Bolus Group Research Articles

Childhood Mortality After Fluid Bolus With Septic or Severe Infection Shock: A Systematic Review and Meta-Analysis.

A considerable debate on whether fluid bolus could decrease childhood mortality in pediatric patients with septic or severe infection shock is still unresolved. A systematic review and meta-analysis was conducted to investigate the mortality rates after fluid bolus among children with septic or severe infection shock. A systematic electronic search of PubMed, MEDLINE, Cochrane Library, and EMBASE databases was conducted to identify relevant published studies till March 30, 2020. A total of 19 studies with 9,321 severe sepsis or septic shock pediatric patients were included and exhibited an acceptable quality. Of the 17 studies that reported mortality at 48 h, no bolus group decreased the mortality rate when compared with bolus group with a risk ratio (RR) of 0.74 [95% confidence interval (CI) = 0.62-0.88, P < 0.01], and showed no heterogeneity (I2 = 0%). Similar results were observed on colloids and crystalloids solution in malaria shock cases with a RR of 0.79 (95% CI = 0.62-1.02). For the subgroup of general shock patients, no significant difference was shown with an RR of 0.79 (95% CI = 0.62-1.02, P = 0.07) and no significant heterogeneity (I2 = 0%). Two studies reported mortality at week 4 and pooled results indicated that no bolus group was protective against mortality when compared with bolus group with RR of 0.71 (95% CI = 0.57-0.88, I2 = 0%). For the mortality at 48 h, the no bolus group showed decreased mortality when compared with the bolus group, especially in the malaria group. Similar results were found in the colloids and crystalloids solution in patients with malaria shock. Meta-analysis studies with long-term follow-up period and larger sample size are warranted to address the conclusion in the future.

Comparison of the benefits and hemodynamic side effects of oxytocin between intravenous infusion with and without bolus injection during caesarean section

The aim of this study was to compare the benefits and hemodynamic side effects of oxytocin between intravenous infusion with and without a bolus injection during a caesarean section. Women with singleton pregnancies who underwent caesarean sections under spinal anaesthesia were included. Oxytocin was administered by an iv bolus injection (5 U) followed by an intravenous infusion (10 U of oxytocin in 500 mL normal saline); this was switched to just an intravenous infusion. The amount of blood loss did not differ between the groups. In a multivariate analysis, the adjusted odds ratios for the risk of hypotension (≥20% reduction of systolic BP) and tachycardia (heart rate ≥100 bpm) were 4.5 (95% confidence interval [CI], 1.6–12.5) and 3.7 (95%CI 1.9–7.2) in the iv bolus group, respectively, compared with the just the infusion group. The oxytocin administration by iv bolus injection did not decrease blood loss and increased the rate of hemodynamic side effects. Impact statement What is already known on this subject? Oxytocin is used as the first-line uterotonic treatment to prevent a postpartum haemorrhage in women undergoing Caesarean Sections. Oxytocin is known to relax vascular smooth muscle, which can cause hypotension and tachycardia. The protocols for administering oxytocin during CS vary by institution. What do the results of this study add? Combined treatment with oxytocin by iv bolus injection (5 U) followed by iv infusion (10 U of oxytocin in 500 mL normal saline) during CS increased the risk of developing adverse hemodynamic side effects, including hypotension, tachycardia, and the need for vasopressors, without any benefit in the control of intraoperative blood loss in comparison to iv infusion alone. What are the implications of these findings for clinical practice and/or further research? We should abandon the iv bolus injection of oxytocin during CS, especially for women undergoing an elective CS who are not in labour.

Cannula complications using elastomeric infusers in Hospital in the Home.

ObjectivesComparison of the short peripheral cannula (SPC) complication rate of patients with cellulitis receiving IV cefazolin via an elastomeric infuser with those receiving twice-daily bolus treatment (control group) in the Hospital in the Home service.MethodsA randomized controlled study using elastomeric infuser versus bolus delivery of IV cefazolin via an SPC of patients referred to the Hospital in the Home service in the Northern Illawarra for treatment of cellulitis. A total of 104 patients were enrolled during the time period of May 2018 to January 2019. Primary outcome measures were SPC complications including phlebitis with a secondary outcome of patient satisfaction.ResultsA total of 104 patients enrolled. After randomization there were 60 in the infuser group and 44 in the bolus group. Patient characteristics of age, gender, weight and mobility were similar for the two groups. There was no statistically significant difference between the groups for the endpoint of cannula complication rates. Patient satisfaction scores showed patient acceptance of both forms of treatment.ConclusionsThis study suggests that using elastomeric infusers to deliver cefazolin via a short peripheral IV catheter has similar complication rates to traditional bolus delivery. Patients surveyed showed high levels of satisfaction with both forms of antibiotic delivery.

I-FiBH trial: intravenous fluids in benign headaches—a randomised, single-blinded clinical trial

BackgroundMany emergency physicians use an intravenous fluid bolus as part of a ‘cocktail’ of therapies for patients with headache, but it is unclear if this is beneficial. The objective of...

A comparative assessment of intravenous norepinephrine and mephentermine during spinal anaesthesia for caesarean section

Background: The present study compared intravenous norepinephrine and mephentermine for maintenance of blood pressure during spinal anaesthesia for caesarean section in known patients. Materials & Methods: The present study was conducted on 62 females planed for elective surgery. Patients were divided into 2 groups of 31 each. Group I received bolus intravenous norepinephrine 8µg and group II received mephentermine 6mg for the maintenance of intraoperative systolic blood pressure. HR, SBP and DBP were recorded at every 2 min interval till 20 min and thereafter at every 5 min interval till the completion of surgery. Complications were also recorded. Results: There was fall in SBP from baseline till 15 minutes in both groups then started increasing till 60 minutes. There was fall in DBP from baseline till 20 minutes in both groups then started increasing till 60 minutes. The difference was non- significant (P>0.05). There were 6 cases in group I and 7 in group II having nausea/vomiting, shivering was seen 5 in group I and 6 in group II, headache 4 in group I and 3 in group II and hypertension 3 in group I and 4 in group II. The difference was non- significant (P>0.05). Conclusion: Authors found that intravenous norepinephrine was better than mephentermine in maintaining blood pressure.

Skipping the Drip: Intravenous Proton Pump Inhibitor Bolus Therapy Leads to Poor Outcomes in High-Risk Bleeding.

Background and AimThe aim of this study was to evaluate the impact of a change in our institute’s protocol from continuous intravenous (IV) proton pump inhibitor (PPI) therapy to bolus IV PPI therapy for the treatment of peptic ulcer-related bleeding on patient outcomes. Current guidelines recommend PPI therapy through high-dose IV bolus followed by continuous infusion for bleeding ulcers. Conflicting data have been reported regarding the practice shift to intermittent IV PPI therapy.MethodsA retrospective record review was conducted of patients treated at West Virginia University between 2017 and 2018 for peptic ulcer related bleeding who underwent endoscopy and had high-risk stigmata. Relevant variables were identified. Outcomes were compared between groups based on PPI strategy. The primary endpoint was any poor outcome defined as rebleeding, need for embolization or surgery, or mortality during hospital stay.ResultsA total of 130 patients were included, with a mean age of 62.18 years. Continuous PPI infusion was used in 39.23%, whereas bolus IV PPI was used 60.76%. Poor outcome was encountered in 11 (21.57%) patients in the continuous and 33 (41.77%) patients in the bolus group (p = 0.028). On multivariable analyses, bolus PPI strategy was independently linked to poor outcome (Wald’s odds ratio: 2.8; 95% CI: 1.21-6.84; p = 0.019) and an increased need for embolization/surgery (OR: 4.12, 95% CI: 1.14-19.99; p = 0.046).ConclusionsIV bolus therapy showed worse outcomes compared with continuous IV PPI therapy for patients with peptic ulcer bleeding with high-risk features. More robust data are needed before a practice shift to bolus PPI may be appropriate.

Constant-rate intravenous infusion of indocyanine green leading to high fluorescence intensity in infrared thoracoscopic segmentectomy.

ObjectivesThe purpose of this study was to determine whether or not fluorescence could be increased by administering indocyanine green at a constant rate, thus stabilizing its blood concentration.MethodsIn 20 consecutive patients undergoing segmentectomy, the dominant pulmonary arteries were ligated, blocking blood in the target segment. Fluorescence intensity was then observed using different indocyanine green administration methods under infrared thoracoscopy. Intravenous administration of indocyanine green, via a syringe pump at a rate of 12.5 mg/min, was defined as the constant rate group. The bolus group was defined by a 5-mg indocyanine green rapid intravenous injection. The fluorescence intensity was compared at the time of maximum fluorescence and 2 minutes after fluorescence initiation.ResultsAt maximum staining, the fluorescence intensity of the normal blood flow area was brighter in the constant rate group (median, 184.2; interquartile range, 170.2-200.1) compared with the bolus group (median, 122.3; interquartile range, 87.3-144.7; P = .0003). The fluorescence of the normal blood flow was retained even after 2 minutes. There was no difference in the fluorescence intensity of the ischemic segments.ConclusionsThe constant rate method showed brighter and better fluorescence than the bolus injection, without an increase in the dose. The contrast between adjacent segments was clear, facilitating the differentiation of the areas.

Epigastric pain after intravenous administration of oxytocin in patients undergoing lower segment cesarean section: A quasi experimental study comparing intravenous bolus with infusion technique

Aim: To compare the frequency of epigastric pain and uterotonic effect of an equivalent dose of oxytocin administered as an intravenous bolus versus intravenous infusion during elective LSCS under spinal anesthesia.&#x0D; Methodology: We recruited 98 parturients undergoing elective LSCS under spinal anesthesia for this prospective quasi experimental study and divided them into two groups. Group-A received 5 IU of oxytocin as bolus intravenous (IV) injection in 5 sec (bolus group, n= 48), and Group-B (infusion group, n= 50) received 5 IU of oxytocin as an infusion over 5 min. Any complaint of epigastric pain by the patients was noted and its frequency was compared between the two groups. The uterine tone was assessed as adequate or inadequate by an obstetrician. The data were entered into SPSS version 22. Patient demographic data were analyzed with independent samples T-test and the study data were analyzed with Chi‑square test and presented as n (%). p &lt; 0.05 was considered statistically significant.&#x0D; Results: Epigastric pain was noted in 25 (52.03%) out of 48 parturients in Group-A and 15 (30%) out of 50 in Group-B (p = 0.026). There was no significant difference in the uterotonic effect of oxytocin between the two groups (p = 0.736).&#x0D; Conclusion: We conclude that oxytocin infusion is associated with lower frequency of epigastric pain in elective LSCS when compared to intravenous bolus of an equivalent dose of oxytocin, However, the effect on uterine contractions was adequate with both methods.&#x0D; Citation: Kashif A, Kiani RB, Shabbir SMA, Mahmood T, Sabir G, Fatima NE, Khan WA. Epigastric pain after intravenous administration of oxytocin in patients undergoing lower segment cesarean section: A quasi experimental study comparing intravenous bolus with infusion technique. Anaesth pain intensive care 2020;24(1):_&#x0D; DOI: https://doi.org/10.35975/apic.v2i1.&#x0D; Received – 20 February 2019;&#x0D; Reviewed – 4, 16 March, 25 June, 9 September, 2, 25 November, 10 December 2019, 7 January 2020;&#x0D; Revised – 19 June, 10 August, 29 September, 1 November 2019, 6 January 2020;&#x0D; Accepted – 10 January 2020;

Hemodynamic effects of carbetocin administered as an intravenous bolus or infusion during cesarean delivery.

BackgroundPostpartum hemorrhage is the leading cause of maternal mortality. Oxytocin being the most popular uterotonic agent, has been routinely administered after both vaginal delivery and cesarean section. Carbetocin is a newer uterotonic agent and provides the benefit of a longer duration of action without additional administration post-delivery.MethodsWe recruited 34 women undergoing elective cesarean section under spinal anesthesia. All patient was received spinal anesthesia using 0.5% hyperbaric Marcaine 8–10 mg in conjugation with fentanyl 20 μg in the left lateral decubitus position. Hartmann’s solution 10–15 ml/kg was administered before carbetocin. The operation started as soon as sensory block at level T4–T6 was confirmed. A non-invasive hemodynamic monitoring cuff (Finometer®) was attached to the patient’s finger soon after the induction of spinal anesthesia. Using the Finometer, we recorded the heart rate and mean arterial pressure at every 15 s, starting from 15 s before the administration of carbetocin to 5 min after. After the removal of the placenta, the bolus group was administered intravenous bolus injection of carbetocin 100 μg and the infusion group was administered carbetocin 100 μg diluted in 50 ml normal saline, over 5 min using an infusion pump.ResultsThe demographic data showed no significant difference between the two groups. Furthermore, there were no significant hemodynamic differences between the two groups.ConclusionsThe method of administration of carbetocin does not influence its hemodynamic effects.

Phase 3 Study of Palonosetron IV Infusion Vs. IV Bolus for Chemotherapy-Induced Nausea and Vomiting Prophylaxis After Highly Emetogenic Chemotherapy

ContextPalonosetron (PALO) is one of the two active components of NEPA, the fixed-combination antiemetic comprising netupitant (oral)/fosnetupitant (IV) and PALO. To increase the convenience of NEPA administration, especially for patients with swallowing difficulties, an IV NEPA formulation has been developed, where PALO is administered as a 30-minute infusion instead of the approved 30-second bolus. ObjectivesTo determine the efficacy and safety of the PALO component used in IV NEPA. MethodsNoninferiority, double-blind, and randomized Phase 3 trial in chemotherapy-naive adult patients with cancer requiring highly emetogenic chemotherapy. Patients were randomized to receive a single dose of PALO 0.25 mg administered IV either as a 30-minute infusion or as a 30-second bolus before highly emetogenic chemotherapy. The primary objective was to demonstrate noninferiority of the 30-minute infusion vs. 30-second bolus in terms of complete response (CR; no emesis and no rescue medication) in the acute phase. Secondary efficacy endpoints were CR in the delayed and overall phases and no emesis and no rescue medication in all phases. Safety was a secondary endpoint. ResultsOverall, 440 patients received study treatment. In the infusion group, 186 (82.7%) patients reported CR in the acute phase vs. 186 (86.5%) patients in the bolus group, demonstrating the noninferiority of PALO infusion vs. bolus (P < 0.001). Secondary endpoints showed similar results between the two treatment groups. ConclusionPALO 0.25-mg 30-minute IV infusion was noninferior to 30-second IV bolus in terms of CR rate in the acute phase. These results support the use of PALO 0.25 mg as a component of IV NEPA.

Epidural bolus versus continuous epidural infusion analgesia on optic nerve sheath diameter in paediatric patients: A prospective, double-blind, randomised trial

The use of programmed intermittent epidural bolus for postoperative analgesia may have greater analgesic efficacy than continuous epidural infusion. However, the rapid delivery speed used with an epidural bolus is more likely to increase intracranial pressure. We compared the effects of lumbar epidural bolus versus continuous infusion epidural analgesia on intracranial pressure in children using optic nerve sheath diameter as a marker. We randomly assigned 40 paediatric patients to bolus or infusion groups. Epidural analgesia (0.15% ropivacaine 0.3 ml·kg−1) was administered via bolus or infusion. Ultrasonography was used to measure the optic nerve sheath diameter before (T0), at 3 min (T1), 10 min (T2), and 70 min (T3) after starting the pump. There were statistically significant between-group differences in optic nerve sheath diameter over time (PGroup x Time = 0.045). From T0–T3, the area under the curve values were similar between the two groups. Although there were differences in the patterns of optic nerve sheath diameter change according to the delivery mode, the use of lumbar epidural bolus did not increase the risk of intracranial pressure increase over that of continuous infusion. Further research is needed to investigate intracranial pressure changes after continuous application of each delivery mode.

Outcome of Continuous versus Intermittent Application of Meropenem in Critically Ill Patients with Septic Shock

Abstract Background Severe infections in critically ill patients and increasing antibiotic resistance are major healthcare problems affecting morbidity and mortality in the intensive care unit. Antibacterial drug discovery and development have slowed considerably in recent years. Aim of the Work Study the outcome of continuous versus intermittent application of meropenem in critically ill patients with septic shock. Patients and Methods This study was carried out on one hundred patients of both sex from those admitted to intensive care unit in Damanhour Medical National Institute.An Informed consent was taken from all patients or their next of kin. Patients were categorized into 2 groups: Group I (Infusion group) patients received a loading dose of 2g of meropenem I.V over 30 minutes followed by continuous infusion of 4g of meropenem over 24 hours. Group II (Bolus group) patients received 2g of meropenem over 30 minutes every 8 hours. Antibiotic therapy stopped at improvement of the clinical state and signs of subsidence of infection (body temperature below 38, 3 °C for more than 24 hours, white blood cells (WBC) count less than 11, 000/mm3 or decrease by 25% of maximal value)minimum time for therapy 5days and maximum time 10 days. Results In the present study there were two groups of critically ill patients with septic shock each of 50 patients. Group one was given meropenem after culture and sensitivity as one gram infusion over 360 minutes every 6 hours. The second group was given meropenem also after culture and sensitivity as two grams bolus over 30 minutes every 8 hours. There were no significant differences between the two groups regarding age and sex distribution. On admission the two groups had high APACHE-II score, but with no significant difference. Also there was no significant difference between the two groups regarding the site of infection nor the infecting organism. As regards WBCs count the mean WBC count was higher in group II than in group I on days 1 and 3 of treatment but there was no statistically significant difference. Conclusion Administration of meropenem on cultured based treatment as 1g/6hrs infusion compared to 2g/8hrs bolus was associated with significant reduction of WBCs count, CRP levels, SOFA score and ICU stay. Improved clinical outcome, reduction in bacterial growth and decreased mortality were better in the infusion group but not significant.

Differences between Continuous Infusion and Intermittent Bolus of Furosemide with Length of Hospital Stay in Patients with Acute Heart Failure in Haji Adam Malik General Hospital Medan

Background: Heart failure is a complication that often occurs in individuals with or without underlying cardiovascular disease. Furosemide serves to reduce preload and improve congestion symptoms. The aim of this study was to determine the difference in length of hospital stay between continuous infusion and intermittent bolus of furosemide in patients with acute heart failure.Methods: This study was a prospective-single blind-randomized controlled study of 54 people with acute heart failure who entered the emergency room and underwent treatment at the H. Adam Malik Hospital from October 2018 to March 2019. Re-examination of urine production, kidney function, and electrolytes was carried out after 72 hours of treatment. Subsequent subjects were observed during treatment for death during treatment and duration of treatment. Follow-up was carried out for 30-days to assess rehospitalization.Results: Between continuous infusion group and intermittent bolus group, we found, respectively, length of hospital stay 7.6±3.2 vs. 7.3±4.8 days, p=0.28; urine production 2241±429 vs 2020±368, p=0.048; ∆BUN 3.6 ± 14.5 vs 4.0 ± 10.9, p=0.91; ∆Ureum 7.9 ± 31.0 vs 8.5 ± 23.3; p=0.92; ∆Creatinine 0.1 ± 0.61 vs. 0.03 ± 0.33; p=0.56; and ∆GFR -5.5 ± 20.6 vs -2.7 ± 22.7; p=0.64. In terms of mortality during hospitalization, we found that 7.4% vs 11.1%, p=0.63 (HR 0.64; 95% CI: 0.098–4.1) and rehospitalization in 30 days showed 22.2% vs 37%; p=0.23 (HR 0.48; 95% CI: 0.14–1.6) in continuous infusion vs. intermittent bolus group, respectively.Conclusions: In patients with acute heart failure, there is no difference between continuous infusion and intermittent bolus of furosemide in regard to length of hospital stay, changes in renal function and electrolyte, death during hospitalization, and rehospitalization within 30-days. However, continuous administration of furosemide infusion is better in urine production.

The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy.

BackgroundIntravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1–2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT).AimThis study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy.MethodsIn this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0–5), moderate (6–14), severe (15–24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups.ResultsIn patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose.ConclusionIn severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.

Comparative study between preoperative ketamine bolus dose versus ketamine bolus plus infusion for perioperative analgesia in orthopedic surgery

Background and aim Postoperative pain severity depends on patient factors, anesthesia-related factors, and type of surgery. Pain after orthopedic surgery has been found to be immediate and severe, which necessitates more attention for its management. The aim of this study was assessment of the effectiveness of intravenous ketamine to provide postoperative analgesia after orthopedic surgery. This randomized double-blind study had been performed in Al-Zahraa University Hospital from December 2019 to October 2020. Patients and methods A total of 75 patients subjected to major orthopedic surgery were registered in the study. The patients had been randomly assigned into three equal groups (control, bolus, and bolus with infusion groups) to receive intravenous ketamine bolus dose alone (0.3 mg/kg) (bolus group); ketamine bolus (0.3 mg/kg) plus infusion (5 µg/kg/min), which terminated at the end of operation (bolus with infusion group); or placebo in the form of normal saline (control group). Visual analog pain scale score, postoperative 24 h morphine requirements, time to first analgesic requirement, and postoperative adverse effects were recorded and compared. Results Postoperative visual analog pain scale score and total morphine requirements were significantly less in bolus with infusion group, followed by bolus group, whereas the highest score and requirements were in control group. Regarding the time to first analgesic requirement, there was a statistically significant increased time to first analgesic in bolus with infusion group, followed by bolus group, whereas the shortest time was in control group, and there were nonsignificant differences among groups regarding postoperative complications. Conclusion Ketamine bolus dose alone before skin incision or followed by infusion had the capability of decreasing postoperative pain and total analgesic requirement and increasing the time to first analgesic requirement after orthopedic surgery, with superiority of ketamine bolus dose plus infusion without increasing the incidence of adverse effects.

A randomized controlled trial of 3 IU Intravenous oxytocin bolus with 7 IU oxytocin infusion versus 10 IU oxytocin intramuscular in the third stage of labor for the prevention of postpartum hemorrhage

Objective: Intravenous oxytocin during vaginal delivery has been rarely used as an intramuscular route or intravenous infusions are preferred. The trial aims to compare low dose Intravenous (IV) bolus 3IU of oxytocin along with 7IU oxytocin infusion to 10IU oxytocin infusion in cesarean section. Materials and Methods: A total of 320 term pregnant women were randomized to either 3IU IV bolus and 7IU infusion of oxytocin or 10IU of IV oxytocin infusion. The difference in pre- and post-delivery haemoglobin levels, tone of the uterus, hemodynamic changes, adverse effects of the drug, need for additional uterotonics and need for blood transfusions were assessed. Results: There were more women who had a drop in the haemoglobin of 3gm/dl in the intramuscular oxytocin group than the IV bolus- infusion group (11%vs 4%), though the difference was not statistically significant. The tone of the uterus was firmer in the IV bolus group at 3 and 5 minutes. There was no significant difference in the hemodynamic changes, adverse effects, need for additional uterotonics or need for blood transfusions. Conclusion: Intravenous bolus of 3IU with 7IU infusion of oxytocin is as safe as and more effective than Intramuscular injection of 10 IU of oxytocin during vaginal delivery for the prevention of postpartum haemorrhage.

Prophylactic phenylephrine and fluid co-administration to reduce spinal hypotension during elective caesarean section in a resource-limited setting: a prospective alternating intervention study.

Spinal hypotension is a common and clinically important problem during caesarean section. Current consensus recommendations for resource-rich settings suggest the use of a titrated phenylephrine infusion, in combination with fluid coloading, for prevention of maternal hypotension. In resource-limited settings, where syringe drivers are unavailable, these recommendations advise the addition of 500μg phenylephrine to the first 1l of intravenous fluid given after initiation of spinal anaesthesia, with additional vasopressor boluses as required. This prospective, alternating intervention study compared the use of a conventional phenylephrine rescue bolus strategy for prevention of hypotension, defined as systolic arterial pressure <90mmHg, with a phenylephrine infusion given according to the consensus recommendation. We studied 300 women having elective caesarean section. There were 77 (51%) women who developed hypotension in the bolus group vs. 55 (37%) in the phenylephrine infusion group (p=0.011). This represented a 29% reduction in hypotension, with a number needed to treat of 6.8. The six highest systolic arterial pressure readings occurred in the phenylephrine infusion group (range 166-188mmHg), and there were four instances of bradycardia (heart rate <50 beats.min-1 ) with preserved systolic arterial pressure in each group. There were no adverse clinical sequelae, and no differences in neonatal Apgar scores in either group. The consensus recommendation for phenylephrine and fluid co-administration in resource-limited settings appears effective in preventing maternal hypotension, but at the cost of sporadic systolic hypertension.

Mortality risk over time after early fluid resuscitation in African children

BackgroundAfrican children hospitalised with severe febrile illness have a high risk of mortality. The Fluid Expansion As Supportive Therapy (FEAST) trial (ISCRTN 69856593) demonstrated increased mortality risk associated with fluid boluses, but the temporal relationship to bolus therapy and underlying mechanism remains unclear.MethodsIn a post hoc retrospective analysis, flexible parametric models were used to compare change in mortality risk post-randomisation in children allocated to bolus therapy with 20–40 ml/kg 5% albumin or 0.9% saline over 1–2 h or no bolus (control, 4 ml/kg/hour maintenance), overall and for different terminal clinical events (cardiogenic, neurological, respiratory, or unknown/other).ResultsTwo thousand ninety-seven and 1041 children were randomised to bolus vs no bolus, of whom 254 (12%) and 91 (9%) respectively died within 28 days. Median (IQR) bolus fluid in the bolus groups received by 4 h was 20 (20, 40) ml/kg and was the same at 8 h; total fluids received in bolus groups at 4 h and 8 h were 38 (28, 43) ml/kg and 40 (30, 50) ml/kg, respectively. Total fluid volumes received in the control group by 4 h and 8 h were median (IQR) 10 (6, 15) ml/kg and 10 (10, 26) ml/kg, respectively. Mortality risk was greatest 30 min post-randomisation in both groups, declining sharply to 4 h and then more slowly to 28 days. Maximum mortality risk was similar in bolus and no bolus groups; however, the risk declined more slowly in the bolus group, with significantly higher mortality risk compared to the no bolus group from 1.6 to 101 h (4 days) post-randomisation. The delay in decline in mortality risk in the bolus groups was most pronounced for cardiogenic modes of death.ConclusionsThe increased risk from bolus therapy was not due to a mechanism occurring immediately after bolus administration. Excess mortality risk in the bolus group resulted from slower decrease in mortality risk over the ensuing 4 days. Thus, administration of modest bolus volumes appeared to prevent mortality risk declining at the same rate that it would have done without a bolus, rather than harm associated with bolus resulting from a concurrent increased risk of death peri-bolus administration.Trial registrationISRCTN69856593. Date of registration 15 December 2008.

Variable versus fixed-rate infusion of phenylephrine during cesarean delivery: a randomized controlled trial

BackgroundPhenylephrine is the most commonly used vasopressor for prophylaxis against maternal hypotension during cesarean delivery; however, the best regimen for its administration is not well established. Although variable infusion protocols had been suggested for phenylephrine infusion, evidence-based evaluation of variable infusion regimens are lacking. The aim of this work is to compare variable infusion, fixed on-and-off infusion, and intermittent boluses of phenylephrine for prophylaxis against maternal hypotension during cesarean delivery.MethodsA randomized controlled study was conducted, including full-term pregnant women scheduled for elective cesarean delivery. Participants were divided into three groups which received phenylephrine by either intermittent boluses (1.5 mcg/Kg phenylephrine), fixed on-and-off infusion (with a dose of 0.75 mcg/Kg/min), or variable infusion (with a starting dose of 0.75 mcg/Kg/min). The three groups were compared with regard to frequency of: maternal hypotension (primary outcome), second episode hypotension, reactive hypertension, and bradycardia. Other outcomes included heart rate, systolic blood pressure, physician interventions, and neonatal outcomes.ResultsTwo-hundred and seventeen mothers were available for final analysis. The 2 infusion groups showed less incidence of maternal hypotension {26/70 (37%), 22/71 (31%), and (51/76 (67%)} and higher incidence of reactive hypertension compared to the intermittent boluses group without significant differences between the two former groups. The number of physician interventions was highest in the variable infusion group compared to the other two groups. The intermittent boluses group showed lower systolic blood pressure and higher heart rate compared to the two infusion groups; whilst the two later groups were comparable.ConclusionBoth phenylephrine infusion regimens equally prevented maternal hypotension during cesarean delivery compared to intermittent boluses regimen. Due to higher number of physician interventions in the variable infusion regimen, the current recommendations which favor this regimen over fixed infusion regimen might need re-evaluation.

Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial

Tracheal intubation is common in the care of critically ill adults and is frequently complicated by hypotension, cardiac arrest, or death. We aimed to evaluate administration of an intravenous fluid bolus to prevent cardiovascular collapse during intubation of critically ill adults. We did a pragmatic, multicentre, unblinded, randomised trial in nine sites (eight ICUs and one emergency department) around the USA. Critically ill adults (≥18 years) undergoing tracheal intubation were randomly assigned (1:1, block sizes of 2, 4, and 6, stratified by study site) to either an intravenous infusion of 500 mL of crystalloid solution or no fluid bolus. The primary outcome, assessed in the intention-to-treat population, was cardiovascular collapse, defined as a new systolic blood pressure <65 mm Hg; new or increased vasopressor receipt between induction and 2 min after tracheal intubation; or cardiac arrest or death within 1 h of tracheal intubation. Adverse events were assessed in the as-treated population. This trial, which is now complete, is registered with ClinicalTrials.gov, number NCT03026777. Patients were enrolled from Feb 6, 2017, to Jan 9, 2018, when the data and safety monitoring board stopped the trial on the basis of futility. By trial termination, 337 (63%) of 537 screened adults had been randomly assigned. Cardiovascular collapse occurred in 33 (20%) of 168 patients in the fluid bolus group compared with 31 (18%) of 169 patients in the no fluid bolus group (absolute difference 1·3% [95% CI -7·1% to 9·7%]; p=0·76). The individual components of the cardiovascular collapse composite outcome did not differ between groups (new systolic blood pressure <65 mm Hg 11 [7%] in the bolus group vs ten [6%] in the no-bolus group, new or increased vasopressor 32 [19%] vs 31 [18%], cardiac arrest within 1 h seven [4%] vs two [1%], death within 1 h of intubation two [1%] vs one [1%]). In-hospital mortality was not significantly different in the fluid bolus group (48 [29%]) compared with no fluid bolus (59 [35%]). Administration of an intravenous fluid bolus did not decrease the overall incidence of cardiovascular collapse during tracheal intubation of critically ill adults compared with no fluid bolus in this trial. US National Institutes of Health.