Administration Of Large Volumes Research Articles

A Pilot Study on the Association Between Early Fluid Status Indicators After Kidney Transplantation and Graft Function Recovery

Progress in short-term kidney graft survival has decreased since 2000 which suggests an unmet need for innovation regarding early kidney graft function optimization.1 Previous studies have revealed that optimal perioperative fluid therapy was associated with a lower incidence of delayed graft function after kidney transplantation.2–4 Contrary to earlier studies, large volume administration is no longer recommended, and an individualized approach is now encouraged to balance the graft perfusion and the possible complications of fluid overload.

Acute intensive care unit resuscitation of severely injured trauma patients: Do we need a new strategy?

Unlike recent advances in blood product resuscitation, intravenous crystalloid (IVF) use after intensive care unit (ICU) admission in hemorrhagic shock has received less attention and current recommendations are based on limited evidence. To address this knowledge gap, we aimed to determine associations between IVF administration during acute ICU resuscitation and outcomes. We hypothesized that larger IVF volumes are associated with worse outcomes. We linked our trauma registry with electronic health record data (2012-2015) to identify adults with an initial lactate level of ≥4 mmol/L and documented lactate normalization (≤2 mmol/L), excluding those with isolated head Abbreviated Injury Scale score ≥3. We focused on the period from ICU admission to lactate normalization, analyzing duration, volume of IVF, and proportion of volume as 1-L boluses. We used linear regression to determine associations with ICU length of stay and duration of mechanical ventilation in survivors, and logistic regression to identify associations with acute kidney injury and home discharge while adjusting for important covariates. We included 337 subjects. Median time to lactate normalization was 15 hours (interquartile range, 7-25 hours), and median IVF volume was 3.7 L (interquartile range, 1.5-6.4 L). The fourfold difference between the upper and lower quartiles of both duration and volume remained after stratifying by injury severity. Hourly volumes tapered over time but persistently aggregated at 0.5 and 1 L, with 167 subjects receiving at least one 0.5-L bolus for 6 hours after ICU admission. Administration of larger volumes was associated with longer ICU length of stay and duration of mechanical ventilation, as well as acute kidney injury. There is substantial variation in volume administered during acute ICU resuscitation, both absolutely and temporally, despite accounting for injury severity. Administration of larger volumes during acute ICU resuscitation is associated with worse outcomes. There is an opportunity to improve outcomes by further investigating and standardizing this important phase of care. Therapeutic/care management, level IV.

Clinical Practice Experience with HyQvia in Adults Using Alternative Dosing Regimens and Pediatric Patients: A Retrospective Study.

IntroductionHyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) was developed to combine the advantages of intravenous and subcutaneous immune globulin (SCIG), allowing administration of larger volumes at a single subcutaneous site with less frequent dosing when compared to other SCIG products. Current US prescribing guidelines for HyQvia are limited to adults and do not encompass the flexibility required to achieve success in all patients with primary immunodeficiency (PID).MethodsThis retrospective study was designed to evaluate the clinical experience of treating patients with PID with HyQvia regimens outside of package insert recommendations as well as in pediatric patients. Data were abstracted from 38 patient records (317 HyQvia infusions), including five patients less than 16 years of age, from seven US immunology clinics.ResultsAmong 37 patients receiving HyQvia regimens differing from prescribing guidelines, the most notable variations included shorter ramp-up periods, use of two rather than one infusion site, and slower than maximal infusion rates to mitigate local adverse events (AEs). The medication volume infused for single site doses ranged from 75 to 200 mL and doses split between two sites ranged from 100 to 750 mL. The most common type of regimen variation was a condensed ramp-up phase (shorter schedule, higher doses), and 96% (24/25) of patients managed in this way completed ramp-up. The most common ramp-up schedule was three infusions (one at 25–45%, another at 50–75%, and the final at 100% of target dose) spread over 2–4 weeks.ConclusionsA shorter ramp-up schedule did not appear to increase the number of AEs compared to standard ramp-up schedules. For patients with AEs, slower infusion rates and the use of two sites may improve medication tolerability. Four of five pediatric patients reported no AEs, and only one discontinued, stating a fear of needles. HyQvia may be tailored to adults requiring alternative rates, ramp-up, and/or dosing regimens and may be especially well-suited to children.Electronic supplementary materialThe online version of this article (10.1007/s12325-020-01264-7) contains supplementary material, which is available to authorized users.

Large volume infusions of hydroxyethyl starch during cardiothoracic surgery may be associated with postoperative kidney injury: propensity-matched analysis

BackgroundThe safety of intraoperative administration of hydroxyethyl starch (HES) has been debated. We hypothesized that intraoperative use of HES is associated with postoperative acute kidney injury (AKI) following cardiopulmonary bypass (CPB).Materials and methodsPatients who underwent cardiothoracic surgery using CPB between 2007 and 2014 were retrospectively reviewed. The incidence of AKI within 7 days after surgery, defined by the Kidney Disease Improving Global Outcome criteria, was compared for patients who did or did not receive 6% (70/0.5) or 6% (130/0.4) HES for anesthesia management before or after CPB. Multivariable logistic regression and propensity matching analysis were performed to examine whether use of HES is associated with postoperative AKI. Outcomes comparing patients receiving HES ≥ 1000 mL and < 1000 mL were also compared.ResultsData from 1976 patients were reviewed. All patients received 70/0.5 HES as a part of the priming solution for CPB. The incidence of postoperative AKI was 28.2% in patients who received HES and 26.0% in patients who did not (p = 0.33). In multivariable analysis, there was no correlation between the use of HES and the incidence of AKI (odds ratio 0.87, 95% CI 0.30–2.58, p = 0.81). Propensity matching showed that the incidence of AKI was not significantly different between 481 patients administered with HES and 962 patients (26.6% vs. 26.9%, p = 0.95) who did not receive HES for anesthesia management. However, peak creatinine levels, needed for renal replacement therapy, and in-hospital mortality were higher, and 28-day hospital-free days were lower in patients receiving HES ≥ 1000 mL than those receiving HES < 1000 mL (p < 0.05).ConclusionsIntraoperative use of HES was not associated with postoperative AKI following CPB. However, administration of large volumes of HES may be associated with kidney-related adverse clinical outcomes.

Association between fluid management and dilutional coagulopathy in severe postpartum haemorrhage: a nationwide retrospective cohort study

BackgroundThe view that 2 l of crystalloid and 1.5 l of colloid can be infused while awaiting compatible blood for patients with major postpartum haemorrhage is based on expert opinion documents. We describe real-world changes in levels of coagulation parameters after the administration of different volumes of clear fluids to women suffering from major postpartum haemorrhage.MethodsWe performed a nationwide retrospective cohort study in the Netherlands among 1038 women experiencing severe postpartum haemorrhage who had received at least four units of red cells or fresh frozen plasma or platelets in addition to red cells. The volume of clear fluids administered before the time of blood sampling was classified into three fluid administration strategies, based on the RCOG guideline: < 2 L, 2–3.5 L and > 3.5 L. Outcomes included haemoglobin, haematocrit, platelet count, fibrinogen, aPTT and PT levels.ResultsHaemoglobin, haematocrit, platelet count, fibrinogen and aPTT were associated with volumes of clear fluids, which was most pronounced early during the course of postpartum haemorrhage. During the earliest phases of postpartum haemorrhage median haemoglobin level was 10.1 g/dl (IQR 8.5–11.6) among the women who received < 2 L clear fluids and 8.1 g/dl (IQR 7.1–8.4) among women who received > 3.5 L of clear fluids; similarly median platelet counts were 181 × 109/litre (IQR 131–239) and 89 × 109/litre (IQR 84–135), aPTT 29 s (IQR 27–33) and 38 s (IQR 35–55) and fibrinogen 3.9 g/L (IQR 2.5–5.2) and 1.6 g/L (IQR 1.3–2.1).ConclusionsIn this large cohort of women with severe postpartum haemorrhage, administration of larger volumes of clear fluids was associated with more severe deterioration of coagulation parameters corresponding to dilution. Our findings provide thus far the best available evidence to support expert opinion-based guidelines recommending restrictive fluid resuscitation in women experiencing postpartum haemorrhage.Trial registrationNetherlands Trial Register (NTR4079), registration date July 17, 2013.

Double trouble: managing diabetic emergencies in patients with heart failure

Double trouble: managing diabetic emergencies in patients with heart failure

Rapid Push vs Pump-Infused Subcutaneous Immunoglobulin Treatment: a Randomized Crossover Study of Quality of Life in Primary Immunodeficiency Patients

PurposeSubcutaneous immunoglobulin replacement therapy (IgRT) may be administered once a week with a pump or every other day with a syringe (rapid push). The objective of the study was to compare the impact of pump and rapid push infusions on patient’s life quality index (LQI).MethodsThis study was a randomized, crossover, multicenter, non-inferiority trial conducted in adults with primary immunodeficiency (PID) accustomed to weekly infusions at home by pump. Patients used pump or rapid push for 3 months each according to the randomized sequence. Main criterion was PID-LQI factor I (treatment interference). Non-inferiority ratio was set at 90%.ResultsThirty patients entered the study; 28 completed the two periods. IgRT exposure was similar during each period. At the end of each period, mean LQI factor 1 was 87.0 (IC95% [80.3; 94.3]) and 77.80 (IC95% [71.5; 84.7]) for pump and rapid push, respectively. There was a slightly larger effect of rapid push on treatment interference than with pump so that the primary endpoint could not be met. No difference was found on other LQI components, satisfaction (TSQM), or quality of life (SF36v2). Eight patients declared to prefer rapid push while 19 others preferred pump. Of rapid push infusions, 67.2% led to local reactions vs 71.8% of pump infusions (p = 0.11) illustrating its good tolerance. Rapid push and pump infusions achieved similar trough IgG levels with similar incidence of infections. Rapid push saved 70% of administration cost when compared to pump.ConclusionsSince IgRT is a lifelong treatment in PID patients, individualization of treatment is of paramount importance. Rapid push is a new administration method in the physician’s armamentarium which is preferred by some patients and is cost-effective.ClinicalTrials.gov IdentifierNCT02180763Clinical ImplicationsSelf-administration of small volumes of immunoglobulins at home, every other day, using a syringe (rapid push) is a cost-effective alternative to administration of larger volumes by pump once a week.Capsule SummaryThis study compared subcutaneous infusions of immunoglobulins either weekly via a pump or every other day via a syringe (rapid push). Rapid push is preferred by some patients and is cost-effective, therefore completing a physician’s armamentarium.

The anion study: effect of different crystalloid solutions on acid base balance, physiology, and survival in a rodent model of acute isovolaemic haemodilution

BackgroundCommercially available crystalloid solutions used for volume replacement do not exactly match the balance of electrolytes found in plasma. Large volume administration may lead to electrolyte imbalance and potential harm. We hypothesised that haemodilution using solutions containing different anions would result in diverse biochemical effects, particularly on acid-base status, and different outcomes. MethodsAnaesthetised, fluid-resuscitated, male Wistar rats underwent isovolaemic haemodilution by removal of 10% blood volume every 15 min, followed by replacement with one of three crystalloid solutions based on acetate, lactate, or chloride. Fluids were administered in a protocolised manner to achieve euvolaemia based on echocardiography-derived left ventrical volumetric measures. Removed blood was sampled for plasma ions, acid-base status, haemoglobin, and glucose. This cycle was repeated at 15-min intervals until death. The primary endpoint was change in plasma bicarbonate within each fluid group. Secondary endpoints included time to death and cardiac function. ResultsDuring haemodilution, chloride-treated rats showed significantly greater decreases in plasma bicarbonate and strong ion difference levels compared with acetate- and lactate-treated rats. Time to death, total volume of fluid administered: chloride group 56 (3) ml, lactate group 62 (3) ml, and acetate group 65 (3) ml; haemodynamic and tissue oxygenation changes were, however, similar between groups. ConclusionsWith progressive haemodilution, resuscitation with a chloride-based solution induced more acidosis compared with lactate- and acetate-based solutions, but outcomes were similar. No short-term impact was seen from hyperchloraemia in this model.

Labor Epidural Intolerance Due to a Congenitally Narrowed Spinal Canal

Reports exist of severe upper back pain of unknown etiology after administration of large volumes into the epidural space. We present a case of an otherwise healthy parturient who developed severe upper back and neck pain after receiving only a small volume of epidural medication. Magnetic resonance imaging revealed a congenitally narrowed spinal canal because of short pedicle syndrome. Epidural injectate occupies and compresses a percentage of the spinal canal and its neuronal contents. This may result in pain and epidural intolerance when continued injectate reaches a critical point, a threshold that is lower with shortened pedicles or congenital spinal stenosis. We believe a similar mechanism may explain the pain that patients sometimes experience after administration of large epidural volumes.

Soybean oil: a potentially new intravascular perfusate

Given that micelles of lipids are colloids, the hypothesis was generated that the rapid administration of large volumes of soybean oil micelles would be an effective perfusion fluid. We also hypothesized that oxygen loading would be enhanced due to the greater solubility of oxygen in lipids compared to water. A 100% lethal mouse model of blood loss was used to compare the ability of soybean oil micelles to that of Ringer's lactate, blood and other fluids, with respect to raising and maintaining the blood pressure for one hour. Oxygen on- and off-loading of various concentrations of soybean oil micelles was determined using mass spectroscopy. Nitric oxide uptake by micelles was also determined in a similar fashion. A 20% soybean oil emulsion was superior to Ringer's lactate in raising and maintaining blood pressure. A 20% soybean oil emulsion with 5% albumin added was superior to shed blood as well as solutions comprised of 5% albumin added to either normal saline or Ringer's lactate. There was a linear relationship between oxygen content and micelle concentration between 10% and 30%. Off-loading of oxygen from the micelles was nearly as fast as off-loading from water. Nitric oxide also loaded preferentially onto soybean oil micelles. (1) Soybean oil emulsions were superior to other fluids in restoring and maintaining the blood pressure; (2) oxygen-carrying ability of soybean oil micelles exceeds that of water and follows Henry's law between 10% and 30% w/v oil content; (3) nitric oxide was carried by the micelles; (4) animals receiving soybean oil micelles did not exhibit fat embolization; (5) colloids comprised of soybean oil-containing micelles may be used to replace blood loss and may be used to deliver oxygen and other potentially therapeutic gases such as nitric oxide to tissues.

Impact of ketogenesis and strong ion difference on acid-base in our CICU

Persistence of a mild metabolic acidosis or base deficit was occasionally observed in our otherwise well patients post cardiac surgery, sometimes delaying discharge. We hypothesised that this metabolic abnormality may be due to either ketogenesis caused by a combination of starvation and the surgical stress response, or strong ion imbalances following fluid administration. The administration of large volumes of chloride-rich fluids (as may occur during cardiac surgery to prime the cardiopulmonary bypass circuit or resuscitate the patient) is known to induce hyperchloraemic metabolic acidosis [1]. Using simplifications of the original Fencl-Stewart's equations, it is possible to partition the base deficit into its constituent parts, subsequently determining the relative contribution of chloride, albumin and unmeasured anions to acidosis [2,3]. Ketone production may contribute significantly to the unmeasured anion component.

Efficacy of drugs in regional anesthesia: A review

Local anesthetics and opioids are the most commonly used drugs in regional anesthesia. Several other drugs are used as adjuvants in addition to local anesthetics. We will review the drugs currently used in regional anesthesia. In April 2009 we searched the PubMed database and found 143 articles related to the clinical use of drugs in regional anesthesia; we divided them into 3 major chapters: local anesthetics, opioids and adjuvants. Among local anesthetics, ropivacaine and levobupivacaine can be considered the drugs of choice in neuraxial and peripheral techniques because their toxicity is low even in large volume administration; mepivacaine can be considered the drug of choice in peripheral techniques when a shorter blockade is needed. Sufentanil is the opioid of choice in both neuraxial and peripheral techniques because it appears to improve the quality of anesthesia and to prolong sensory blockade in the postoperative period. Among the adjuvants to local anesthetics, clonidine is by far the most used drug in regional anesthesia; its yield in improving and prolonging the effects of local anesthetics is apparent in neuraxial techniques. Other drugs have been studied as adjuvants to local anesthetics but clinical evidence of their benefit is controversial in many cases and further trials are unquestionably warranted. In conclusion, since many different drugs are available for regional anesthesia, we must choose wisely the one that exhibits the best safety-efficacy profile and that suits the chosen technique and type of anesthesia/analgesia best.

Saline-induced hyperchloraemic metabolic acidosis: an unrecognised phenomenon among medical staff?

Hyperchloraemic acidosis is well recognised within critical care, is implicated in the development of organ dysfunction and is an important consequence of administration of large volumes of chloride-containing intravenous (i.v.) fluid, such as normal (0.9%) saline [1,2]. Within most hospitals, junior medical staff with differing levels of experience prescribe the majority of i.v. fluid therapy.

Hyperhydration prior to moderate-intensity exercise causes arterial hypoxaemia.

The second day of a 3-day event is the most physically demanding of the 3 days. If this is performed under hot and humid environmental conditions, detrimental effects on cardiovascular and thermoregulatory function and, therefore, on exercise capacity, may occur due to exercise-induced dehydration. We hypothesised that the administration of fluid equivalent to 6% of the horse's bodyweight prior to a simulated second day of a 3-day event would increase plasma volume and limit increases in core temperature. Seven Standardbred geldings underwent a training protocol prior to the study. A standardised exercise test was developed for each horse so that exercise intensity at each phase would be the same percentage of the maximal heart rate for all horses. The exercise test involved 4 phases: Phase A involved 30 min exercise at 3.7 m/s (approximately 25% VO2max); Phase B 4 min exercise at 8 m/s (approximately 60% VO2max); and Phase C 50 min at 3.7 m/s, after which there was a 10 min rest. Phase D involved 14 min at 7.3 m/s (55% VO2max). In a cross-over design, horses were grouped randomly and allocated to either exercise with no fluid (control) or approximately 26 l isotonic fluid by nasogastric tube, 120 min prior to exercise. Arterial and mixed venous blood samples were collected prior to exercise, towards the end of each of the phases and during the rest period. The administration of fluid prior to exercise resulted in a pre-exercise bodyweight gain of 21.3 +/- 1.2 kg. Hyperhydration resulted in a greater degree of arterial hypoxaemia than the control group in Phases B and D, but not in Phases A and C or at rest. During Phases B and D, mean PaO2 values in the horses that received fluid were about 15 torr lower than in the control group, but there were no differences in PaCO2 values between the 2 groups. In both arterial and mixed venous blood, pH and HCO3- were significantly lower in the group that were hyperhydrated. We concluded that the most likely cause of the more severe arterial hypoxaemia in the hyperhydrated group during the intense exercise phase was some degree of pulmonary oedema, from the extravasation of the administered fluid. Hyperhydration prior to exercise may be detrimental to respiratory function and therefore care must be taken in administration of large volumes of fluid prior to exercise.

Pathogenesis and management of septic shock

Summary In summary, the diagnosis of septic shock should prompt an aggressive diagnostic and therapeutic regimen. Infected fluid collections should be drained urgently, intravascular devices should be removed (if possible), and appropriate antimicrobial therapy should be initiated. Rapid administration of large volumes of fluid is routinely required. Initiation of mechanical ventilation should be considered early during resuscitation efforts. Careful supportive care may minimize occurrence of secondary sepsis caused by gut-derived bacteremia/endotoxemia, intravascular device infection, nosocomial pneumonia, or other sources. If aggressive volume resuscitation fails to achieve satisfactory perfusion indices or precipitates pulmonary edema/hypoxemic respiratory failure, then PAC placement should be considered. A trial of DB therapy to reverse any element of septic myocardial depression may be useful if perfusion is inadequate after appropriate volume resuscitation but should be initiated with caution, and drug effects should be monitored carefully at the bedside. If a vasoconstrictor agent is administered, a splanchnic and/or renal vasodilator (low-dose DA, FNP, DX, DB) probably should be added to offset regional hypoperfusion, although the benefit of this approach in septic shock is currently unproven. Whatever strategy is used for hemodynamic support, careful bedside serial assessments should gauge the effects of each intervention and guide subsequent therapeutic maneuvers. Septic shock is among the most urgent conditions treated by any physician, and there is no substitute for bedside management guided by an integrated synthesis of all available information.

Washout kinetics of colloidal starch as a partial or full replacement for plasma exchange.

Colloidal starch has been used safely as a plasma expander and an erythrocyte sedimenting agent for over 25 years. However, there remains some concern in regard to the long term sequelae of the administration of large volumes of colloid starch such as would be administered if colloidal starch were used as a plasma replacement during serial plasma exchanges. We identified mathematical relations that allowed for the calculations of the theoretical circulating residual starch in a patient undergoing serial plasma exchanges and used it to model a variety of possible clinical scenarios. Following six one plasma volume exchanges, one would expect only 11, 13, 14, or 17% of the total infused starch to be remaining in the circulation. For example, in the case of a 4L exchange with full replacement, only the starch in 4.1 liters (4L x 6 exchanges x 17% = 4.1L) would be expected to remain in the circulation despite an infusion of 24 L (4L x 6 exchanges = 24L) of starch. The results suggest that relatively small amounts of starch would be expected to remain circulating relative to the large amounts infused following a series of plasma exchanges with partial or full starch replacement.

Brain Edema and Neurologic Status with Rapid Infusion of 0.9% Saline or 5% Dextrose After Head Trauma

We previously reported that intravenous (i.v.) administration of large volumes (0.2 ml/g) of either an isotonic dextrose-free solution or 5% dextrose solution given over 18 h after closed head trauma (CHT) in rats did not significantly affect neurological severity score or brain tissue specific gravity. However, it is possible that with more rapid administration, isotonic or 5% dextrose i.v. solutions may alter neurological outcome after CHT. Our study examined whether neurological severity score, brain tissue specific gravity and water content, and blood composition were significantly altered when 0.25 ml/g of either 0.9% saline or 5% dextrose was given i.v. over 0.5 h (rather than over 18 h) after CHT. Eight-four rats that survived ether anesthesia and CHT were randomly assigned to one of 11 experimental groups. Saline- and dextrose-treated rats were evaluated at 4 and 48 h after CHT and were compared to rats without CHT and to untreated rats at 4 and 48 h after CHT. There were no statistically significant differences in neurologic outcome and brain edema between the untreated and the saline-treated groups. However, 5% dextrose i.v. increased mortality (group 6 and 11, 50 and 0% survivors, respectively), decreased specific gravity in the noncontused hemisphere, and worsened neurologic outcome with and without CHT. Blood osmolality remained stable in comparison to the baseline value of 291.9 +/- 7.4 mOsm/kg (mean +/- SD).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical study of normothermic cardiopulmonary bypass in 100 patients with coronary artery disease

During normothermic cardiopulmonary bypass (CPB), the body temperature is maintained at 37 degrees C. Since 1987, it has been our standard practice to use normothermic CPB in our patients undergoing a cardiac operation, and our experience now consists of more than 3,000 consecutive patients. Myocardial protection is achieved through the combination of cold intermittent antegrade blood cardioplegia, no topical cooling, and a terminal "hot shot" of blood cardioplegia. We disagree with the stance of the Toronto group that normothermic CPB requires the administration of large volumes of cardioplegic and crystalloid solutions and the frequent use of phenylephrine hydrochloride to ensure a low systemic vascular resistance. To establish a routine technique of cold heartwarm body bypass, we conducted a clinical study in 100 consecutive patients with coronary artery disease. We found that the total cardioplegia volume needed in our patients was 1,946 +/- 257 mL, versus 4,700 +/- 1,900 mL in the Toronto study, and an additional crystalloid volume loading of 400 +/- 141 mL during CPB was needed in 26% of our patients, versus a total volume of 3,650 +/- 800 mL in the Toronto series. Phenylephrine (250 micrograms) was used in 16% of our patients, versus 88% of the patients in the Toronto study (mean dose, 1.3 mg). During normothermic CPB, the mean radial arterial pressure was 57.3 +/- 9.4 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of Hypertonic-Hyperoncotic Fluids for Resuscitation of Trauma Patients

Hypertonic sodium chloride solutions in concentrations ranging from 1.5% to 24% have been studied for use in the resuscitation of burn and hemorrhagic shock victims for many years. In animal studies, in the setting of small volume resuscitation, hypertonic sodium chloride is superior to standard isotonic crystalloid resuscitation for restoration of hemodynamic stability. The combination of hypertonic sodium chloride with a hyperoncotic colloid solution sustains hemodynamic improvements for an additional hour. Hypertonic-hyperoncotic solutions restore vascular volume primarily by drawing water out of the cell and then selectively partitioning some of the newly recruited fluid within the plasma space. The hyperosmolar state also augments microcirculatory flow, reduces cerebral edema formation, and perhaps increases myocardial contractility. The ability to increase cardiac output with small volume hypertonic-hyperoncotic resuscitation may solve some of the problems related to fluid resuscitation in the prehospital setting when transport times are prolonged or mass casualties need to be treated. Decreasing the volume of fluid required during resuscitation may also prove beneficial in the setting of craniocerebral trauma where the administration of large volumes of crystalloid can increase intracranial pressure. The largest clinical experiences have been reported with the administration of 4 mL/kg of 7.5% sodium chloride combined with 6% dextran 70. These studies have shown that this solution is safe to administer and effective for reversal of hypotension. Whether or not the ability to reverse hypotension will translate into improved survival remains undetermined at present and will require larger multi-institutional trials.

Emergency intraosseous infusion in severely burned children

Severely burned patients require rapid administration of large volumes of isotonic fluids. Obtaining adequate intravenous (IV) access in children with greater than 70% total body surface area burns may be difficult, time-consuming, and sometimes impossible. This report describes the use of intraosseous infusion technique as a life-saving means of establishing IV access in two severely burned children.