Conservative Fluid Management Research Articles

Identifying novel clinical phenotypes of acute respiratory distress syndrome using trajectories of daily fluid balance: a secondary analysis of randomized controlled trials

BackgroundPreviously identified phenotypes of acute respiratory distress syndrome (ARDS) could not reveal the dynamic change of phenotypes over time. We aimed to identify novel clinical phenotypes in ARDS using trajectories of fluid balance, to test whether phenotypes respond differently to different treatment, and to develop a simplified model for phenotype identification.MethodsFACTT (conservative vs liberal fluid management) trial was classified as a development cohort, joint latent class mixed models (JLCMMs) were employed to identify trajectories of fluid balance. Heterogeneity of treatment effect (HTE) for fluid management strategy across phenotypes was investigated. We also constructed a parsimonious probabilistic model using baseline data to predict the fluid trajectories in the development cohort. The trajectory groups and the probabilistic model were externally validated in EDEN (initial trophic vs full enteral feeding) trial.ResultsUsing JLCMM, we identified two trajectory groups in the development cohort: Class 1 (n = 758, 76.4% of the cohort) had an early positive fluid balance, but achieved negative fluid balance rapidly, and Class 2 (n = 234, 24.6% of the cohort) was characterized by persistent positive fluid balance. Compared to Class 1 patients, patients in Class 2 had significantly higher 60-day mortality (53.5% vs. 17.8%, p < 0.001), and fewer ventilator-free days (0 vs. 20, p < 0.001). A significant HTE between phenotypes and fluid management strategies was observed in the FACTT. An 8-variables model was derived for phenotype assignment.ConclusionsWe identified and validated two novel clinical trajectories for ARDS patients, with both prognostic and predictive enrichment. The trajectories of ARDS can be identified with simple classifier models.

Fluid management and active fluid removal practices: a global survey of paediatric critical care physicians

AimsFluid accumulation (FA) in critically ill children is associated with poor clinical outcomes. While conservative fluid management has been proposed, evidence to guide practice is scarce. We surveyed paediatric critical care (PCC) physicians worldwide regarding their perceptions of FA, active fluid removal (AFR) practices, safety parameters, and willingness to participate in a clinical trial on the topic.MethodsCross-sectional international electronic survey of PCC physicians, distributed through research networks worldwide.ResultsA total of 409 PCC physicians from 48 countries participated in the survey; 40% (164/409) cared for cardiac patients. The majority believed FA was a modifiable source of morbidity (88%, 359/407) and expressed support for a trial on conservative fluid management trial (94%, 383/407). Restriction of maintenance fluid was more commonly practiced (87%, 335/387) than resuscitation fluid (54%, 210/387), with variability observed among individuals and patient categories. AFR was widely practiced (93%, 361/387), yet significant differences existed in patient selection, timing, modality, and rate. The most common reported time for starting AFR was 48 h (49%, 172/384), with most respondents (92%, 355/385) comfortable doing so in the setting of catecholamine infusions. While most respondents would continue diuretics with mild electrolyte or acid–base disturbances, 52% (179/342) would withhold them in cases of mild hypotension.ConclusionsFluid accumulation remains a significant concern among paediatric intensivists. The observed practice variability underscores the challenges in establishing evidence-based guidelines. Our survey highlights an urgent need for randomized trials in this field and provides valuable insights to inform the design of such future studies.

Controlled Mechanical Ventilation in Critically Ill Patients and the Potential Role of Venous Bagging in Acute Kidney Injury.

A very low incidence of acute kidney injury (AKI) has been observed in COVID-19 patients purposefully treated with early pressure support ventilation (PSV) compared to those receiving mainly controlled ventilation. The prevention of subdiaphragmatic venous congestion through limited fluid intake and the lowering of intrathoracic pressure is a possible and attractive explanation for this observed phenomenon. Both venous congestion, or "venous bagging", and a positive fluid balance correlate with the occurrence of AKI. The impact of PSV on venous return, in addition to the effects of limiting intravenous fluids, may, at least in part, explain this even more clearly when there is no primary kidney disease or the presence of nephrotoxins. Optimizing the patient-ventilator interaction in PSV is challenging, in part because of the need for the ongoing titration of sedatives and opioids. The known benefits include improved ventilation/perfusion matching and reduced ventilator time. Furthermore, conservative fluid management positively influences cognitive and psychiatric morbidities in ICU patients and survivors. Here, it is hypothesized that cranial lymphatic congestion in relation to a more positive intrathoracic pressure, i.e., in patients predominantly treated with controlled mechanical ventilation (CMV), is a contributing risk factor for ICU delirium. No studies have addressed the question of how PSV can limit AKI, nor are there studies providing high-level evidence relating controlled mechanical ventilation to AKI. For this perspective article, we discuss studies in the literature demonstrating the effects of venous congestion leading to AKI. We aim to shed light on early PSV as a preventive measure, especially for the development of AKI and ICU delirium and emphasize the need for further research in this domain.

Modern mechanical ventilation strategies for the acute care surgeon: What you need to know.

Acute respiratory failure (ARF) is associated with significant morbidity and mortality in trauma and emergency surgery patients. Pulmonary complications following surgery among the most frequent and costly postoperative events. ARF support with mechanical ventilation is life-saving but may lead to ventilator-induced lung injury (VILI), worsening secondary injury. Decades of randomized clinical trials have demonstrated that evidence-based ventilator management can improve outcomes, but one-size-fits-all mechanical ventilation protocols fail to achieve true individualized, personalized care for ARF. This review presents the current evidence for mechanical ventilation support strategies for ARF including lung protective ventilation, judicious target setting, conservative fluid management appropriate light sedation, strategies to prevent ventilator-associated pneumonia and early attempts at ventilator weaning and extubation to be deployed to optimized patient outcomes. Specific mechanical ventilation strategies for patients with traumatic brain injury, obesity and acute respiratory distress syndrome will also be reviewed.

Acute Respiratory Distress Syndrome: A Case Report and Review on Diagnosis and Novel Interventions in Management

Acute respiratory distress syndrome is a type of acute diffuse lung injury, frequently brought on by sepsis, trauma, and severe pulmonary infections and continues to be one of the major causes of morbidity and mortality in critically ill patients, despite the constantly involving advancements. The management strategies have constantly evolved with a wide array of ventilation strategies, conservative fluid management, neuromuscular blockade. As we move into the post pandemic Era, the mortality rate due to ARDS continues to remain high hence improving patient outcomes is the primary goal of the various treatment approaches. The two most effective techniques are still prone ventilation and lung protection ventilation. In this report we aim to present the case of a 30-year old female who has undergone left lobectomy in childhood and presents to the clinic with palpitations, fever, shortness of breath and spasmodic cough with phlegm. The workup included chest Xray, CT scan, arterial blood gas with electrolytes, echocardiography and urinanalysis. Based on clinical and imaging findings, the diagnosis of acute respiratory distress syndrome was made. Against the background of intensive treatment, the patient’s condition improved to some extent, with positive dynamics. Lung protective ventilation, prone ventilation, high frequency oscillatory ventilation among many other novel interventions and futuristic direction of ARDS with mesenchymal stromal cells and Ulinastatin, a urinary glycoprotein and protease inhibitor provides a ray of hope in the management of this acute condition. Keywords: Acute respiratory distress syndrome; hypoplasia; lung ventilation; prone ventilation; mesenchymal stem cells; ulinastatin

Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program

BackgroundOur thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated. MethodsFrom 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared. ResultsThe cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups. ConclusionsERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.

Hyperhydration to Improve Kidney Outcomes in Children with Shiga Toxin-Producing E. coli Infection: a multinational embedded cluster crossover randomized trial (the HIKO STEC trial)

BackgroundShiga toxin-producing E. coli (STEC) infections affect children and adults worldwide, and treatment remain solely supportive. Up to 15–20% of children infected by high-risk STEC (i.e., E. coli that produce Shiga toxin 2) develop hemolytic anemia, thrombocytopenia, and kidney failure (i.e., hemolytic uremic syndrome (HUS)), over half of whom require acute dialysis and 3% die. Although no therapy is widely accepted as being able to prevent the development of HUS and its complications, several observational studies suggest that intravascular volume expansion (hyperhydration) may prevent end organ damage. A randomized trial is needed to confirm or refute this hypothesis.MethodsWe will conduct a pragmatic, embedded, cluster-randomized, crossover trial in 26 pediatric institutions to determine if hyperhydration, compared to conservative fluid management, improves outcomes in 1040 children with high-risk STEC infections. The primary outcome is major adverse kidney events within 30 days (MAKE30), a composite measure that includes death, initiation of new renal replacement therapy, or persistent kidney dysfunction. Secondary outcomes include life-threatening, extrarenal complications, and development of HUS. Pathway eligible children will be treated per institutional allocation to each pathway. In the hyperhydration pathway, all eligible children are hospitalized and administered 200% maintenance balanced crystalloid fluids up to targets of 10% weight gain and 20% reduction in hematocrit. Sites in the conservative fluid management pathway manage children as in- or outpatients, based on clinician preference, with the pathway focused on close laboratory monitoring, and maintenance of euvolemia. Based on historical data, we estimate that 10% of children in our conservative fluid management pathway will experience the primary outcome. With 26 clusters enrolling a mean of 40 patients each with an intraclass correlation coefficient of 0.11, we will have 90% power to detect a 5% absolute risk reduction.DiscussionHUS is a devastating illness with no treatment options. This pragmatic study will determine if hyperhydration can reduce morbidity associated with HUS in children with high-risk STEC infection.Trial registrationClinicalTrials.gov NCT05219110. Registered on February 1, 2022.

2045. IVAC Plus in the Time of COVID-19: An Imperfect Metric?

Abstract Background Prior to the COVID-19 pandemic, the incidence of infection related ventilator associated complications plus possible ventilator associated pneumonias (IVAC+) was decreasing; however, as the number of COVID-19 hospitalizations increased, so did the number of IVAC+. Our goal was to investigate if there was a relationship between these two occurrences. Methods This was a retrospective study at the Audie Murphy VA Hospital (ALMVA) from October 2017 to December 2021. ALMVA is a level 1A facility with 232 beds and an active bone marrow transplant program in San Antonio, Texas. This study included acute care COVID-19 hospitalizations per 10,000 bed days of care and IVAC+ per 1000 ventilator days. Monthly acute and intensive care COVID-19 hospitalization rates were correlated with IVAC+ rates using Pearson correlation for the overall study period and in the subgroup of COVID pandemic months (Mar 2020-December 2021). Results During the overall study period, COVID-19 hospitalization rates were significantly associated with IVAC+ rates: acute care correlation 0.86 (p&amp;lt; 0.01) and intensive care correlation 0.33 (p=0.04). During the COVID-19 pandemic months, acute care COVID-19 hospitalizations but not intensive care COVID-19 hospitalizations, were correlated with IVAC+ (correlation 0.90, p&amp;lt; 0.01 and correlation 0.21, p=0.53, respectively). There were 0 IVAC+ before the pandemic months and this rose to 14 during (0 per 1000 ventilator days and 3.05 per 1000 ventilator days, respectively). All but 2 cases of IVAC+ had COVID-19. COVID-19 Hospitalizations and IVAC Plus, October 2017 to December 2021 A sharp increase in COVID-19 hospitalizations correlated with a rise in patients meeting criteria for IVAC Plus. Conclusion The natural history of COVID-19 disease has presented challenges for IVAC+ monitoring. COVID-19 can cause persistent fevers and worsening oxygenation, and antibiotic use is common during periods of clinical deterioration. These factors can fulfill criteria for IVAC+. In this study, each IVAC+ case was traced for safety bundle compliance. These bundles were followed, along with conservative fluid management, low tidal volume ventilation, and sedation breaks. Patients met NHSN criteria for IVAC+ despite these measures and most had COVID-19. Given the common occurrence of IVAC+ in COVID-19 patients, futures studies are needed to define if IVAC+ are preventable in this population and whether IVAC+ surveillance has any value among COVID-19 patients. Disclosures All Authors: No reported disclosures.

Terlipressin combined with conservative fluid management attenuates hemorrhagic shock-induced acute kidney injury in rats

Hemorrhagic shock (HS), a major cause of trauma-related mortality, is mainly treated by crystalloid fluid administration, typically with lactated Ringer’s (LR). Despite beneficial hemodynamic effects, such as the restoration of mean arterial pressure (MAP), LR administration has major side effects, including organ damage due to edema. One strategy to avoid such effects is pre-hospitalization intravenous administration of the potent vasoconstrictor terlipressin, which can restore hemodynamic stability/homeostasis and has anti-inflammatory effects. Wistar rats were subjected to HS for 60 min, at a target MAP of 30–40 mmHg, thereafter being allocated to receive LR infusion at 3 times the volume of the blood withdrawn (liberal fluid management); at 2 times the volume (conservative fluid management), plus terlipressin (10 µg/100 g body weight); and at an equal volume (conservative fluid management), plus terlipressin (10 µg/100 g body weight). A control group comprised rats not subjected to HS and receiving no fluid resuscitation or treatment. At 15 min after fluid resuscitation/treatment, the blood previously withdrawn was reinfused. At 24 h after HS, MAP was higher among the terlipressin-treated animals. Terlipressin also improved post-HS survival and provided significant improvements in glomerular/tubular function (creatinine clearance), neutrophil gelatinase-associated lipocalin expression, fractional excretion of sodium, aquaporin 2 expression, tubular injury, macrophage infiltration, interleukin 6 levels, interleukin 18 levels, and nuclear factor kappa B expression. In terlipressin-treated animals, there was also significantly higher angiotensin II type 1 receptor expression and normalization of arginine vasopressin 1a receptor expression. Terlipressin associated with conservative fluid management could be a viable therapy for HS-induced acute kidney injury, likely attenuating such injury by modulating the inflammatory response via the arginine vasopressin 1a receptor.

Longitudinal phenotypes in patients with acute respiratory distress syndrome: a multi-database study

BackgroundPreviously identified phenotypes of acute respiratory distress syndrome (ARDS) have been limited by a disregard for temporal dynamics. We aimed to identify longitudinal phenotypes in ARDS to test the prognostic and predictive enrichment of longitudinal phenotypes, and to develop simplified models for phenotype identification.MethodsWe conducted a multi-database study based on the Chinese Database in Intensive Care (CDIC) and four ARDS randomized clinical trials (RCTs). We employed latent class analysis (LCA) to identify longitudinal phenotypes using 24-hourly data from the first four days of invasive ventilation. We used the Cox regression model to explore the association between time-varying respiratory parameters and 28-day mortality across phenotypes. Phenotypes were validated in four RCTs, and the heterogeneity of treatment effect (HTE) was investigated. We also constructed two multinomial logistical regression analyses to develop the probabilistic models.FindingsA total of 605 ARDS patients in CDIC were enrolled. The three-class LCA model was identified and had the optimal fit, as follows: Class 1 (n = 400, 66.1% of the cohort) was the largest phenotype over all study days, and had fewer abnormal values, less organ dysfunction and the lowest 28-day mortality rate (30.5%). Class 2 (n = 102, 16.9% of the cohort) was characterized by pulmonary mechanical dysfunction and had the highest proportion of poorly aerated lung volume, the 28-day mortality rate was 47.1%. Class 3 (n = 103, 17% of the cohort) was correlated with extra-pulmonary dysfunction and had the highest 28-day mortality rate (56.3%). Time-varying mechanical power was more significantly associated with 28-day mortality in Class 2 patients compared to other phenotypes. Similar phenotypes were identified in four RCTs. A significant HTE between phenotypes and treatment strategies was observed in the ALVEOLI (high PEEP vs. low PEEP) and the FACTT trials (conservative vs. liberal fluid management). Two parsimonious probabilistic models were constructed to identify longitudinal phenotypes.InterpretationWe identified and validated three novel longitudinal phenotypes for ARDS patients, with both prognostic and predictive enrichment. The phenotypes of ARDS can be accurately identified with simple classifier models, except for Class 3.

A Comprehensive Review of the Management of Acute Respiratory Distress Syndrome.

Acute respiratory distress syndrome (ARDS) is an inflammatory process in the lungs that induces non-hydrostatic protein-rich pulmonary edema.ARDS occurs in roughly halfof coronavirus disease 2019 (COVID-19) pneumonia patients, with most of them requiring intensive care. Oxygen saturation, partial pressure of the oxygen, and the fraction of the inspired oxygen are health indicators that may indicate a severe illnessnecessitating further investigation.As treatments have evolved, a typical pattern of ARDS has likewise evolved. In cases where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (partial pressure to fractional inspired oxygenratio <20), prone positioning was recommended for at least 16 hours per day. By contrast, high-frequency oscillation was not recommended. The use of inhaled vasodilators was recommended in patients with persistent hypoxemia despite invasive ventilation and prone position until extracorporeal membrane oxygenation (ECMO). The use of a conservative fluid management strategy was suggested for all patients. Mechanical ventilation with high positive end-expiratory pressure (PEEP) was suggestedfor patients with ARDS with a ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios. ECMO was suggested as an adjunct to protective mechanical ventilation for patients with severe ARDS. In the absence of adequate evidence, research recommendations were made for corticosteroids and extracorporeal carbon dioxide removal. While decades of research have been conducted, treatment options for underlying pathologies remain limited, and mechanical ventilation, which removes carbon dioxide from the body, remains essential to achieving better clinical outcomes. This review aims to identify the best ARDStreatments that are currently available.

Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome.

Purpose of ReviewTo summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS).Recent FindingsARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered.SummaryThe management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.

Shock Management Without Formal Fluid Responsiveness Assessment: A Retrospective Analysis of Fluid Responsiveness and Its Outcomes.

In order to quantify fluid administration and evaluate the clinical consequences of conservative fluid management without hemodynamic monitoring in undifferentiated shock, we analyzed previously collected data from a study of carotid Doppler monitoring as a predictor of fluid responsiveness (FR). This study was a retrospective analysis of data collected from a single tertiary academic center from a previous study. Seventy-four patients were included for post-hoc analysis, and 52 of them were identified as fluid responsive (cardiac output increase > 10% with passive leg raise) according to NICOMTM bioreactance monitoring (Cheetah Medical, Newton Center, MA, USA). Treating teams provided standard of care conservative fluid resuscitation but were blinded to independently performed FR testing results. Outcomes were compared between fluid responsive and fluid non-responsive patients. Primary outcome measures were volume fluids administered and net fluid balance 24- and 72-hour post-FR assessment. Secondary outcome measures included change in vasopressor requirements, mean peak lactate levels, length of hospital/intensive care unit stay, acute respiratory failure, hemodialysis requirement, and durations of vasopressors and mechanical ventilation. Mean fluids administered within 72 hours were similar between fluid non-responsive and fluid responsive patients (139 mL/kg [95% confidence interval [CI]: 102.00-175.00] vs.136 mL/kg [95% CI: 113.00-158.00], p = 0.92, respectively). We observed an insignificant trend toward higher 28-day mortality among fluid non-responsive patients (36% vs.19%, p = 0.14). Volume of fluids administered significantly correlated with adverse outcomes such as increased hemodialysis requirements (32 patients, 43%), (odds ratio [OR] = 1.7200, p = 0.0018). Subgroup analysis suggested administering ≥ 30 mL/kg fluids to fluid responsive patients had a trend toward increased mortality (25% vs.0%, p = 0.09) and a significant increase in hemodialysis (55% vs.17%, p = 0.024). Without formal FR assessment, similar amounts of total fluids were administered in both fluid responsive and non-responsive patients. As greater volumes of intravenous fluids administered were associated with adverse outcomes, we suggest that dedicated FR assessment may be a beneficial utility in early shock resuscitation.

Use of albumin : State of the art

Die Saline vs. Albumin Fluid Evaluation (SAFE) Studie hat gezeigt, dass der Einsatz von Albumin als Infusionslösung im Bereich der Volumentherapie fast überall sicher ist. Eine Ausnahme stellt hypoonkotisches Albumin beim Schädel-Hirn-Trauma dar. Während für Patientinnen und Patienten mit Leberzirrhose klare Indikationen existieren, fehlen für andere Einsatzgebiete noch große Studien, die einen klinisch relevanten Vorteil jenseits der hämodynamischen Wirksamkeit zweifelsfrei zeigen konnten und damit einen breiteren Einsatz rechtfertigen würden. Bei der „Large-volume“-Parazentese, der spontanen bakteriellen Peritonitis, aber auch beim hepatorenalen Syndrom ist der Einsatz von Albumin aufgrund eines klinischen Benefits in randomisierten kontrollierten Studien klar empfohlen und etabliert. Beim septischen Schock kann ein Einsatz von Albumin in Erwägung gezogen werden, wobei sich zwei große Studien zu dieser Fragestellung in Deutschland und Italien noch in der Rekrutierungsphase befinden. Für viele Einsatzgebiete in der Volumentherapie gilt, dass Albumin vor allem dann eingesetzt werden kann, wenn andere Maßnahmen zur hämodynamischen Stabilisierung bereits ausgeschöpft sind. Das gilt sowohl für die Volumengabe bei Hypovolämie als auch für das konservative Volumenmanagement einschließlich der sog. Deresuscitation-Phase. Inwieweit die Korrektur einer ausgeprägten Hypoalbuminämie durch Gabe von exogenem Albumin auch das schlechtere Outcome solcher Patientinnen und Patienten verbessert, ist ebenfalls Teil laufender Studien. Auf dem Weg zu einem Mehr an individualisierter Therapie kann in Zukunft die Hypoalbuminämie bei Entscheidungen für oder gegen einen Einsatz von intravenösen Albuminlösungen in der Volumentherapie eine wichtige Rolle einnehmen.

Management of the patient with the open abdomen.

The aim of this study was to outline the management of the patient with the open abdomen. An open abdomen approach is used after damage control laparotomy, to decrease risk for postsurgery intra-abdominal hypertension, if reoperation is likely and after primary abdominal decompression.Temporary abdominal wall closure without negative pressure is associated with higher rates of intra-abdominal infection and evisceration. Negative pressure systems improve fascial closure rates but increase fistula formation. Definitive abdominal wall closure should be considered once oedema has subsided and the patient has stabilized. Delayed abdominal closure after trauma (>24-48 h) is associated with less achievement of fascial closure and more complications. Protective lung ventilation should be employed early, particularly if respiratory compromise is evident. Conservative fluid management and less sedation may decrease delirium and increase definitive abdominal closure rates. Extubation may be performed before definitive abdominal closure in selected patients. Antibiotic therapy should be brief, targeted and guideline concordant. Survival depends on the underlying disease, the closure method and the course of hospitalization. Changes in the treatment of patients with the open abdomen include negative temporary closure, conservative fluid management, early protective lung ventilation, decreased sedation and extubation before abdominal closure in selected patients.

ARDS Patients Exhibiting a "Hyperinflammatory Anasarca" Phenotype Could Benefit From a Conservative Fluid Management Strategy.

Object: The fluid management strategy in ARDS is not very clear. A secondary analysis of RCT data was conducted to identify patients with ARDS benefitting from a conservative strategy of fluid management.Methods: The data of this study were downloaded from the ARDS network series of randomized controlled trials (Conservative Strategy vs. Liberal Strategy in 2006). Based on the clinical feature of patients, within the first 24 h after admission, clustering was performed using the k-means clustering algorithm to identify the phenotypes of ARDS. Survival was analyzed using the Kaplan-Meier survival analysis to assess the effect of the two fluid management strategies on the 90-day cumulative mortality. Categorical/dichotomic variables were analyzed by the chi-square test. Continuous variables were expressed as the mean and standard deviation and evaluated through a one-way ANOVA. A P-value < 0.05 was defined as the statistically significant cut-off value.Results: A total of 1,000 ARDS patients were enrolled in this unsupervised clustering research study, of which 503 patients were treated with a conservative fluid-management strategy, and 497 patients were treated with a liberal fluid-management strategy. The first 7-day cumulative fluid balance in patients with the conservative strategy and liberal strategy were −136 ± 491 ml and 6,992 ± 502 ml, respectively (P < 0.001). Four phenotypes were found, and the conservative fluid-management strategy significantly improved the 90-day cumulative mortality compared with the liberal fluid-management strategy (HR = 0.532, P = 0.024) in patients classified as “hyperinflammatory anasarca” phenotype (phenotype II). The characteristics of this phenotype exhibited a higher WBC count (20487.51 ± 7223.86/mm3) with a higher incidence of anasarca (8.3%) and incidence of shock (26.6%) at baseline. The furthermore analysis found that the conservative fluid management strategy was superior to the liberal fluid management strategy in avoiding superinfection (10.10 vs. 14.40%, P = 0.037) and returned to assisted breathing (4.60 vs. 16.20%, P = 0.030) in patients classified as “hyperinflammatory anasarca” phenotype. In addition, patients with other phenotypes given the different fluid management strategies did not show significant differences in clinical outcomes.Conclusion: Patients exhibiting a “hyperinflammatory anasarca” phenotype could benefit from a conservative fluid management strategy.

Cumulative Fluid Balance during Extracorporeal Membrane Oxygenation and Mortality in Patients with Acute Respiratory Distress Syndrome.

Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in cases of severe acute respiratory distress syndrome (ARDS) with profound hypoxemia. However, the need for high-volume fluid resuscitation and blood transfusions after ECMO initiation introduces a risk of fluid overload. Positive fluid balance is associated with mortality in critically ill patients, and conservative fluid management for ARDS patients has been shown to shorten both the duration of mechanical ventilation and time spent in intensive care, albeit without a significant effect on survival. Nonetheless, few studies have addressed the influence of fluid balance on clinical outcomes in severe ARDS patients undergoing ECMO. In the current retrospective study, we examined the impact of cumulative fluid balance (CFB) on hospital mortality in 152 cases of severe ARDS treated using ECMO. Overall hospital mortality was 53.3%, and we observed a stepwise positive correlation between CFB and the risk of death. Cox regression models revealed that CFB during the first 3 days of ECMO was independently associated with higher hospital mortality (adjusted hazard ratio 1.110 [95% CI 1.027–1.201]; p = 0.009). Our findings indicate the benefits of a conservative treatment approach to avoid fluid overload during the early phase of ECMO when dealing with severe ARDS patients.

The Role of Alveolar Edema in COVID-19.

The coronavirus disease 2019 (COVID-19) has spread over the world for more than one year. COVID-19 often develops life-threatening hypoxemia. Endothelial injury caused by the viral infection leads to intravascular coagulation and ventilation-perfusion mismatch. However, besides above pathogenic mechanisms, the role of alveolar edema in the disease progression has not been discussed comprehensively. Since the exudation of pulmonary edema fluid was extremely serious in COVID-19 patients, we bring out a hypothesis that severity of alveolar edema may determine the size of poorly-ventilated area and the blood oxygen content. Treatments to pulmonary edema (conservative fluid management, exogenous surfactant replacements and ethanol–oxygen vapor therapy hypothetically) may be greatly helpful for reducing the occurrences of severe cases. Given that late mechanical ventilation may cause mucus (edema fluid) to be blown deep into the small airways, oxygen therapy should be given at the early stages. The optimal time and blood oxygen saturation (SpO2) threshold for oxygen therapy are also discussed.

Coronavirus disease 2019 respiratory failure: what is the best supportive care for patients who require ICU admission?

Purpose of reviewCurrently, there is no cure for SARS-CoV-2 infection, yet hospital mortality rates for COVID-19 have improved over the course of the pandemic and may be due in part to improved supportive care in the ICU. This review highlights the evidence for and against various ICU supportive therapies for the treatment of critically ill patients with COVID-19.Recent findingsEarly in the pandemic, there was great interest in novel ICU supportive care, both for the benefit of the patient, and the safety of clinicians. With a few exceptions (e.g. prone ventilation of nonintubated patients), clinicians abandoned most of these approaches (e.g. early intubation, avoidance of high flow or noninvasive ventilation). Standard critical care measures, especially for the treatment of severe viral respiratory infection including acute respiratory distress syndrome (ARDS) were applied to patients with COVID-19 with apparent success.SummaryIn general, the COVID-19 pandemic reaffirmed the benefits of standard supportive care for respiratory failure and in particular, recent advances in ARDS treatment. Prone ventilation of nonintubated patients, an approach that was adopted early in the pandemic, is associated with improvement in oxygenation, but its impact on clinical outcome remains unclear. Otherwise, prone mechanical ventilation and avoidance of excessive tidal volumes, conservative fluid management, antibiotic stewardship and early evaluation for extracorporeal membrane oxygenation (ECMO) -- basic tenants of severe respiratory infections and ARDS care -- remain at the core of management of patients with severe COVID-19.

Induced hypernatremia in patients with moderate-to-severe ARDS: a randomized controlled study

BackgroundInduced hypernatremia and hyperosmolarity is protective in animal models of lung injury. We hypothesized that increasing and maintaining plasma sodium between 145 and 150 mmol/l in patients with moderate-to-severe ARDS would be safe and will reduce lung injury. This was a prospective randomized feasibility study in moderate-to-severe ARDS, comparing standard care with intravenous hypertonic saline to achieve and maintain plasma sodium between 145 and 150 mmol/l for 7 days (HTS group). Both groups of patients were managed with lung protective ventilation and conservative fluid management. The primary outcome was 1-point reduction in lung injury score (LIS) or successful extubation by day 7.ResultsForty patients were randomized with 20 in each group. Baseline characteristics of severity of illness were well balanced. Patients in the HTS group had higher plasma sodium levels during the first 7 days after randomization when compared with the control group (p = 0.04). Seventy five percent (15/20) of patients in the HTS group were extubated or had ≥ 1-point reduction in LIS compared with 35% (7/20) in the control group (p = 0.02). There was also a decrease in length of mechanical ventilation and hospital length of stay in the HTS group.ConclusionWe have shown clinical improvement in patients with moderate-to-severe ARDS following induced hypernatremia, suggesting that administration of hypertonic saline is a safe and feasible intervention in patients with moderate-to-severe ARDS. This suggests progress to a phase II study.Clinical Trial Registration Australian and New Zealand Clinical Trials Registry (ACTRN12615001282572)