Intravenous Fluid Administration Research Articles

Intravenous fluid therapy in hospitalized adult dengue patients without shock: Impact on subsequent severe dengue and potential adverse effects.

There is a lack of evidence on the optimal administration of intravenous (IV) fluids in hospitalized adult dengue patients without compensated and hypotensive shock. This study utilized a well-established cohort of dengue patients to compare risks of progressing to severe dengue (SD) over time for patients who were administered IV fluid versus others who were not. We included adult patients (n = 4781) who were hospitalized for dengue infection from 2005 to 2008. Cases were patients who developed SD (n = 689) and controls were patients who did not up until discharge (n = 4092). We estimated the hazardratios (HRs) and risk of SD over time between groups administered different volumes of IV fluids versus the no IV fluid comparison group using Cox models with time-dependent covariates. The doubly-robust estimation approach was used to control for the propensity of fluid administration given clinical characteristics of patients. Subgroup analyses by age, sex, and dengue warning signs before IV fluid administration were conducted. High (>2000 mL/day) IV fluids volume was associated with a higher risk of development of SD for those who had warning signs (HR: 1.77 [1.05-2.97], p: 0.0713) and for those below 55 years old (HR: 1.53 [1.04-2.25], p: 0.0713). Low (<1000 mL/day) IV fluids volume was protective against SD for patients without warning signs (HR: 0.757 [0.578-0.990], p: 0.0883), no lethargy (HR: 0.770 [0.600-0.998], p: 0.0847), and females (HR: 0.711 [0.516-0.980], p: 0.0804). Over the course of hospitalization, there were no significant differences in IV fluid administration and SD risk in most subgroups, except in those who experienced lethargy and were administered IV fluid volume or quantity. Administering high volumes of IV fluids may be associated with an increased risk of SD during hospitalization for adult dengue patients without shock. Judicious use of IV fluids as supportive therapy is warranted.

A Novel 3D-Printed Gravity-Independent Air-Eliminating Filter for Rapid Intravenous Infusions.

INTRODUCTION: The absence of a consistent downward G vector can make separation of gases from liquids challenging, such as in field medicine without stable upright equipment or during spaceflight. This limits the use of medical equipment and procedures like administration of intravenous (IV) fluids in microgravity and can make field medicine hazardous. Administering IV fluids and medications in microgravity requires a technique to separate air from the liquid phase. Current commercial filters for separation of gases are incompatible with high flow and blood. We present a novel filter designed to provide adequate air clearance without a consistent downward G vector.METHODS: Inline air-eliminating filters were designed for use with IV fluid tubing in microgravity using computer-aided design software and printed using nylon 12 on an EOS Selective Laser Sintering 3D printer. A 0.2-μm membrane filter was adhered around a central, hollow pillar with external spiral baffles allowing separation and venting of air from the fluid. Results were compared against commercially available inline air-eliminating filters.RESULTS: The 3D-printed filters outperformed the commercial filters in both percentage of air removed and flow rates. The centrifugal, baffled filter had flow rates that far exceeded the commercial filters during rapid transfusion.DISCUSSION: IV fluid administration is an often underappreciated and a necessary basic requirement for medical treatment. An air-eliminating filter compatible with blood and rapid transfusion was developed and validated with crystalloid solutions to allow the successful administration of IV fluid and medication without a consistent downward G vector.Formanek A, Townsend J, Ottensmeyer MP, Kamine TH. A novel 3D-printed gravity-independent air-eliminating filter for rapid intravenous infusions. Aerosp Med Hum Perform. 2024; 95(6):327-332.

Effect of lidocaine on intraoperative blood pressure variability in patients undergoing major vascular surgery

BackgroundDynamic fluctuations of arterial blood pressure known as blood pressure variability (BPV) may have short and long-term undesirable consequences. During surgical procedures blood pressure is usually measured in equal intervals allowing to assess its intraoperative variability, which significance for peri and post-operative period is still under debate. Lidocaine has positive cardiovascular effects, which may go beyond its antiarrhythmic activity. The aim of the study was to verify whether the use of intravenous lidocaine may affect intraoperative BPV in patients undergoing major vascular procedures.MethodsWe performed a post-hoc analysis of the data collected during the previous randomized clinical trial by Gajniak et al. In the original study patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive intravenous infusion of 1% lidocaine or placebo at the same infusion rate based on ideal body weight, in concomitance with general anesthesia. We analyzed systolic (SBP), diastolic (DBP) and mean arterial blood (MAP) pressure recorded in 5-minute intervals (from the first measurement before induction of general anaesthesia until the last after emergence from anaesthesia). Blood pressure variability was then calculated for SBP and MAP, and expressed as: standard deviation (SD), coefficient of variation (CV), average real variability (ARV) and coefficient of hemodynamic stability (C10%), and compared between both groups.ResultsAll calculated indexes were comparable between groups. In the lidocaine and placebo groups systolic blood pressure SD, CV, AVR and C10% were 20.17 vs. 19.28, 16.40 vs. 15.64, 14.74 vs. 14.08 and 0.45 vs. 0.45 respectively. No differences were observed regarding type of surgery, operating and anaesthetic time, administration of vasoactive agents and intravenous fluids, including blood products.ConclusionIn high-risk vascular surgery performed under general anesthesia, lidocaine infusion had no effect on arterial blood pressure variability.Trial registrationClinicalTrials.gov; NCT04691726 post-hoc analysis; date of registration 31/12/2020.

Fluid balance during acute phase extracorporeal cardiopulmonary resuscitation and outcomes in OHCA patients: a retrospective multicenter cohort study.

The association between fluid balance and outcomes in patients who underwent out-of-hospital cardiac arrest (OHCA) and received extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. We aimed to examine the above relationship during the first 24 h following intensive care unit (ICU) admission. We performed a secondary analysis of the SAVE-J II study, a retrospective multicenter study involving OHCA patients aged ≥ 18 years treated with ECPR between 2013 and 2018 and who received fluid therapy following ICU admission. Fluid balance was calculated based on intravenous fluid administration, blood transfusion, and urine output. The primary outcome was in-hospital mortality. The secondary outcomes included unfavorable outcome (cerebral performance category scores of 3-5 at discharge), acute kidney injury (AKI), and need for renal replacement therapy (RRT). Overall, 959 patients met our inclusion criteria. In-hospital mortality was 63.6%, and the proportion of unfavorable outcome at discharge was 82.0%. The median fluid balance in the first 24 h following ICU admission was 3673 mL. Multivariable analysis revealed that fluid balance was significantly associated with in-hospital mortality (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.02-1.06; p < 0.001), unfavorable outcome (OR, 1.03; 95% CI, 1.01-1.06; p = 0.005), AKI (OR, 1.04; 95% CI, 1.02-1.05; p < 0.001), and RRT (OR, 1.05; 95% CI, 1.03-1.07; p < 0.001). Excessive positive fluid balance in the first day following ICU admission was associated with in-hospital mortality, unfavorable outcome, AKI, and RRT in ECPR patients. Further investigation is warranted.

Teaching Ultrasound-Guided Venous Cannulation to Newly Qualified Doctors.

Background Venous cannulation is an essential taskthat allows the intravenous administration of fluids and medications. In the United Kingdom, this task is often performed by newly qualified Foundation Year 1 (FY1) doctors; however, difficulties are commonly encountered. The usage of ultrasound increases the chance of successful cannulation, provided the operator has been trained. Some medical schools now include ultrasound in their undergraduate curricula, though this is far from universal. Methods Forty-eight FY1s received a one-hour teaching session on ultrasound-guided venous cannulation, delivered by near-peer Education Fellows. FY1s completed questionnaires immediately after the teaching session, and a follow-up questionnaire three months later. Findings 44.44% of FY1s felt "fairly" or "very" confident in ultrasound-guided venous cannulation at follow-up, compared to 6.66% before the session. Sixty-three attempts were made in the month before the follow-up survey, compared to six in the month prior to the teaching session. The success rate at follow-up was 60% (38/63), up from 50% (3/6) prior to the session. One third fewer cannulas were escalated to senior doctors (72 vs 48), although there was little change in escalations to anesthetists, from 15 vs 18. FY1s identified the lack of ultrasound machines on the wards as a barrier to using ultrasound-guided venous cannulation more often. Conclusion A short, near-peer teaching session can improve FY1s' confidence, usage, and success rates in ultrasound-guided venous cannulation.

Monitoring of infusion therapy in patients with reduced cardiac reserve during abdominal operations

Background. In the pathogenesis of many intra- and postoperative complications, the composition, volume and rate of infusion therapy (IT) play a significant role. This problem is especially relevant for patients with concomitant chronic pathology of the cardiovascular, respiratory systems and kidneys. Informative indicators for assessing the correctness of IT and early diagnosis of intraoperative complications associated with errors in its implementation are complex monitoring of functional indicators of the cardiovascular and respiratory systems. Purpose – of the study is to investigate changes in biochemical markers of heart failure and ultrasound signs of venous stasis in two modes of infusion therapy (restrictive and liberal), on the basis of a comparative study, to determine the optimal mode of perioperative IT in patients undergoing elective surgery for diseases of the abdominal cavity and have comorbid pathology in the form of coronary heart disease (CHD) and heart failure (HF). Materials and Methods. 86 patients were included in a single-center, prospective, randomized study. All patients were randomly divided into two groups depending on the mode of intraoperative IT: in the first group (n = 44) – a restrictive mode of 5–8 ml/kg/hour was applied, in the second (n = 42) – a liberal mode. Echocardiography was performed at the stages of the study. Heart contractility, central hemodynamics, and ejection fraction were evaluated. An ultrasound scan of the inferior vena cava (IVC) was performed during breathing as a non-invasive method of assessing the intravascular blood volume. The diameter of the vein during inhalation and exhalation was evaluated. Based on the respiratory change in the diameter of the IVC, the caval index is calculated, which is expressed as a percentage. An index approaching 100% indicates near-complete collapse and probable volume depletion, while an index close to 0% indicates minimal collapse and intravascular overflow. Ultrasound of the lungs was performed according to the BLUE protocol with a convex sensor in 8 zones along the front chest wall. The severity of pulmonary congestion was assessed based on the sum of B-lines: 5 and less – no congestion, 6 to 15 – slight congestion, 15 to 29 – moderate, 30 and more – significant. Results. The conducted study shows the advantage of the restrictive regimen of IT in patients with concomitant coronary artery disease and minimal signs of congestive heart failure during abdominal surgical operations. The regime with restriction of intravenous fluid administration was better, as it reduces venous congestion, reduces the amount of fluid in the interstitial space of the lungs, causes a smaller compensatory reaction of the cardiovascular system to infusion with normal values of NT-proBNP. The task of the anesthesiologist in this case is careful control of daily and cumulative water balance, adequate monitoring of indicators of the cardiovascular system, use of modern ultrasound technologies and protocols for controlling volemic status, assessment of the dynamics of biomarkers of heart failure, which will allow complex abdominal operations to be safely performed in patients with reduced cardiac reserve. Conclusions. As a result of the conducted research, it was established that: the use of a liberal regimen of infusion therapy in the perioperative period in patients with coronary heart disease and HF I, I-II FC compared to a restrictive regimen leads to a statistically significant increase in biomarkers of heart failure and ultrasound signs of volemic overload. The restrictive regimen of IT in a dose of 5–8 ml/kg/hour, in comparison with a liberal one in a dose of 12–15 ml/kg/hour, can be recognized as optimal and safe in patients with coronary heart disease and HF I, I-II FC during surgery on the organs of the abdominal cavity. The use and widespread implementation in practice of complex determination of the level of the amino-terminal prohormone of brain natriuretic peptide (NT-proBNP) NT-proBNP, non-invasive methods of ultrasound of the heart – echocardiography, ultrasound of the lungs and central vessels – assessment of the dynamic filling of the inferior vena cava (IVC) allows significantly supplement clinical information on volemic status, venous stasis, contractility of the heart and fluid retention in the interstitial space of the lungs and may be key in the prevention of cardiac complications in this category of patients.

Developing a Clinically Relevant Hemorrhagic Shock Model in Rats.

Over the recent decades, the development of animal models allowed us to better understand various pathologies and identify new treatments. Hemorrhagic shock, i.e., organ failure due to rapid loss of a large volume of blood, is associated with a highly complex pathophysiology involving several pathways. Numerous existing animal models of hemorrhagic shock strive to replicate what happens in humans, but these models have limits in terms of clinical relevance, reproducibility, or standardization. The aim of this study was to refine these models to develop a new model of hemorrhagic shock. Briefly, hemorrhagic shock was induced in male Wistar Han rats (11-13 weeks old) by a controlled exsanguination responsible for a drop in the mean arterial pressure. The next phase of 75 min was to maintain a low mean arterial blood pressure, between 32 mmHg and 38 mmHg, to trigger the pathophysiological pathways of hemorrhagic shock. The final phase of the protocol mimicked patient care with an administration of intravenous fluids, Ringer Lactate solution, to elevate the blood pressure. Lactate and behavioral scores were assessed 16 h after the protocol started, while hemodynamics parameters and plasmatic markers were evaluated 24 h after injury. Twenty-four hours post-hemorrhagic shock induction, the mean arterial and diastolic blood pressure were decreased in the hemorrhagic shock group (p< 0.05). Heart rate and systolic blood pressure remained unchanged. All organ damage markers were increased with the hemorrhagic shock (p < 0.05). The lactatemia and behavioral scores were increased compared to the sham group (p < 0.05). In conclusion, we demonstrated that the protocol described here is a relevant model of hemorrhagic shock that can be used in subsequent studies, particularly to evaluate the therapeutic potential of new molecules.

Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy

ObjectiveThe current study used a composite outcome to investigate whether applying the ERAS protocol would enhance the recovery of patients undergoing laparoscopic total gastrectomy (LTG).ExposuresLaparoscopic total gastrectomy and perioperative interventions were the exposure. An ERAS clinical pathway consisting of 14 items was implemented and assessed. Patients were divided into either ERAS-compliant or non-ERAS-compliant group according the adherence above 9/14 or not.Main outcomes and measuresThe primary study outcome was a composite outcome called ‘optimal postoperative recovery’ with the definition as below: discharge within 6 days with no sever complications and no unplanned re-operation or readmission within 30 days postoperatively. Univariate logistic regression analysis and multivariate logistic regression analysis were used to model optimal postoperative recovery and compliance, adjusting for patient-related and disease-related characteristics.ResultsA total of 252 patients were included in this retrospective study, 129 in the ERAS compliant group and 123 in the non-ERAS-compliant group. Of these, 79.07% of the patients in ERAS compliant group achieved optimal postoperative recovery, whereas 61.79% of patients in non-ERAS-compliant group did (P = 0.0026). The incidence of sever complications was lower in the ERAS-compliant group (1.55% vs. 6.5%, P = 0.0441). No patients in ERAS compliant group had unplanned re-operation, whereas 5.69% (7/123) of patients in non-ERAS-compliant group had (p = 0.006). The median length of the postoperative hospital stay was shorter in the in the ERAS compliant group (5.51 vs. 5.68 days, P = 0.01). Both logistic (OR 2.01, 95% CI 1.21–3.34) and stepwise regression (OR 2.07, 95% CI 1.25–3.41) analysis showed that high overall compliance with the ERAS protocol facilitated optimal recovery in such patients. In bivariate analysis of compliance for patients who had an optimal postoperative recovery, carbohydrate drinks (p = 0.0196), early oral feeding (P = 0.0043), early mobilization (P = 0.0340), and restrictive intravenous fluid administration (P < 0.0001) were significantly associated with optimal postoperative recovery.Conclusions and relevancePatients with higher ERAS compliance (almost 70% of the accomplishment) suffered less severe postoperative complications and were more likely to achieve optimal postoperative recovery.

Factors related to nurse compliance in monitoring infusion fluid in hospital

Infusion therapy involves the intravenous administration of drugs, fluids, and blood products to hospitalized clients. This study aimed to identify factors influencing nurse compliance in monitoring infusion fluids according to Standard Operating Procedures (SOPs). The research adopted a quantitative approach with a descriptive correlational design and a cross-sectional approach, focusing on a study population of 50 nurses. Data collection utilized observation techniques and questionnaires as research instruments, with the analysis employing Kendall's Tau B and Kendall's Tau C methods. The findings revealed significant correlations between age (p-value=0.000), education (p-value=0.006), career path level (p-value=0.013), and knowledge (p-value=0.011). However, there was no significant relationship between the length of work experience and nurse compliance in monitoring infusion fluids (p-value=0.257) according to SOPs in this private hospital. To enhance the quality of care, it is recommended that nurses receive additional training provided by the nursing education team at the hospital, focusing specifically on the monitoring of infusion fluids. This targeted training could contribute to reducing instances of complaints related to mismatched patient needs and ultimately improve compliance with established SOPs in infusion therapy.

A comparative study of postoperative acidemia after intraoperative administration of balanced crystalloid (Plasma-lyte A@) versus 0.9% sodium chloride in gastrointestinal surgery

Background: The administration of intravenous fluids is one of the most common and universal interventions in medicine. Fluid therapy is the most challenging and debated aspect of perioperative care. Plasma-lyte A® Injection (multiple electrolytes injection, type 1, USP) is indicated as a source of water and electrolytes or as an alkalinizing agent. 0.9% sodium chloride is an isotonic crystalloid solution having a sodium concentration higher is useful in replacing fluid and electrolyte loss. Aims and Objectives: The study was designed to compare the effects of intraoperative administration of balanced crystalloid solution (Plasma-Lyte A®) and 0.9% NaCl on acid-base balance in the post-operative period in patients undergoing gastrointestinal surgery. Materials and Methods: Eighty consenting patients of ASA-l and ASA-II who underwent Gastrointestinal surgery were at first randomly allocated to 2 groups. One group received Plasma-Lyte A® as the sole crystalloid and the other group received 0.9% sodium chloride. Results: Serum Na+ conc. of the groups were comparable and no difference was shown at the time of induction, but postoperatively at 12 h, there was a significant increase in group 2. There was no significant difference in serum K+ concentration in both the groups except at 6 h postoperatively when there was an increase in K+ concentration in group 1. Serum Cl− concentration was having no significant difference at the time of induction and 1 h intraoperative, but postoperatively at 1, 6, and 12 h the Cl− concentration significantly increased in group 2. HCO3− concentration of the two groups had no difference between them throughout the study period. The pH of patients in both the groups showed no statistically significant difference during the entire procedure (P&gt;0.05). A significant decrease in pH observed in 0.9% sodium chloride group in comparison to Plasma-Lyte® group when the duration of surgery increased to more than 120 min. Conclusion: Both plasma-lyte A and 0.9% sodium chloride can be used safely as intravenous infusion fluid without altering pH status and blood electrolyte concentration in patients undergoing gastrointestinal surgery.

Rising Inpatient Utilization and Costs of Cannabis Hyperemesis Syndrome Hospitalizations in Massachusetts After Cannabis Legalization.

We described the demographics, inpatient utilization, and cost of services among patients hospitalized for putative cannabinoid hyperemesis syndrome (CHS) predating and postdating cannabis legalization in Massachusetts. As the recreational use of cannabis has been widely legalized nationally, the resulting shifts in clinical presentation, health care utilization, and estimated costs of CHS hospitalizations remain unclear in the postlegalization era. We performed a retrospective cohort study among patients admitted to a large urban hospital between 2012 and 2021, before and after the date of cannabis legalization in Massachusetts (Dec 15, 2016). We examined the demographic and clinical characteristics of patients admitted for putative CHS, the utilization of hospital services, and estimated inpatient costs pre and postlegalization. We identified a significant increase in putative CHS hospitalizations pre and post-cannabis legalization in Massachusetts (0.1% vs 0.02% of total admissions per time period, P < 0.05). Across 72 CHS hospitalizations, patient demographics were similar pre and postlegalization. Hospital resource utilization increased postlegalization, with increased length of stay (3 d vs 1 d, P < 0.005), and need for antiemetics ( P < 0.05). Multivariate linear regression confirmed that postlegalization admissions were independently associated with increased length of stay ( Β = 5.35, P < 0.05). The mean cost of hospitalization was significantly higher postlegalization ($18,714 vs $7460, P < 0.0005), even after adjusting for medical inflation ($18,714 vs $8520, P < 0.001) with intravenous fluid administration and endoscopy costs increased ( P < 0.05). On multivariate linear regression, hospitalization for putative CHS during postlegalization predicted increased costs ( Β = 10,131.25, P < 0.05). In the postlegalization era of cannabis in Massachusetts, we found increased putative CHS hospitalizations, with a concomitant increased length of hospital stay and total cost per hospitalization. As cannabis use increases, the recognition and costs of its deleterious effects are necessary to incorporate into future clinical practice strategies and health policy.

The Prevalence and Associated Factors of Peripheral Intravenous Complications in a Thai Hospital.

Complications of peripheral intravenous catheters (PIVCs) remain a major contributor to health care costs and are a patient safety problem. The objective of this cross-sectional descriptive study was to examine the prevalence of complications and factors associated with complications from peripheral intravenous fluid administration. The study was conducted at a tertiary care hospital in Thailand. The instruments were developed from the literature review. Data were analyzed using SPSS statistics, version 22. The study examined 441 patients with a total of 497 PIVC sites. Phlebitis (level 1 and 2 only) occurred at 2.41% of all sites; infiltration (level 1 and 2 only) occurred at 1.01% of all sites, and extravasation (mild and moderate only) occurred at 0.60% of all sites. Factors associated with the occurrence of infiltration complications included receiving intravenous (IV) crystalloids (P = .03) and receiving IV analgesic drugs (P = .001). Age was statistically significantly related to extravasation complications (P = .001). Nurses should be aware of possible complications from peripheral intravenous fluid administration, especially in older patients and those receiving IV crystalloids or analgesic drugs.

Prehospital care and interfacility transfer of trauma patients before reaching the emergency of a level-1 trauma care center.

Management of trauma patients includes prevention, prehospital care, appropriate resuscitation at a hospital, definitive treatment, and rehabilitation. Timely and adequate care for a trauma patient is paramount, which can dramatically impact survival. This study was planned to assess the proportion of patients who failed to receive adequate prehospital care before reaching our institute. A retrospective study was conducted in the trauma and emergency department of a level-1 trauma center in eastern India from February to April 2022. The demographic profile, vital parameters, injury, mode of transport, travel duration, referring hospital, and any interventions as per airway/breathing/circulation/hypothermia were collected. The records of a hundred-two patients who were brought to the trauma and emergency department in the study period were reviewed. Road traffic accident involving two wheelers was the leading cause of injury. Eighty-three percent of the patients were referred from other health centers, of which 49 were referred from district headquarters hospitals. Only three patients out of 14 had been provided with an oropharyngeal airway for whom endotracheal intubation was indicated. Only one among the 41 patients needing Philadelphia collar actually received. Sixteen patients were provided supplemental oxygen out of the 35 for whom it was indicated. Out of 68 patients in whom intravenous cannulation and fluid administration were indicated, only 35 patients had received it. Out of 31 patients with fractures, none were provided immobilization. The care of the trauma patients with respect to airway, breathing, circulation, and fracture immobilization was found to be grossly inadequate, emphasizing the need of structured and protocol based prehospital trauma care.

Emergency department visits in the United States by adults with a complaint of diarrhea (2016-2021).

For adults with a complaint of diarrhea presenting to United States emergency departments (EDs) from 2016 to 2021, we examined the: (1) occurrence and temporal trends in these ED visits, (2) frequency with which services were provided (laboratory testing, radiologic imaging, and intravenous fluids (IV fluids) administration) and patients were admitted; and (3) factors associated with service provision and admission. Data from the National Hospital Ambulatory Medical Care Survey (2016-2021) were analyzed. Multivariable logistic regression modeling was employed to examine factors associated with service provision and admission, according to patient demographic characteristics, healthcare insurance status, and associated clinical symptoms; ED geographic location; and type of ED medical staff who evaluated the patient. From 2016 to 2017, there were 3.3-3.7 million ED visits/year by adults with a complaint of diarrhea (3.1% [95% CI 2.9-3.3] of all adult US ED visits). Services were provided and patients were admitted per these frequencies: complete blood count (80%; 95% CI 76-83); blood culture (8%; 95% CI 6-9); metabolic panel (94%; 95% CI 86-97); ultrasound (8%; 95% CI 7-10); abdominal/pelvic CT (33%; 95% CI 29-35); IV fluids (63%; 95% CI 50-66); and admission (16%; 95% CI 14-18). Factors associated with receipt of these services and admission included other presenting symptoms (abdominal pain, vomiting, and nausea), ED geographic location, ED medical staff member evaluating the patient, race, Hispanic ethnicity, and type of health insurance. For adult patients presenting to US EDs with a complaint of diarrhea, US EDs highly utilized selected laboratory tests and radiologic imaging. Differences in utilization raise concerns about equitable healthcare delivery and call for further investigation into the underlying reasons, as well as the development and adoption of standardized care pathways.

Application and control of intravenous fluids in German intensive care units : Anational survey among critical care physicians

The administration of intravenous fluids includes various indications, e.g., fluid replacement, nutritional therapy or as asolvent for drugs and is acommon routine in the intensive care unit (ICU); however, overuse of intravenous fluids can lead to fluid overload, which can be associated with a poorer outcome in critically ill patients. The aim of this survey was to find out the current status of the use and management of intravenous fluids as well as the interprofessional cooperation involving clinical pharmacists on German ICUs. An online survey with 33questions was developed. The answers of 62participants from the Scientific Working Group on Intensive Care Medicine of the German Society for Anesthesiology and Intensive Care Medicine were evaluated. Fluid overload occurs "frequently" in 62.9% (39/62) and "very frequently" in 9.7% (6/62) of the ICUs of respondents. An established standard for an infusion management system is unknown to 71.0% (44/62) of participants and 45.2% of the respondents stated that they did not have apatient data management system. In addition, the participants indicated how they define fluid overload. This was defined by the presence of edema by 50.9% (28/55) and by positive fluid balance by 30.9% (17/55). According to the participants septic patients (38/60; 63.3%) and cardiological/cardiac surgical patients (26/60; 43.3%) are most susceptible to the occurrence of fluid overload. Interprofessional collaboration among intensive care physicians, critical care nurses, and clinical pharmacists to optimize fluid therapy was described as "relevant" by 38.7% (24/62) and "very relevant" by 45.2% (28/62). Participants with clinical pharmacists on the wards (24/62; 38.7%) answered this question more often as "very relevant" with 62.5% (15/24). Fluid overload is afrequent and relevant problem in German intensive care units. Yet there are few established standards in this area. There is also alack of validated diagnostic parameters and aclear definition of fluid overload. These are required to ensure appropriate and effective treatment that is tailored to the patient and adapted to the respective situation. Intravenous fluids should be considered as drugs that may exert side effects or can be overdosed with severe adverse consequences for the patients. One approach to optimize fluid therapy could be achieved by afluid stewardship corresponding to comparable established procedures of the antibiotic stewardship. In particular, fluid stewardship will contribute to drug safety of intravenous fluids profiting from joined expertise in asetting of interprofessional collaboration. An important principle of fluid stewardship is to consider intravenous fluids in the same way as medication in terms of their importance. Furthermore, more in-depth studies are needed to investigate the effects of interprofessional fluid stewardship in aprospective and controlled manner.

Fluid management based on renal function considerations

Intravenous fluid administration is one of the most commonly used interventions in acutely ill patients. Almost all hospitalized patients receive intravenous fluids for either volume resuscitation or as diluents for drug administration. However, recent studies suggest that fluid overload is associated with acute kidney injury and that fluid administration beyond the volume needed to correct the fluid deficit is associated with increased morbidity, longer hospital stays, and mortality. The exact cause and effect underlying this association remains uncertain. Previous studies have reported a correlation between fluid overload and mortality in critically ill patients with acute respiratory distress syndrome, acute lung injury, sepsis, and acute kidney injury. In patients with acute kidney injury, a higher percentage of fluid overload has been associated with higher mortality and shorter ventilator-free days starting during the initial management in the intensive care unit. Similarly, in a large multicenter study, a positive fluid balance was an important factor associated with increased 60-day mortality in patients with acute kidney injury. This review analyzes the use of intravenous fluids and renal function, including types of intravenous fluid, cumulative fluid targets, endpoint hemodynamic indicators, and renal replacement therapy for acute kidney injury.&#x0D; &#x0D; Key words: volume status, intravenous fluids, fluid balance, acute kidney injury, volume excess

Efficacy and safety of linaclotide in treating functional constipation in paediatric patients: a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial

Linaclotide, a guanylate cyclase C agonist, has been approved in the USA for the treatment of chronic idiopathic constipation and irritable bowel syndrome with predominant constipation in adults. We aimed to assess the efficacy and safety of linaclotide in paediatric patients aged 6-17 years with functional constipation. This randomised, double-blind, placebo-controlled, multicentre, phase 3 study was done at 64 clinic or hospital sites in seven countries (USA, Canada, Israel, Italy, the Netherlands, Ukraine, and Estonia). Patients aged 6-17 years who met modified Rome III criteria for functional constipation were randomly assigned (1:1), with a block size of four and stratified by age (6-11 years and 12-17 years), to receive either oral linaclotide 72 μg or placebo once daily for 12 weeks. Participants, investigators, and data assessors were masked to assignment. The primary efficacy endpoint was change from baseline (CFB) in the 12-week frequency rate of spontaneous bowel movements (SBMs; occurring in the absence of rescue medication on the calendar day of or before the bowel movement) per week and the secondary efficacy endpoint was CFB in stool consistency over the 12-week treatment period; efficacy and safety were analysed in all patients in the randomised population who received at least one dose of study intervention (modified intention-to-treat population and safety population, respectively). The study is registered with ClinicalTrials.gov, NCT04026113, and the functional constipation part of the study is complete. Between Oct 1, 2019, and March 21, 2022, 330 patients were enrolled and randomly assigned to linaclotide (n=166) or placebo (n=164). Two patients in the linaclotide group did not receive any treatment; thus, efficacy and safety endpoints were assessed in 328 patients (164 patients in each group). 293 (89%) patients completed the 12-week treatment period (148 in the linaclotide group and 145 in the placebo group). 181 (55%) of 328 patients were female and 147 (45%) were male. At baseline, the mean frequency rate for SBMs was 1·28 SBMs per week (SD 0·87) for placebo and 1·16 SBMs per week (0·83) for linaclotide, increasing to 2·29 SBMs per week (1·99) for placebo and 3·41 SBMs per week (2·76) for linaclotide during intervention. Compared with placebo (least-squares mean [LSM] CFB 1·05 SBMs per week [SE 0·19]), patients treated with linaclotide showed significant improvement in SBM frequency (LSM CFB 2·22 SBMs per week [0·19]; LSM CFB difference 1·17 SBMs per week [95% CI 0·65-1·69]; p<0·0001). Linaclotide also significantly improved stool consistency over placebo (LSM CFB 1·11 [SE 0·08] vs 0·69 [0·08]; LSM CFB difference 0·42 [95% CI 0·21-0·64]; p=0·0001). The most reported treatment-emergent adverse event (TEAE) by patients treated with linaclotide was diarrhoea (seven [4%] of 164 vs three [2%] of 164 patients in the placebo group) and by patients treated with placebo was COVID-19 (five [3%] vs four [2%] in the linaclotide group). The most frequent treatment-related TEAE was diarrhoea (linaclotide: six [4%] patients; placebo: two [1%] patients). One serious adverse event of special interest (treatment-related severe diarrhoea resulting in dehydration and hospitalisation) occurred in a female patient aged 17 years in the linaclotide group; this case resolved without sequelae after administration of intravenous fluids. No deaths occurred during the study. Linaclotide is an efficacious and well tolerated treatment for functional constipation in paediatric patients and has subsequently been approved by the US Food and Drug Administration for this indication. AbbVie and Ironwood Pharmaceuticals.

Factors that impact on the quality of life of intestinal failure patients treated with home parenteral nutrition: protocol for a multicentre, longitudinal observational study

BackgroundHome parenteral nutrition (HPN) refers to the intravenous administration of macronutrients, micronutrients and fluid. The aims of treatment are to increase survival and improve quality of life (QoL). However, patients...

Effect of hyperchloremia on mortality of pediatric trauma patients: a retrospective cohort study.

Hyperchloremia is often encountered due to the frequent administration of intravenous fluids in critically ill patients with conditions such as shock or hypotension in the pediatric intensive care unit, and high serum levels of chloride are associated with poor clinical outcomes. This study aimed to determine the association between hyperchloremia and in-hospital mortality in pediatric patients with major trauma. This retrospective cohort study was conducted at a tertiary university hospital in Turkey. Data were collected between March 2020 and April 2022. Patients aged 1 month to 18 years with major trauma who received intravenous fluids with a concentration > 0.9% sodium chloride were enrolled. Hyperchloremia was defined as a serum chloride level > 110 mmol/L. Clinical and laboratory data were compared between the survivors and nonsurvivors. The mortality rate was 23% (n = 20). The incidence of hyperchloremia was significantly higher in nonsurvivors than in survivors (P = 0.05). In multivariate logistic analysis, hyperchloremia at 48 h was found to be an independent risk factor for mortality in pediatric patients with major trauma. In pediatric patients with major trauma, hyperchloremia at 48-h postadmission was associated with 28-day mortality. This parameter might be a beneficial prognostic indicator.

Sepsis epidemiology in Australian and New Zealand children (SENTINEL): protocol for a multicountry prospective observational study

IntroductionSepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and...