Crystalloid Fluid Research Articles

Opportunities for achieving resuscitation goals during the inter-emergency department transfer of severe sepsis patients by emergency medical services: A case series

PurposeThis study aimed to describe the care provide by Emergency Medical Services (EMS) to severe sepsis patients being transferred between acute care hospitals and identify how that care contributes to sepsis care goals. MethodsThis was a single-center retrospective cohort study conducted at a 60,000-visit Midwestern academic emergency department, using run reports from 13 ambulance services transferring from 9 hospitals. Results39 patients were included in the final cohort, transferred by 13 ambulance services from 9 hospitals. Included patients were adults with severe sepsis transferred by ambulance between 2009 and 2014. Thirty-nine patients were included in this cohort. 41% (n = 12) of patients received an adequate fluid bolus of 30 mL/kg (median 42.9 mL/kg crystalloid fluid, IQR 8.0 mL/kg) prior to tertiary care arrival. Seventeen percent (n = 2) of patients completed the adequate bolus during transfer time. Broad-spectrum antibiotics were initiated during transfer in 2 patients. ConclusionsEMS sepsis care during transfer was limited. EMS crews primarily continued treatments previously initiated and did not take additional steps toward resuscitation targets. Data suggests the inter-emergency department transfer period may provide an opportunity to continue working toward treatment targets, though the time is currently underutilized.

Sepsis - What's new in 2019?

Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics. Traditional therapies such as type of crystalloid fluid administration and steroid therapy for sepsis are currently under re-evaluation. Angiotensin II is investigated for reversing vasodilatory shock. The role of capillary endothelium leak and cellular metabolism can be affected by vitamin C and thiamine levels. Biomarker level trends, specifically PCT, can aid clinical suspicion of infection. Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.

Tissue Inflammatory Markers and Oxidative Stress in Swine Subjected to a 40% TBSA Burn Injury

Burn injury is well known to induce a robust inflammatory response and hypermetabolic state. Intravenous (IV) crystalloid fluid resuscitation of burn patients is the foundation of modern burn care to improve tissue perfusion and outcomes. However, under military scenarios of far‐forward burn care or under civilian mass casualty situations, the availability of large volumes of such fluids for IV burn resuscitation will be logistically challenging and definitive burn care may be delayed for days. More recently, enteral resuscitation of burns has received renewed attention and some evidence suggests that it may reduce IV fluid requirements to support urine output. The present study investigated the early response of tissue inflammatory markers and evidence for oxidative stress in swine subjected to a 40% burn and resuscitated with enteral fluids compared to no fluids or a standard of care IV fluid regimen. Anesthetized Yorkshire swine (n=6 per group) were subjected to a 40% full thickness total body surface area (TBSA) burn with brass probes heated to 100°C. They were then randomized to 4 groups: 1) no fluid (NF), 2) 15 ml/kg/d WHO oral rehydration solution (ORS) (15‐ORS), 3) 70 ml/kg ORS (70‐ORS) or 4) 2 ml/kg/% burn IV lactated Ringer's (Modified Brooke (MB) formula‐ a standard of care). After 48 h, animals were euthanized and heart, liver, kidney, lung and small intestine collected and analyzed for tissue cytokine levels and indices of oxidative stress. As expected, urine output was higher in the 70‐ORS and MB groups than the NF group (p<0.01). Although plasma creatinine and BUN peaked 6 h after burn, levels returned to baseline by 48 h in all groups except 15‐ORS and NF. In the kidney, levels of IL‐1β, IL‐6 and TNF‐α tended to be higher in the 70‐ORS and MB groups, whereas IL‐10 levels were similar among groups. In liver, heart and jejunum, only IL‐1β levels tended to be higher in MB than the other groups, with a similar trend in IL‐10 concentrations. With regard to oxidant status in kidney, total antioxidant levels, glutathione reductase (GR) and glutathione peroxidase activities were higher in 70‐ORS than the other groups. Mn‐superoxide dismutase (SOD) activity was higher in both 70‐ORS and MB groups, with no differences in catalase activity or nitric oxide levels. In liver, the lowest levels of total antioxidants, SOD, GR and catalase activities were observed in the NF groups compared to the others. No significant differences in indices of antioxidant status were observed in jejunum, heart or lung among groups. Typically, these variables in 15‐ORS were similar to the NF group in all tissues. The results of this study indicate that enteral fluids may be as effective as a standard of care IV fluid regimen in maintaining antioxidant status in vital organs without major changes in pro‐inflammatory cytokines. As such, this oral resuscitation may prove lifesaving in resource poor environments and reduce potential IVfluid‐related complications until definitive clinical care is available.Support or Funding InformationFunded by US Army MRMCThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients After Cardiac Surgery (the HAS FLAIR Study)

To compare the effects of fluid bolus therapy using 20% albumin versus crystalloid on fluid balance, hemodynamic parameters, and intensive care unit (ICU) treatment effects in post-cardiac surgery patients. Sequential period open-label pilot study. University teaching hospital. One hundred adult cardiac surgery patients who were prescribed fluid bolus therapy to correct hypotension or perceived hypovolemia or to optimize cardiac index during the first 24 hours in the ICU. The first 50 patients were treated with crystalloid fluid bolus therapy in the first period (control), and 50 patients with up to 2 treatments of 100 mL of 20% albumin fluid bolus therapy in the second period (intervention), followed by crystalloid therapy if needed. Demographic characteristics were similar at baseline. The intervention was associated with a less positive median fluid balance in the first 24 hours (albumin: 1,100 [650-1,960] v crystalloid: 1,970 [1,430-2,550] p = 0.001), fewer episodes of fluid bolus therapy (3 [2-5] v 5 [4-7]; p < 0.0001) and a lesser volume of fluid bolus therapy (700 [200-1,450] v 1,500 mL/24 h [1,100-2,250]; p < 0.0001). The intervention also was associated with a decreased median overall dose of norepinephrine in the first 24 hours of ICU stay (19 [0-52] v 47 µg/kg/24 hours [0-134]; p = 0.025) and shorter median time to cessation of norepinephrine (17 [5-28] v 28 hours [20-48]; p = 0.002). Post-cardiac surgery fluid bolus therapy with 20% albumin when compared with crystalloid fluid resulted in less positive fluid balance as well as several hemodynamic and potential ICU treatment advantages.

The effect of a novel intravenous fluid (Oxsealife®) on recovery from haemorrhagic shock in pigs.

Blood transfusion is given according to haemoglobin thresholds aimed at restoration of arterial oxygen-carrying capacity. Patient survival after severe haemorrhagic shock depends on restoration of microvascular perfusion, tissue oxygen delivery, endothelial function and organ integrity. We investigated a novel crystalloid fluid designed for tissue oxygen delivery, Oxsealife® , with components that generate microvascular nitric oxide and scavenge reactive oxygen species generated during ischaemia-reperfusion injury. The amount of dissolved oxygen in blood progressively increased during step-wise invitro haemodilution with this fluid, suggesting that the oxygen solubility coefficient of blood is dynamic, not static. We performed a pilot safety and efficacy study to compare resuscitation with this novel crystalloid vs. whole blood transfusion in a swine haemorrhagic shock model with animals bled to an arterial lactate oxygen debt target. Despite contributing no haemoglobin, viscosity nor oncotic potential, resuscitation with Oxsealife after severe haemorrhagic shock restored central haemodynamic parameters comparable to stored allogeneic blood transfusion. Tissue perfusion, oxygenation and metabolic outcomes were equivalent between treatment groups. Increased consumption of bicarbonate in animals given Oxsealife suggested greater capillary recruitment and enhanced clearance of acidic tissue metabolites. Serum markers of organ function, animal activity during recovery and histological analysis of tissue morphology and endothelial glycocalyx integrity confirmed functional recovery from haemorrhagic shock. We conclude that recovery of tissue oxygen delivery and organ function after haemorrhagic shock may not be dependent on treatments that increase haemoglobin levels. Oxsealife shows promise for treatment of severe haemorrhagic shock and may reduce the requirement for allogeneic blood products.

The haemodynamic effects of crystalloid and colloid volume resuscitation on primary, derived and efficiency variables in post-CABG patients

BackgroundRecent studies in haemodynamic management have focused on fluid management and assessed its effects in terms of increase in cardiac output based on fluid challenges or variations in pulse pressure caused by cyclical positive pressure ventilation. The theoretical scope may be characterised as Starling-oriented. This approach ignores the actual events of right-sided excitation and left-sided response which is consistently described in a Guyton-oriented model of the cardiovascular system.AimBased on data from a previous study, we aim to elucidate the primary response to crystalloid and colloid fluids in terms of cardiac output, mean blood pressure and right atrial pressure as well as derived and efficiency variables defined in terms of Guyton venous return physiology.MethodRe-analyses of previously published data.ResultsCardiac output invariably increased on infusion of crystalloid and colloid solutions, whereas static and dynamic efficiency measures declined in spite of increasing pressure gradient for venous return.DiscussionWe argue that primary as well as derived and efficiency measures should be reported and discussed when haemodynamic studies are reported involving fluid administrations.

Nurses' Indications for Administration of Perioperative Intravenous Fluid Therapy—A Prospective, Descriptive, Single-Center Cohort Study

To examine whether nurse anesthetists and postanesthesia nurses' administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit is based on evidence. Secondarily to investigate if providing indications for IV fluid administration changed nursing practice. Prospective, descriptive, single-center study in Scandinavia comparing two cohorts. Descriptive, fluid volume, and type data were obtained in both cohorts. Cohort 1 (n=126) was used as baseline data. In cohort 2 (n=130), nurses recorded indications for type and volume of fluid therapy using a validated list. Analysis compared median volumes of crystalloid or colloid fluids of surgical types by cohort. Analysis compared frequency of given indication reasons for each IV fluid by surgical type. Basic static variables were chosen most frequently for indications of IV fluid needed for all surgeries except high-risk abdominal surgery where dynamic variables were more frequent. Signs and symptoms of inadequate tissue perfusion were only sparsely indicated. The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort2. Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signs of inadequate tissue perfusion when they make decisions about fluid administration. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. This indicates the need of a stronger intervention to change practice to follow evidence-based clinical guidelines.

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

IntroductionFluid resuscitation is a fundamental component of the management of critically ill patients, but whether choice of crystalloid affects patient outcomes remains controversial. Therefore, we performed this meta-analysis to compare the efficacy and safety of balanced crystalloids with normal saline. MethodsWe searched the MEDLINE, Cochrane Central and EMBASE up to October 2018 to identify randomized controlled trials (RCTs) that compared balanced crystalloids versus normal saline in critically ill patients. The primary outcome was mortality. The secondary results were the incidence of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). Two authors independently screened articles based on the inclusion and exclusion criteria. The meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. ResultsNine RCTs were identified. The pooled analyses showed that there were no significant differences in mortality (relative risk (RR) = 0.93, 95% confidence interval (CI) = 0.86, 1.01, P = 0.08), incidence of AKI (RR 0.94, 95% CI 0.88, 1.00, P = 0.06) or RRT use rate (RR 0.94, 95% CI 0.69, 1.27, P = 0.67) between balanced crystalloids and normal saline groups. However, TSA did not provide conclusive evidence. ConclusionsAmong critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding. Trial registrationA protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42018094857).

Magnitude and associated factors of Perioperative hypothermia in patients who underwent Elective surgery at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Background : Body temperature is a vital sign and 37°C is the mean core body temperature of a healthy human. Core body temperature is normally tightly regulated and maintained within narrow range. Perioperative hypothermia is one of the major problems during surgery and anesthesia that can affect operated patients. Methods: Institutional based cross-sectional study was conducted. Patient interview, chart review and temperature measurement were employed for data collection. Temperature was measured using tympanic membrane thermometer. SPSS version 20 software was used for analysis. binary logistic regression was used to look at associations anda p-value of &lt;0.05 was considered statistically significant.&#x0D; Result :The overall magnitude of preoperative, intra and post-operative hypothermia in this study was 16.2%, 53.2% and 31.3%, respectively. Age (AOR=7.15, 95% CI, 1.16, 43.99), coexisting illness (AOR, 3.32, 95% CI, 1.06; 10.36), preoperative hypothermia (AOR; 57; 95% CI; 7.1, 455.4), operation room temperature (AOR=1.91; 95 % CI, 1.04; 3.5) and crystalloid fluids administered (AOR; 2.3; 95% CI, 1.07, 4.9) were found to be factors associated with intraoperative hypothermia.&#x0D; Conclusion and recommendation: The magnitude of perioperative hypothermia remains high. Measures should focus on improving room temperature and warming up fluids. Susceptible patients like the aged and those with coexisting disease should be given extra attention.&#x0D;

Effects of chloride content of intravenous crystalloid solutions in critically ill adult patients: a meta-analysis with trial sequential analysis of randomized trials

BackgroundIntravenous crystalloid solutions are administered commonly for critically ill patients. We performed this meta-analysis of randomized trials with trial sequential analysis (TSA) to evaluate effects of chloride content of intravenous crystalloid solutions on clinical outcomes among critically ill adult patients.MethodsElectronic databases were searched up to June 1, 2018, for randomized trials of use of balanced crystalloids versus 0.9% saline solutions in critically ill adult patients. The outcome variables included mortality, renal outcomes, serum content alterations and organ function. Subgroup analysis was conducted according to patient settings, types or volume of crystalloid fluid, or among sepsis versus non-sepsis, TBI versus non-TBI or subpopulations by the categories of baseline kidney function. Random errors were evaluated by trial sequential analysis.ResultsEight studies with 19,301 patients were analyzed. A trend of in-hospital survival benefit with no statistical difference could be observed with balanced crystalloids compared with 0.9% saline (RR 0.92, 95% CI 0.85–1.0, p = 0.06). The use of balanced crystalloid solutions was associated with longer RRT-free days (SMD 0.09, 95% CI 0.06–0.12, p < 0.001), less risk of increase in serum concentrations of chloride (SMD − 1.23, 95% CI − 1.59 to − 0.87, p < 0.001) and sodium (SMD − 1.28, 95% CI − 1.65 to − 0.92, p < 0.001), less risk of decline in serum base deficit (SMD − 0.58, 95% CI − 0.98 to − 0.18, p = 0.004), longer ventilator-free days (SMD 0.08, 95% CI 0.05–0.11, p < 0.001) and vasopressor-free days (SMD 0.04, 95% CI 0.00–0.07, p = 0.02). Subgroup analysis showed that balanced crystalloid solutions were associated with a reduced in-hospital mortality rate among septic patients (RR 0.86, 95% CI 0.75–0.98; p = 0.02) and non-traumatic brain injury patients (RR 0.90, 95% CI 0.82–0.99, p = 0.02), while the TSA results indicated a larger sample size is still in need.ConclusionsLimited evidence supported statistical survival benefit with balanced crystalloid solutions, while it benefited in reducing organ support duration and fluctuations in serum electrolyte and base excess and was associated with decreased in-hospital mortality in subpopulation with sepsis and non-TBI. Large-scale rigorous randomized trials with better designs are needed to provide robust evidence for clinical management.Trial registration The protocol for this meta-analysis was registered on PROSPERO: International prospective register of systematic reviews (CRD42018102661), https://www.crd.york.ac.uk/prospero/#recordDetails

Abstract WMP74: Resuscitation Fluid With Drag Reducing Additive Reduces Microthrombosis and Oxidative Stress After Traumatic Brain Injury Complicated by Hemorrhagic Shock

Objective: Traumatic brain injury (TBI) is frequently accompanied by hemorrhagic shock (HS) significantly worsening morbidity and mortality. Existing colloid or crystalloid resuscitation fluids (RF) for volume expansion do not adequately mitigate impaired microvascular cerebral blood flow (mCBF) and causes post-reperfusion mitochondrial oxidative stress. We previously showed that resuscitation fluid with drag reducing polymers (DRP-RF) improves CBF by rheological modulation of hemodynamics. In this work, we have evaluated the efficiency of DRP-RF in the reduction of microthrombosis and post-reperfusion mitochondrial oxidative stress. Methods: TBI was induced in rats by fluid percussion (1.5 ATA, 50 ms) and followed by controlled hemorrhage to a mean arterial pressure (MAP) =40 mmHg. DRP-RF or Lactated Ringers (LR-RF) was infused to MAP =60 mmHg for one hour (pre-hospital), followed by blood re-infusion to a MAP=70 mmHg (hospital). In vivo 2-photon laser scanning microscopy over the parietal cortex was used to monitor microvascular blood flow, tissue hypoxia (NADH) and level of superoxide in the cortex as a measure of mitochondrial oxidative stress (i.v. hydroethidine [HEt], 1 mg/kg) for 5 hours after TBI/HS, followed by DiI vascular painting during perfusion-fixation. Temperatures, MAP, blood gases and electrolytes were monitored. Results: TBI/HS compromised CBF leading to capillary microthrombosis and tissue hypoxia. As in our previous work, DRP-RF better than LR-RF improved mCBF and tissue oxygenation (p&lt;0.05). Reperfusion-induced oxidative stress, reflected by HEt fluorescence, was 32 ± 6% higher in LR-RF vs. DRP-RF (p &lt; 0.05). Post-mortem whole-brain visualization of DiI painted vessels revealed multiple microthromboses in both hemispheres that were 29 ± 3% less in DRP-RF vs. LR-RF group (p &lt; 0.05). Conclusions: Resuscitation after TBI/HS using DRP-RF effectively restores mCBF, reduces hypoxia, microthrombosis formation and mitochondrial oxidative stress compared to conventional volume expansion with LR-RF. Supported by DOD DM160142.

Certification Is for You ….

Certification Is for You ….

Crystalloid Administration Is Associated with the Recovery of Pediatric Elective Roux-en-Y Hepaticojejunostomy.

Intraoperative fluid administration is important for postoperative recovery and might be associated with postoperative complications. This retrospective review included 471 patients who underwent Roux-en-Y hepaticojejunostomy. Patients were separated into two groups based on whether they received low (<15.27 mL/kg/h) or high (>15.27 mL/kg/h) volumes of corrected crystalloid fluids. Propensity score matching was performed to adjust for any potential selection bios for the two groups. In 192 matched patients, clinical outcomes, including postoperative complications and length of hospital stay, were compared. Higher use of diuresis (p = 0.027) was found in the high fluid group. Receiving low volumes of crystalloids was associated with postoperative gastrointestinal functional recovery, reflected by the first defecation (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.31-1.07; p = 0.047) and first bowel movement (OR, 0.56; 95% CI, 0.38-0.98; p = 0.013). However, the occurrence of renal complications did not show significant differences between the groups. A lower postoperative complication rate (OR, 0.54; 95% CI, 0.42-0.94; p = 0.016) was noted in patients with low crystalloids compared with high crystalloids. The total length of hospital stay was longer in patients with high crystalloid fluid (9.21 ± 3.24 days) than patients with low volumes (7.83 ± 2.58 days; p = 0.012). Low crystalloid fluid administration was associated with favorable postoperative outcomes.

Impact of Capnoperitoneum on Renal Perfusion and Urine Production in Infant and Adolescent Pigs: Crystalloid versus Colloid Fluid Resuscitation.

Infants are likely to develop anuria during laparoscopy which is uncommon in older patients. The reason for this susceptibility remains unknown. We compared the impact of CO2 pneumoperitoneum on renal perfusion and urine production in piglets compared with adolescent pigs. We furthermore investigated the effects of different resuscitation strategies. Male piglets (n = 21) were divided into four groups: (a) infant controls (n = 5), (b) infants with crystalloid restitution (n = 6), (c) infants with colloidal restitution (n = 5), and (d) adolescents with crystalloid restitution (n = 5). Animals were ventilated, the central vessels and ureters were cannulated, and the animals were subjected to a 3-hour, 10 mm Hg CO2 pneumoperitoneum followed by 2-hour resuscitation. Renal perfusion was assessed by fluorescent microspheres and the rate of urine flow was measured. Urine production significantly decreased after insufflation only in the infant crystalloid and adolescent group, but not in controls or infants treated with colloids. In the infant crystalloid group, urine production remained at levels below 20% of baseline throughout the experiment. In this group, the renal perfusion dropped significantly after the beginning of the capnoperitoneum and remained significantly reduced throughout the experiment. Our data indicates that capnoperitoneum impairs renal perfusion and urine production in infants. In moderate-pressure capnoperitoneum, this effect cannot be compensated by application of crystalloids but with colloids.

Lactate versus acetate buffered crystalloid solutions: Protocol for a scoping review.

Intravenous (IV) fluid therapy has become a ubiquitous intervention in everyday clinical practice. Several types of fluid are available including isotonic crystalloid fluids. Among crystalloid fluids, buffered solutions (derivatives of the original Hartmann's and Ringer's solutions) are increasingly recommended as first-line resuscitation fluids. However, the choice between different buffered solutions appears to be difficult with limited data to support the use of lactate vs. acetate buffered solutions. Accordingly, we aim at systematically describing the body of evidence on the use of the different types of buffered crystalloid solutions in hospitalised patients. We will conduct a scoping review of all study designs (i.e. no study design will per se be excluded from the proposed review) in accordance with the Preferred Reporting Items for Systematic reviews and Meta Analyses (PRISMA) statement. We will provide descriptive analysis of the included studies/trials, i.e. no meta-analyses will be conducted. We will include studies on adult hospitalised patients receiving IV fluid for any reason. Studies must compare any crystalloid solution primarily buffered with lactate versus any primarily acetate buffered solution. All outcome measures will be reported. The quality of evidence will be assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. This outlined scoping review will provide a summary of the current body of evidence on the use, effects and side-effects of buffered crystalloid solutions. This will provide an important update of the current evidence on the use, of "buffered" crystalloid solutions including evidence of potential benefits and harms.

Life Quality of Pediatric Patient with Dengue Hemorrhagic Fever (DHF) Who Received Crystalloid and Colloid Fluid Treatment in PKU Muhammadiyah Hospital Yogyakarta

Dengue hemorrhagic fever (DHF) in the community can have an impact of panic, death, and reduced age of hope in the family. Research on the quality of life of DHF pediatric patient who got the treatment of crystalloid and colloid fluids has never been done before. The purpose of this study was to determine the quality of life of DHF pediatric patients who received crystalloids and colloids with PedsQL instruments. The study design was a cohort with block randomization. The inclusion criteria in this study were hospitalized DHF pediatric patients aged one month -18 years from February to May 2018. The exclusion criteria were DHF patients who came with referrals from other hospitals who had received fluid therapy. Research data include the length of stay (LOS) and quality of life score with the PedsQL questionnaire. The statistical analysis was using an independent t-test and the Mann Whitney test. The length of stay for the crystalloid group is five days longer than the colloid group, which is four days. From a total of 48 subjects studied, the score for the physical function of the crystalloid fluid group 84.54 ± 9.90 was higher than the colloid group of 77.58 ± 19.30 (p = 0.125). The emotional functions in the crystalloid group obtained a score of 81.88 ± 12.14 higher than the colloid group, i.e., 79.17 ± 18.5 (p = 0.552). The social function in the crystalloid group had a score of 92.08 ± 8.84 higher than the colloid group of 86.67 ± 13.96 (p = 0.232). The school functions in the crystalloid group had a score of 50.42 ± 33.68 higher than in the colloid group of 37.92 ± 36.62 (p = 0.225). The results of this study showed that the crystalloid group had a higher quality of life score compared to the colloid group, although it was not significant.

Prehospital Whole Blood in SOF: Current Use and Future Directions.

The US Joint Trauma System (JTS) recommends stored whole blood (SWB) as the preferred product for prehospital resuscitation of battlefield casualties in both their Tactical Combat Casualty Care (TCCC) guidelines and their clinical practice guidelines (CPGs). Clinical data from nearly 2 decades of war during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) suggest that whole blood (WB) is safe, effective, and far superior to crystalloid and colloid resuscitation fluids. The JTS CPG for whole blood transfusion reflects the most recent clinical evidence but poses unique challenges for execution by Special Operations Forces (SOF) operating in austere environments. Given the limited shelf-life of 35 days, WB requires a constant steady pool of donors. Additionally, the cold-chain requirement for storage poses challenges for SOF on long missions without access to blood refrigerators. SOF operating in less-developed theaters face additional logistical challenges. To mitigate the challenges of WB delivery, US SOF have implemented various protocols to ensure optimal donor pool, awareness/education among medics and specialized equipment for tactical methods of blood-carry and delivery. In general, steps taken include the following: (1) Prior to deployment, soldiers are screened for blood type and titers in order to establish a large donor pool. Support soldiers have been found to be particularly beneficial donors as they typically are in closer proximity to the blood support detachment. (2) In units that operate in smaller teams, such as ODAs, medics are outfitted with "blood kits" to carry blood on missions for point of injury transfusion. In units with larger teams, LTOWB donors are identified on missions and deliver fresh WB in the event of casualties. (3) Medics receive a WB transfusion refresher tabletop exercise and review after action reviews from previous rotations. Additionally, prehospital WB delivery is a required component of scenario-based premission training. The expectation is that medics will administer WB on missions when tactically feasible. Using the prolonged field care framework (ruck, truck, house) as a template, medics now use different methods to store and transport the SWB depending on phase. Medic "truck" and "house" kits include the Dometic CFX™ powered coolers that run on AC, DC, or solar power and allow for constant temperature monitoring. When on foot, medics have been outfitted with tactical blood coolers including the Pelican Biomedical Medic 4™ or Combat Medical Blood Box™ along with a Belmont Buddy-Lite™ intravenous (IV) infusion warmer and IV administration kit with standard micron filter. Presently, SOF medics have the donor support, logistical framework, training, and equipment to deliver WB at the point of injury. However, widespread implementation will require expanded distribution and standardization of "blood kits." Additionally, SOF medical planners must put greater emphasis on education and the importance of WB over crystalloids or colloids-as many medics continue to carry only these products out of convenience. As SOF strive to establish tactics, techniques, and procedures (TTPs) and streamline prehospital WB delivery, we must constantly reassess and refine our procedures, incorporate the latest evidence and technology, and adapt to an evolving battlefield.

Pre-clinical study protocol: Blood transfusion in endotoxaemic shock

The Surviving Sepsis Campaign (SCC) and the American College of Critical Care Medicine (ACCM) guidelines recommend blood transfusion in sepsis when the haemoglobin concentration drops below 7.0 g/dL and 10.0 g/dL respectively, while the World Health Organisation (WHO) guideline recommends transfusion in septic shock ‘if intravenous (IV) fluids do not maintain adequate circulation’, as a supportive measure of last resort. Volume expansion using crystalloid and colloid fluid boluses for haemodynamic resuscitation in severe illness/sepsis, has been associated with adverse outcomes in recent literature. However, the volume expansion effect(s) following blood transfusion for haemodynamic circulatory support, in severe illness remain unclear with most previous studies having focused on evaluating effects of either different RBC storage durations (short versus long duration) or haemoglobin thresholds (low versus high threshold) pre-transfusion.•We describe the protocol for a pre-clinical randomised controlled trial designed to examine haemodynamic effect(s) of early volume expansion using packed RBCs (PRBCs) transfusion (before any crystalloids or colloids) in a validated ovine-model of hyperdynamic endotoxaemic shock.•Additional exploration of mechanisms underlying any physiological, haemodynamic, haematological, immunologic and tissue specific-effects of blood transfusion will be undertaken including comparison of effects of short (≤5 days) versus long (≥30 days) storage duration of PRBCs prior to transfusion.

Variations in the management of diarrhoea induced by cancer therapy: results from an international, cross-sectional survey among European oncologists

BackgroundChemotherapy-induced diarrhoea (CID) is a common side effect of cancer treatment. While cytotoxic agents are the main cause of CID, targeted drugs, immunotherapy and radiotherapy can also cause diarrhoea. Patients with severe CID often require hospital admission for intravenous fluid resuscitation and supportive treatment. In other patient populations, such as children with infectious diarrhoea, therapy is based on evidence from randomised-controlled clinical trials. In contrast, few trials have investigated CID management, and hence, treatment guidelines are largely based on expert opinion.MethodsWe conducted an online survey on CID management and institutional routines across Europe to obtain a more detailed picture of current practice in CID treatment. We analysed the responses from a total of 156 clinicians from 83 different medical centres in 31 countries.ResultsCID (any grade) is recognised as a common clinical problem in patients undergoing antitumoral treatment and it can require hospital admission in a substantial subgroup of patients. There is a strong consensus among clinicians as to the choice of resuscitation strategies and drug treatment for severe CID; 85.9% (n=134) of all respondents prefer intravenous crystalloid fluids and 95.5% (n=149) routinely use loperamide. In sharp contrast, we have identified disparities in the use of bowel rest in CID; approximately half of all participants (57.7%; n=90) consider bowel rest in initial CID management, while the remainder (42.3%; n=66) does not.ConclusionsAs previous studies have shown that bowel rest is associated with adverse outcomes in diarrhoea due to causes other than chemotherapy, the results from this survey suggest that further research is needed as to its role in CID.

Goal-directed fluid therapy in the perioperative setting.

Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a “zero-balance” approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications.