 4135212: An Overlap Between Takotsubo Cardiomyopathy and Hypertrophic Obstructive Cardiomyopathy Causing Dynamic Left Ventricular Outflow Tract Obstruction: A Unique Case Report

Background: Takotsubo cardiomyopathy (TC) can cause dynamic left ventricular outflow tract (LVOT) obstruction leading to cardiogenic shock. Due to differential wall-motion abnormalities, flow acceleration in the LVOT can lead to systolic anterior motion (SAM) of the mitral valve which worsens LVOT obstruction and leads to hemodynamic compromise. We present a case of overlap between TC and hypertrophic obstructive cardiomyopathy (HOCM) with worsening LVOT obstruction leading to cardiogenic shock. Case: A 76-year-old female presented with typical chest pain, nausea, and worsening shortness of breath. On examination, she was hypotensive and cold to touch. EKG showed T-wave inversions in lateral leads with elevated cardiac troponins. Coronary angiogram showed non-obstructive coronary artery disease, and right heart catheterization revealed elevated filling pressures. Transthoracic echocardiogram (TTE) showed septal hypertrophy and SAM of the mitral valve causing dynamic LVOT obstruction (Figure 1) and ejection fraction (EF) of 20%. TTE with contrast showed apical ballooning consistent with TC (Figure 2). Decision Making: Initially with diuresis, she became hypotensive so it was stopped and she received controlled intravenous fluids along with phenylephrine to reduce LVOT obstruction. Her blood pressure improved and she was started on low-dose metoprolol succinate along with ivabradine to reduce heart rate. She tolerated this therapy and hemodynamics stabilized. Conclusion: Cardiogenic shock can be a severe complication of TC. Early detection of LVOT obstruction in cardiogenic shock is important as traditional management strategies of increased inotropy and reduction of afterload can be fatal in these cases. The treatment strategy focuses on reducing the LVOT gradient and includes fluid administration to increase preload, beta-blockers to increase diastolic filling time, and vasopressors to raise afterload.

Predictors of Post-operative ABG Changes to Pre-operative Levels in Kidney Transplant Patients, a Cross-Sectional Study

Background: Kidney transplant is the treatment of choice for chronic renal failure (CRF), significantly improving patient outcomes. Fluid administration during surgery can lead to the accumulation of acid ions and electrolytes, inducing pH changes from the pre-operative to post-operative period, which may compromise transplant success. The impact of acid-base balance changes on transplant outcomes is crucial, yet research on predictors and arterial blood gas (ABG) changes post-kidney transplant is limited. Understanding ABG changes can enhance perioperative management, early detection of complications, and long-term graft function, thereby optimizing patient care and increasing transplant success rates. Objectives: To assess ABG changes before and after kidney transplant and identify predictors of post-operative acidosis in patients with renal failure through cross-sectional studies. Methods: In a retrospective cohort study, we included 97 patients who had undergone kidney transplant. During surgery, patients received crystalloid fluids, with 49 receiving only normal saline and 48 receiving only Ringer's lactate. Data collection involved the insertion of an arterial line after anesthesia induction, and the first ABG sample was obtained as a pre-operative measure. A post-operative measure was taken at the end of the surgery. Ethical considerations were followed throughout the study. Statistical analysis included paired t-test or Wilcoxon signed-rank test to compare pre- and post-operative ABG measures, with a significance level set at a P-value less than 0.05. Results: Total of 97 patients, which 65 (69.4%) were male and 32 (30.6%) were female and mean age was 38.6 ± 12.2. Variables significantly associated with post-op acidosis were fluid administered (OR: 3.25, 95% CI: 1.45 - 4.58), post-op central venous pressure (CVP) (OR: 2.31, 95% CI: 1.23 - 2.62, p &lt; 0.05), post-op base excess (BE) (OR: 2.16, 95% CI: 1.50 - 2.95, P &lt; 0.05). HCO₃ (P = 0.010), BE (P = 0.002), pH (P = 0.023) were significantly lower in the normal saline group compared to the Ringer's group. Post-op pH and BE was also associated with increased post-op CVP. Post-op acidosis and post-op CVP were significantly associated with post-op BE. Conclusions: Post-operative ABG changes, including decreases in pH and HCO3, are key indicators of transplant outcomes, reflecting graft function and patient stability. These findings highlight the critical need for prompt management of ABG abnormalities to optimize transplant success and minimize complications, making vigilant monitoring a vital part of post-transplant care.

Effect of buprenorphine delivered by target-controlled infusion on the minimum alveolar concentration of isoflurane in cats

ObjectiveTo characterize the effect of buprenorphine on the minimum alveolar concentration of isoflurane (MACiso) in cats. Study designRandomized, crossover experimental study. AnimalsA group of six healthy 2 to 8 years old male neutered cats, body mass 5.0 ± 0.3 kg. MethodsThe MACiso had been determined in each cat in a previous study. Cats were anesthetized with isoflurane in oxygen. Catheters were placed in a medial saphenous vein for drug and fluid administration and in a jugular vein for blood sampling. Buprenorphine was given intravenously using a target-controlled infusion system to reach and maintain plasma concentrations of 0.5, 1, 2, 4, 8, 16, 32 and 64 ng mL-1 and MACiso was determined in duplicate at each concentration using the tail clamp technique. Four target plasma buprenorphine concentrations were administered on each study day, with at least 2 weeks between experiments. Blood was sampled after the second MAC determination at each target for determination of plasma buprenorphine concentration. ResultsA significant effect of buprenorphine on MAC was found; however, pairwise comparisons to MACiso without buprenorphine did not reach statistical significance. Maximum reduction in MACiso in individual cats ranged from 2 to 34% at plasma buprenorphine concentrations ranging from 0.25 to 8.15 ng mL-1. Conclusions and clinical relevanceAlthough buprenorphine significantly affected MACiso in cats, the magnitude of the effect and the plasma concentration at which the largest effect occurred was highly variable among cats, limiting the clinical usefulness of buprenorphine as an agent to reduce MAC in cats.

Changes in portal pulsatility index induced by a fluid challenge in patients with haemodynamic instability and systemic venous congestion: a prospective cohort study

BackgroundIt is uncertain whether fluid administration can improve patients with systemic venous congestion and haemodynamic instability. This study aimed to describe the changes in systemic venous congestion and peripheral perfusion parameters induced by a fluid challenge in these patients, and to analyse the influence of the fluid responsiveness status on these changes.MethodsThe study is a single-centre prospective cohort study of 36 critically ill ICU patients with haemodynamic instability and a maximum vena cava diameter ≥ 20 mm. Changes in cardiac index during a fluid challenge (4 mL/kg of lactated Ringer’s solution during 5 min) assessed by pulse contour analysis, central venous pressure, ultrasound systemic congestion parameters (portal venous flow pulsatility index, supra hepatic and intrarenal venous Doppler), and peripheral perfusion parameters (capillary refill time and peripheral perfusion index) were assessed in the overall population. All these data were compared between patients presenting a cardiac index increase > 10% during the fluid challenge (fluid responders) and the others (fluid non-responders).ResultsTwenty-eight (78%) patients were admitted for postoperative care following cardiac surgery; their mean ± SD left ventricular ejection fraction was 42 ± 9% and right ventricular dysfunction was found in at least 61% of the patients. The mean ± SD SOFA score was 9 ± 3. Thirteen (36%) patients were fluid responders. The fluid challenge administration induced a significant increase in portal pulsatility index, VExUS score, and central venous pressure without significant difference of these changes between fluid responders and non-responders. No significant change in perfusion parameters was observed.ConclusionFluid administration in patients with haemodynamic instability and systemic venous congestion worsens venous congestion regardless of the fluid responsiveness status, without improving perfusion parameters.

The impact of spinal anesthesia on cardiac function in euvolemic vascular surgery patients: insights from echocardiography and biomarkers.

Existing evidence of the effect of spinal anesthesia (SA) on cardiac systolic function is scarce and inconclusive. This study aimed to evaluate the effects induced by a single injection of SA for elective vascular surgery on left (LV) and right (RV) ventricular systolic performance using transthoracic echocardiography (TTE). A prospective study. Single-center study, university hospital. Adult patients undergoing elective vascular surgery with SA. During patients' evaluations fluid administration was targeted using arterial waveform monitoring. All patients underwent TTE studies before and after SA induction for the assessment of indices reflective of LV and RV systolic function. Blood samples were drawn to measure troponin and brain natriuretic peptide (BNP) levels. A total of 62 patients (88.7% males, 71.00 ± 9.42 years) were included in the study. The primary outcome was the difference before and after SA in LV ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE). In total population, LVEF significantly increased after SA 53.07% [16.51]vs 53.86% [13.28]; p < 0.001). End-systolic volume (ESV, 69.50 [51.50] vs. 65.00 [29.50] ml; p < 0.001) decreased while stroke volume (SV) insignificantly increased (70.51 ± 16.70 vs. 73.00 ± 18.76ml; p = 0.131) during SA. TAPSE remained unchanged (2.23 [0.56] vs. 2.25 [0.69] mm; p = 0.558). In patients with impaired compared to those with preserved LV systolic function, the changes evidenced in LVEF (7.49 ± 4.15 vs. 0.59 ± 2.79; p < 0.001), ESV (-18.13 ± 18.20 vs-1.53 ± 9.09; p < 0.001) and SV (8.71 ± 11.96 vs-1.43 ± 11.89; p = 0.002) were greater. This study provides evidence that SA in patients undergoing elective vascular surgery improved LV systolic function, while changes in RV systolic function are minimal.

A case of frequent of prerenal acute kidney injury attacks: importance of recognizing systemic capillary leak syndrome: a case report.

Systemic capillary leak syndrome (SCLS) is a rare and life-threatening disorder. A man in his 60s presented for emergency care because of fatigue, decreased urine output and difficulty in moving his body. On admission, he was conscious, afebrile and had relative hypotension. Blood tests and urinary analysis revealed the following: white blood cell count, 19 500/μl; haematocrit, 64.5%; creatinine, 2.16 mg/dl; albumin, 3.3 g/dl; and 0.2% for fractional excretion of sodium. The patient was diagnosed with prerenal acute kidney injury (AKI) and was treated with intravenous fluid administration of more than 2 l/day. His kidney function gradually recovered after 4 days and creatinine decreased (1.15 mg/dl). However, he developed two more attacks of prerenal AKI during hospitalization, one of which needed intensive care unit management. Specific findings of hypotension, haemoconcentration, and hypoalbuminaemia were observed during all AKI attacks. Finally, he was diagnosed as idiopathic SCLS and was treated with intravenous immunoglobulin. SCLS might remain undiagnosed because of its rarity, but it can rapidly progress and lead to severe complications in absence of treatment. Clinicians need to consider this disease as a differential diagnosis when encountering patients who present with frequent prerenal AKI attacks accompanied by hypotension, haemoconcentration and hypoalbuminaemia.

The path to individualization of infusion therapy for emergency conditions according to the ROSE concept

The article is devoted to the role of intravenous fluid therapy in conditions of impaired fluid homeostasis, which often occur during major surgical interventions and critical conditions, such as sepsis and trauma. The importance of adequate fluid administration to maintain cellular homeostasis, as well as the management of conditions associated with hypovolemia and hemodynamic disturbances, is described. It is noted that, despite numerous studies, the topic of optimal fluid management strategies remains controversial, with potential risks of adverse effects of excessive fluid administration on clinical outcomes. The concept of liquid resuscitation ROSE is presented, which includes four stages: resuscitation, optimization, stabilization and evacuation. This concept will assist physicians in making decisions about fluid therapy management. Different types of fluids are reviewed, including balanced solutions and the multifunctional hyperosmolar solution Reosorbilact, and the importance of individualizing therapy based on the needs of each patient is emphasized. The importance of the need for careful monitoring and control of fluid balance is emphasized to avoid complications and ensure improved clinical outcomes

Comparison of the Effectiveness of Warmed Versus Room Temperature Intravenous Fluids Administration to Prevent Intraoperative Heat Loss in Anaesthetised Calves Undergoing Umbilical Herniorrhaphy.

Warmed intravenous (IV) fluids administration to prevent hypothermia provide controversial results in humans, cats and dogs, but its effect on calves is unknown. To evaluate the effectiveness of warmed IV fluids administered to prevent intraoperative heat loss in anaesthetised calves undergoing umbilical herniorrhaphy. Thirty Simmental breed calves (aged 10-30days) were randomly divided between two equal groups, wherein the infusion fluid (Ringer's lactate, 5mL/kg/h) was administered either at room temperature (Group RoT) or warmed (Group WF). Pulse rate (PR), respiratory rate (fR), peripheral haemoglobin oxygen saturation (SpO2) and rectal temperature (RT) were recorded immediately after the onset of anaesthesia induction (T0) at T5, T10, T15, T30, T45 and T60. Duration of anaesthesia, surgery time and recovery scores were also noted. The PR, RT and fR values showed no significant difference between groups over time (p>0.05). There was no significant difference in duration of anaesthesia, surgery time or recovery score between groups (p>0.05). The findings of the current study suggest that warmed IV fluid as the warming method did not prevent intraoperative hypothermia in calves. A constant-rate infusion of warmed fluid (5mL/kg/h) is insufficient to prevent intraoperative hypothermia in calves.

IMPACT OF ADVANCED HEMODYNAMIC MONITORING ON MYOCARDIAL REVASCULARIZATION SURGERY IN HIGH-RISK PATIENTS

Coronary artery bypass grafting is a critical procedure for patients with advanced coronary disease, especially those classified as high risk due to comorbidities such as heart failure, hypertension and diabetes. Advanced hemodynamic monitoring has proved essential in this context, allowing continuous and accurate surveillance of cardiac and vascular parameters, which can reduce intra- and post-operative complications. This abstract aims to assess the impact of advanced hemodynamic monitoring during coronary artery bypass graft surgery in high-risk patients. The aim is to explore the advantages of this type of monitoring, the technologies used and the benefits in terms of clinical outcomes and reduction of complications. This is a literature review with a qualitative approach, carried out in the PubMed, SciELO, LILACS, BVS and Google Scholar databases. In order to optimize the search, descriptors such as Hemodynamic Monitoring, Cardiac Surgery, High Risk Patients and Fluid Management were used. For time delimitation, the research considered publications between the years 2019 and 2022, a period that reflects the latest advances in hemodynamic monitoring technologies in high-risk cardiac surgeries. Advanced hemodynamic monitoring includes the use of devices such as the pulmonary artery catheter and non-invasive bioimpedance systems, which provide real-time data on cardiac output, blood pressure, oxygen saturation and systemic vascular resistance. In high-risk patients, these devices allow for precise adjustments in the administration of fluids and vasoactive drugs, promoting better hemodynamic stability. Studies indicate that this approach reduces the incidence of serious complications, such as cardiogenic shock and arrhythmias, optimizing post-operative recovery. Therefore, advanced hemodynamic monitoring is a crucial tool in CABG surgeries, especially for high-risk patients. Its implementation improves intraoperative management, reducing the risk of complications and promoting better clinical outcomes. Therefore, its use should be considered an integral part of strategies for complex cardiac surgeries.

Incidence, predictability, and outcomes of systemic venous congestion following a fluid challenge in initially fluid-tolerant preload-responders after cardiac surgery: a pilot trial

BackgroundFluid administration has traditionally focused on preload responsiveness (PR). However, preventing fluid intolerance, particularly due to systemic venous congestion (VC), is equally important. This study evaluated the incidence and predictability of VC following a 7 ml/kg crystalloid infusion in fluid-tolerant preload-responders and its association with adverse outcomes.MethodsThis single-center, prospective, observational study (May 2023–July 2024) included 40 consecutive patients who were mechanically ventilated within 6 h of intensive care unit (ICU) admission after elective open-heart surgery and had acute circulatory failure. Patients were eligible if they were both fluid-tolerant and preload-responsive. PR was defined as a ≥ 12% increase in left-ventricular outflow tract velocity time integral (LVOT-VTI) 1 min after a passive leg raising (PLR) test. VC was defined by a portal vein pulsatility index (PVPI) ≥ 50%. Patients received a 7 ml/kg Ringer’s Lactate infusion over 10 min. The primary outcome was the incidence of VC 2 min post-infusion (early-VC). Secondary outcomes included VC at 20 min, the incidence of acute kidney injury (AKI) and severe AKI at 7 days, and ICU length of stay (LOS).Results45% of patients developed early-VC, with VC persisting in only 5% at 20 min. One-third of patients developed AKI, with 17.5% progressing to severe AKI. The median ICU LOS was 4 days. Patients with early-VC had significantly higher central venous pressure, lower mean perfusion pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. While LVOT-VTI returned to baseline by 20 min in both groups, PVPI remained elevated in early-VC patients (p < 0.001). The LVOT-VTI versus PVPI regression line showed similar slopes (p = 0.755) but different intercepts (p < 0.001), indicating that, despite fluid tolerance and PR at baseline, early-VC patients had reduced right ventricular diastolic reserve (RVDR). Post-PLR PVPI predicted early-VC with an area under the curve of 0.998, using a threshold of 44.3% (p < 0.001).ConclusionPost-PLR PVPI effectively predicts fluid-induced early-VC in fluid-tolerant preload-responders, identifying those with poor RVDR. Its use can guide fluid management in cardiac surgery patients, helping to prevent unnecessary fluid administration and associated complications.Trial Registration: NCT06440772. Registered 30 May 2024. Retrospectively registered.

Practice of Fluid and Vasopressor Therapy in Critically Ill Invasively Ventilated Patients (PRoFLUID)-study protocol for an international multicenter observational cohort study.

The practice of intravenous fluid and vasopressor therapy in intensive care unit (ICU) patients, particularly in those who receive invasive ventilation, has been subject to change. Traditional approaches of 'early and liberal fluid administration' and 'late and restrictive vasopressor use' have been challenged, leading to recommendations for giving less fluids and earlier administration of vasopressors. Recommendations for fluid deresuscitation-active fluid removal-are absent. The global approach to fluid and vasopressor therapy in invasively ventilated patients is currently unclear. Our aim is to explore the practice of intravenous fluid and vasopressor therapy in invasively ventilated ICU patients in a study named 'Practice of Fluid and Vasopressor Therapy in Critically Ill Invasively Ventilated Patients' (PRoFLUID). PRoFLUID is an international, multicenter, observational cohort study in critically ill adult patients that are invasively ventilated for more than 24 hours. The outcomes include various aspects of fluid and vasopressor therapy, urine output and cumulative fluid balances. We will also collect duration of ventilation, lengths of stay and mortality in ICU and hospital. We expect to collect granular data on fluid and vasopressor therapy in a sample of at least 2,500 patients. PRoFLUID will provide useful insights into the practice of fluid and vasopressor therapy in invasively ventilated critically ill patients. PRoFLUID also allows us to determine whether geo-economic differences in management of intravenous fluid and vasopressor therapy exist, and allows for analyses of associations of aspects of fluid and vasopressor therapy with outcomes. Last but not least, its findings could feed sample size calculations of future randomized clinical trials of fluid and vasopressor therapy. In conclusion, PRoFLUID will collect data on fluid and vasopressor therapy in invasively ventilated ICU patients worldwide, providing insights that will guide future clinical decisions and randomized trial designs. ClinicalTrials.gov NCT05968066. Registered on August 1, 2023. Intensive care; invasive ventilation; fluid therapy; fluid management; vasopressor.

Use of a two-bag fluid administration protocol in the treatment of paediatric diabetic ketoacidosis: A retrospective review

ABSTRACT Objectives The ‘two-bag method’ for the treatment of diabetic ketoacidosis (DKA) uses two intravenous fluid bags, only one of which contains 10% dextrose. The bags are run concurrently with rates adjusted according to a rate change table to allow the relative amount of dextrose administered to be adjusted over time, without the need for bag replacements. The Children’s Hospital at London Health Sciences Centre (CHLHSC) two-bag protocol is a simplified version of that used by other centres. The objective of this study was to ensure implementation of the CHLHSC two-bag protocol continues to provide safe and effective treatment of paediatric DKA and decreases resource utilization. Methods This retrospective chart review compared treatment pre- and post-protocol implementation. Results A total of 22 admissions were included. No significant differences in efficacy or safety outcomes were found between the protocol groups. There was no statistically significant difference between the two and one-bag protocols in time to normalization of serum bicarbonate (13.80 ± 7.68 versus 15.01 ± 7.53 h, P = 0.714), blood glucose correction (8.75 ± 4.86 versus 11.85 ± 4.92 h, P = 0.152), and critical care unit length of stay (24.26 ± 9.94 versus 32.30 ± 13.36, P = 0.399). The nursing staff appeared to appropriately implement the rate change table, but the chart documentation was poor. Conclusions The CHLHSC simplified two-bag protocol provides a safe and effective alternative to the one-bag protocol for DKA correction in paediatric patients and may also result in decreased resource utilization.