Crystalloid Fluid Resuscitation Research Articles

Therapeutic assessment of crystalloid fluid resuscitation in experimental military injury.

A significant part of blast injury is accompanied by hemorrhagic shock (BS), while research on its fluid resuscitation strategies have not been reported. Although blood products are usually recommended in most resuscitation cases, they are less available in certain conditions. To this end, here, we focused on a widely used and more accessible fluid type- crystalloid fluid, in BS treatment. We conducted studies in rats comparing the therapeutic effects of 3 different crystalloid solutions at different time points after BS, and explored the underlying mechanisms. Generally, the survival rates gradually dropped along with the time when fluid resuscitation was given. Among different types of solution, the hypertonic saline (HS) group showed the highest survival rates. The lactated Ringer's solution (LR) only displayed lifesaving effect at 0.5h resuscitation time point. Moreover, it is worth noting that the survival rates of the normal saline (NS) group at all the time points were lower than the non-treatment control. Mechanism study in rats indicated that the therapeutic differences may be caused by varied degrees of pulmonary edema and inflammatory responses under different crystalloid fluid resuscitation. In conclusion, we assessed the effects and investigated the mechanisms of different crystalloid fluid resuscitation strategies for BS for the first time, which potentially contributes to the establishment of guidance for crystalloid fluid resuscitation of BS patients.

Successfully Managing Severe Anemia in a Trauma Patient Who Refused Blood Transfusion: A Case Report.

BACKGROUND Surgical management in patients who undergo traumatic blood loss but who refuse blood transfusion can be challenging, but physicians and surgeons must comply with the wishes and beliefs of their patients. This report describes the management of severe anemia, with hemoglobin level of 2.5 g/dL, in a 71-year-old male Korean trauma patient who declined blood transfusion. CASE REPORT A 71-year-old man was admitted to hospital with severe blood loss following trauma. He declined blood transfusion due to his religious belief as a Jehovah's Witness. On day 4, the patient's hemoglobin level dropped from 7.7 to 3.9 g/dL. Despite the need for blood transfusion, the patient refused. Hence, therapeutic strategies, including crystalloid fluid resuscitation, bleeding control, vasopressor support, erythropoietin administration, supplementation with iron, folic acid, and vitamin B12, coagulopathy correction, oxygen consumption reduction, and mechanical ventilation were implemented. Following 16 days of supportive management, the hemoglobin reached 7.4 g/dL. However, it suddenly decreased on day 41 (2.5 g/dL) due to episodes of melena secondary to an actively bleeding gastric ulcer, which was successfully managed with endoscopic hemostasis. Despite increased vasopressor dosage and addition of vasopressin and hydrocortisone, the patient became unresponsive with persistent hypotension. Methylene blue was used as the final therapeutic agent. The patient responded well and subsequently recovered without blood transfusion. CONCLUSIONS This report has presented the clinical challenges of managing the case of a patient who requires but declines blood transfusion and has highlighted the approach to clinical care while respecting the wishes of the patient.

Myocardial alterations following traumatic hemorrhagic injury.

Cardiac dysfunction (CD) has emerged as a key contributor to delayed organ failure and late mortality in patients surviving the initial traumatic hemorrhagic response. Inflammatory processes are implicated in the initial stages of this CD; however, downstream pathways leading to a characteristic rapid fall in stroke volume and cardiac output are not yet fully defined. Currently, no cardioprotective treatments are available. We investigated the role of myocardial oxidative stress in the pathogenesis of CD associated to traumatic hemorrhagic injury, and its related metabolomic profile. Ex vivo tissue from a 3-hour murine model of pressure-controlled trauma hemorrhagic shock (THS) was analyzed. Animals were randomized to echocardiography-guided crystalloid fluid resuscitation or a control group (sham: cannulation and anesthesia only, or naïve: no intervention). Trauma hemorrhagic shock and naïve samples were assessed by immunohistochemistry for nuclear 8-hydroxy-2'-deoxyguanosine expression as a marker of oxidative stress. Metabolomic analysis of THS and sham group tissue was performed by LC-MS. 8-Hydroxy-2'-deoxyguanosine expression across the myocardium was significantly higher following THS injury compared to naïve group (33.01 ± 14.40% vs. 15.08 ± 3.96%, p < 0.05). Trauma hemorrhagic shock injury significantly increased lysine ( p = 0.022), and decreased aconitate ( p = 0.016) and glutamate ( p = 0.047) in the myocardium, indicating activation of a catabolic metabolism and oxidative stress response. We confirm the acute development of oxidative stress lesions and altered cardiac energy metabolism following traumatic hemorrhage injury, providing insight into the relationship between inflammatory damage and impaired cardiac contractility. These findings may provide targets for development of novel cardioprotective therapeutics aiming to decrease late mortality from trauma.

Protocol for a systematic review and meta-analysis assessing conservative versus liberal intravenous fluid administration in patients with sepsis or septic shock at risk of fluid overload

IntroductionIntravenous crystalloid fluid resuscitation forms a crucial part of the early intervention bundle for sepsis and septic shock, with the Surviving Sepsis Campaign guidelines recommending a 30 mL/kg fluid bolus...

Electrolyte derangements in critically ill children receiving balanced versus unbalanced crystalloid fluid resuscitation

BackgroundAdult studies have demonstrated potential harm from resuscitation with 0.9% sodium chloride (0.9%NaCl), resulting in increased utilization of balanced crystalloids like lactated ringers (LR). The sodium and potassium content of LR has resulted in theoretical safety concerns, although limited data exists in pediatrics. We hypothesized that use of LR for resuscitation would not be associated with increased electrolyte derangements compared to 0.9%NaCl.MethodsA prospective, observational cohort study of critically ill children who received ≥ 20 ml/kg of fluid resuscitation and were admitted to two pediatric intensive care units from November 2017 to February 2020. Fluid groups included patients who received > 75% of fluids from 0.9%NaCl, > 75% of fluids from LR, and a mixed group. The primary outcome was incidence of electrolyte derangements (sodium, chloride, potassium) and acidosis.ResultsAmong 559 patients, 297 (53%) received predominantly 0.9%NaCl, 74 (13%) received predominantly LR, and 188 (34%) received a mixture. Extreme hyperkalemia (potassium ≥ 6 mmol/L) was more common in 0.9%NaCl group (5.8%) compared to LR group (0%), p 0.05. Extreme acidosis (pH > 7.1) was more common in 0.9%NaCl group (11%) compared to LR group (1.6%), p 0.016.ConclusionsLR is associated with fewer electrolyte derangements compared to 0.9%NaCl. Prospective interventional trials are needed to validate these findings.

Percutaneous delivery of self-propelling thrombin-containing powder increases survival from noncompressible truncal hemorrhage in a swine model of coagulopathy and hypothermia

Noncompressible truncal hemorrhage (NCTH) remains a leading cause of preventable death on the battlefield. Definitively managing severe NCTH requires surgery within the first hour after injury, which is difficult when evacuating casualties from remote and austere environments. During delays to surgery, hemostatic interventions that are performed prehospital can prevent coagulopathy and hemorrhagic shock and increase the likelihood that casualties survive to receive definitive care. We previously reported that a self-propelling thrombin-containing powder (SPTP) can be delivered percutaneously into the abdomen as a minimally invasive intervention and can self-disperse through pooled blood to deliver the hemostatic agents thrombin and tranexamic acid locally to noncompressible intracavitary wounds. We hypothesized that, in swine with massive NCTH, dilutional coagulopathy, and hypothermia, delivering SPTP could extend survival times. Ten swine (n = 5 per group) underwent NCTH from a Grade V liver injury following a midline laparotomy. The laparotomy was closed with sutures afterwards, creating a hemoperitoneum, and animals were managed with crystalloid fluid resuscitation, or crystalloid resuscitation and SPTP. Self-propelling thrombin-containing powder was delivered into the closed abdomen using a CO 2 -powered spray device and a catheter placed into the hemoperitoneum, entering through the upper right quadrant using the Seldinger technique. Survival to 1 and 3 hours was recorded. In an additional animal, hemorrhage was created laparoscopically, and SPTP was imaged in situ within the abdomen to visually track dispersion of the particles. Self-propelling thrombin-containing powder dispersed as far as 35 ± 5.0 cm within the abdomen. It increased survival to 1 and 3 hours (Kaplan-Meier p = 0.007 for both). The median survival time was 61 minutes with SPTP and 31 minutes without ( p = 0.016). Self-propelling thrombin-containing powder effectively disperses medications throughout a hemoperitoneum and increases survival in a model of NCTH. It is a promising strategy for nonsurgical management of NCTH, warranting further testing of its safety and efficacy.

Renal Safety of Hydroxyethyl starch 130/0.42 After Cardiac Surgery: A Retrospective Cohort Analysis

IntroductionThe risk for renal complications from hydroxyethyl starch 130/0.42 (HES) impacts treatment decisions in patients after cardiac surgery.ObjectiveThe objective of this study was to determine the impact of postoperatively administered HES on renal function and 90-day mortality compared to sole crystalloid administration in patients after elective cardiac surgery.MethodsUsing electronic health records from a university hospital, confounding-adjusted models analyzed the associations between postoperative HES administration and the occurrence of postoperative acute kidney injury. In addition, 90-day mortality was evaluated. The impact of HES dosage and timing on renal function on trajectories of estimated glomerular filtration rates over the postoperative period was investigated using linear mixed-effects models.ResultsOverall 1009 patients (45.0%) experienced acute kidney injury. Less acute kidney injury occurred in patients receiving HES compared with patients receiving only crystalloids for fluid resuscitation (43.7% vs 51.2%, p = 0.008). In multivariate acute kidney injury models, HES had a protective association (odds ratio: 0.89; 95% confidence interval 0.82–0.96). Crystalloids were not as protective as HES (odds ratio: 0.98; 95% confidence interval 0.95–1.00). There was no association between HES and 90-day mortality (odds ratio: 1.05; 95% confidence interval 0.88–1.25). Renal function trajectories were dose dependent and biphasic, HES appeared to slow down the late postoperative decline.ConclusionsThis study showed no association between HES and the postoperative occurrence of acute kidney injury and thus further closes the evidence gap on HES safety in cardiac surgery patients. Although this was a retrospective cohort study, the results indicated that HES might be safely administered to cardiac surgery patients with regard to renal outcomes, especially if it was administered early and dosed appropriately.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40264-021-01116-5.

51-Year-Old Man With Ascites and Abdominal Pain

51-Year-Old Man With Ascites and Abdominal Pain

Effects of extensive bleeding in pigs on laboratory biomarkers.

BackgroundDuring hemorrhage and resuscitation, clinical and laboratory monitoring is useful to guide further management. However, acute changes in the biochemistry due to blood loss and subsequent crystalloid fluid resuscitation have not been fully studied.Materials and methodsTwelve anesthetized, juvenile pigs were used. Atraumatic exsanguination, corresponding to a total blood loss of 40%, was performed through a catheter and completed 2 h after initiation of the experiment. Arterial samples were analyzed by point-of-care testing and venous samples were analyzed. Oxygen delivery was calculated.ResultsShortly after 40% hemorrhage and concomitant fluid supplementation, there were significant reductions in arterial hemoglobin and hematocrit (approximately 25%, respectively). Oxygen delivery was less than half of the baseline value. Lactate in arterial blood was more than doubled after 40% exsanguination. On average, no other clinically significant changes in any of the analytes were observed, but interindividual dispersion was pronounced.ConclusionsAcute exsanguination was associated with decreased hemoglobin and hematocrit levels and increased lactate levels but limited effects on the other biomarkers that were studied. Increased levels of biomarkers in severely bleeding patients could indicate tissue damage and the source should be further investigated.

Volume Resuscitation and Progression to Organ Failure in Shiga Toxin-Producing Escherichia coli Infection in Adults.

OBJECTIVES:Shiga toxin-producing Escherichia coli infection is associated with dysentery and the hemolytic uremic syndrome, marked by the triad of microangiopathic hemolytic anemia, acute kidney failure, and thrombocytopenia. Descriptions of Shiga toxin-producing Escherichia coli outbreaks causing hemolytic uremic syndrome in adults are sparse, and management strategies are largely adapted from pediatric literature where aggressive fluid administration is recommended. However, these may not be ideal for adults.DESIGN:We present a case series of an Shiga toxin-producing Escherichia coli outbreak in U.S. Marine Corps recruits.SETTING:We review the clinical course, laboratory data, and fluid resuscitation used in hospitalized patients during the 2017 Shiga toxin-producing Escherichia coli outbreak at Marine Corps Recruit Depot, San Diego.PATIENTS:Patients admitted to the hospital for complications from Shiga toxin-producing Escherichia coli infection. All were previously healthy men between the ages of 17 and 20 years.INTERVENTIONS:Isotonic crystalloid fluid resuscitation during the first 72 hours.MEASUREMENTS AND MAIN RESULTS:Of 244 identified cases of Shiga toxin-producing Escherichia coli infection, 30 required hospitalization, 15 progressed to hemolytic uremic syndrome, and five required hemodialysis. Patients were admitted and given aggressive IV fluid hydration. Those who progressed to hemolytic uremic syndrome received on average 8.4 L of isotonic crystalloid over the initial 72 hours, with up to 18% of body weight delivered. The six critically ill patients received a mean 12.2 L in the first 72 hours. Those who did not progress to hemolytic uremic syndrome received a mean 3.0 L of crystalloid. If oligoanuria developed, a net-even fluid balance was maintained. The amount of volume infused was not associated with improved outcomes. The patients with the highest fluid balance totals more often required dialysis than those who received less fluid. One hemolytic uremic syndrome patient developed flash pulmonary edema.CONCLUSIONS:The aggressive IV hydration protocols (as a percentage of body weight) in the pediatric literature may not be applicable to adults diagnosed with hemolytic uremic syndrome. A more conservative fluid strategy in adults with hemolytic uremic syndrome merits further investigation.

Haemostatic changes associated with fluid resuscitation in canine parvoviral enteritis.

The haemostatic status of dogs with canine parvovirus (CPV) enteritis, within 24 h of admission after initial fluid administration, has been described previously, but the haemostatic status at admission and after standard fluid resuscitation, as well as after initial fluid redistribution, has not been investigated previously. The objective of this study was to characterise the haemostatic status at admission and describe the effect of crystalloid fluid resuscitation on haemostatic variables in dogs with CPV enteritis. Twenty-seven client-owned, hospitalised dogs with confirmed natural CPV infection and 15 healthy age-matched controls were included in a prospective, observational clinical study. The volume of resuscitation fluid, haematocrit (HCT), platelet count, thromboelastography (TEG) variables, antithrombin (AT) activity, fibrinogen- and C-reactive protein (CRP) concentrations were measured in all dogs at admission, after fluid resuscitation and, in 10 dogs, after receiving an additional 3 hours of maintenance-rate crystalloid fluids. For the CPV group at admission, the median TEG reaction time (R) and maximum amplitude (MA) or clot strength, as well as the median HCT, fibrinogen and CRP concentrations, were significantly increased compared to the controls. After fluid resuscitation, median R was significantly shorter, MA significantly increased and HCT and AT activity significantly decreased compared to admission values. The haemostatic variables remained unchanged after 3 h of maintenance-rate crystalloid therapy. The increased clot strength present in dogs with CPV enteritis at admission was exacerbated after fluid resuscitation and persisted for hours after large-volume crystalloid fluid administration.

Intraoperative management of brain-dead organ donors by anesthesiologists during an organ procurement procedure: results from a French survey

BackgroundThis study aimed at describing usual anesthetic practices for brain-dead donors (BDD) during an organ procurement (OP) procedure and to assess the knowledge and self-confidence of French anesthesiologists with this practice.MethodsAn electronic and anonymous survey with closed-questions about anesthetic management of BDD was distributed to French anesthesiologists via the mailing list of the French Society of Anesthesiology and Intensive Care Medicine.ResultsFour hundred fifty-eight responses were analyzed. Respondents were mainly attending physicians with more than 10 years of clinical experience. 78% of them declared being cognizant of guidelines regarding management of BDD. Advanced hemodynamic monitoring and endocrine substitution were rarely considered by respondents (31 and 35% of respondents, respectively). 98% of the respondents used crystalloids for fluid resuscitation. During the procedure, use of neuromuscular blockers, opioids and sedative agents were considered by respectively 84, 61 and 27% of the respondents. A very high level of agreement (10 [8–10], on a ten-points Likert-style scale) was reported concerning the expected impact of intraoperative anesthetic management on the primary function of grafts.ConclusionsDeclared anesthetic practice appeared in accordance with guidelines concerning organ donor management in the ICU. Further studies are needed to evaluate the specific impact of intraoperative management during this procedure and thus the need for specific anesthetic guidelines.

Exertional Heatstroke, Asesmen Cepat Dan Penatalaksanaan Tepat: Laporan Kasus

Heatstroke is the most severe heat illness which homeostatic thermoregulatory mechanism is failed, characterized by an elevation of the core body temperature above 40 oC, central nervous system dysfunction, and possible multi-organ failure. Heatstroke is the third leading cause of death among athletes. Exertional heatstroke (EHS) is exercise-induced; usually affects young healthy people during strenuous physical activity and have not acclimatized to environmental heat stress. Frequently encountered complications include encephalopathy, acute respiratory distress syndrome, myocardial injury, acute kidney injury, hypoglycemia, intestinal ishemia or infarction, pancreatic injury, rhabdomyolysis, disseminated intravascular coagulation (DIC), hypocalcemia, lactic acidosis, and hepatic failure. Immediate cooling is the cornerstone of treatment which evaporative cooling is preferred. Aspiration and seizure are common; airway management, oxygenation, and ventilation have to be adequately maintained. Crystalloid-fluid resuscitation is essential, averaging 1200 mL in first 4 hours. Systemic complications of heatstroke should be well-managed to prevent worse outcome. A case of 32-years-old man with no significant medical history was brought to emergency department after collapsing while running into the 20-kilometres marathon. He was unresponsive (GCS E1V2M1), had serial generalized seizure and hematemesis-melena. On primary survey, the patient was shocked (BP 67/24 mmHg, HR 165 bpm, cold extremity), tachypnea (41/min), hyperthermia (40.5oC rectally), SpO2 95% on simple mask 10 L/min. His laboratory results showed full-blown complications of heatstroke. Immediate rehydration therapy using saline solution and colloid solution intravenously was started, followed with blood or blood component transfusion. Tracheal intubation and mechanical ventilation were performed. During the intensive treatment, he became fully conscious and was extubated on hospital day 7. He was hemodynamically stable without any support, but developed multi-organ failure. Unfortunately, on twentieth day, he was cardiac arrest during hemodialysis and died four days later.

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&lt;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.

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.

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.

Comparison of crystalloid resuscitation fluids for treatment of acute brain injury: a clinical and pre-clinical systematic review and network meta-analysis protocol

BackgroundCurrent guidelines identify the choice of fluid resuscitation as important in minimizing the incidence of secondary brain injury from cerebral edema. It is widely accepted that isotonic crystalloid resuscitation fluids, specifically normal saline (NS), are optimal for resuscitation and that other relatively hypotonic fluids, such as Ringer’s lactate (RL), should be avoided in this patient population. The aim of this review is to systematically compare the use of relatively hypotonic versus isotonic crystalloid resuscitation fluids in clinical and pre-clinical models of acute brain injury and their effect on outcomes. In recognition of the potential need for a network meta-analysis (NMA), we have also included all other relevant crystalloid resuscitation fluids as interventions of relevance to potentially inform indirect comparisons.MethodsSystematic searches of MEDLINE, Embase, and Web of Science BIOSIS Previews® will be used to identify eligible clinical and pre-clinical studies, which included studies examining acute brain injury (human and in vivo animal brain injury models) within the first 7 days of therapy. The intervention of interest is the intravenous use of relatively hypotonic crystalloid resuscitation fluids (e.g., Ringer’s lactate, Hartmann’s or Plasma Lyte® fluids). The main comparator of interest is an isotonic crystalloid resuscitation fluid, specifically normal saline (0.9%). Other crystalloid resuscitation fluids (e.g., hypertonic saline (3–23.4%)) will also be included as an additional intervention of interest. The primary outcome measures of interest are intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Secondary outcomes include the effect of resuscitation on cerebral edema, brain and serum osmolarity, and electrolyte concentrations and clinical outcomes including modified Rankin Scale (mRS), (extended) Glasgow Outcome Scale (GOS/eGOS), and mortality. Separate meta-analyses will be conducted to quantify the effects of the different fluid resuscitation on acute brain injury outcomes in clinical and pre-clinical populations. Network meta-analyses to compare interventions will also be performed to compare the effects of different interventions.DiscussionThis systematic review will comprehensively summarize the difference in treatment efficacy of various crystalloid resuscitation fluids in acute brain injury. This review is essential to underscore the evidence, or lack thereof, present in the literature to date to support current preference-driven practice and to direct future study.Systematic review registrationPROSPERO #CRD42016042960

Fewer Adverse Kidney Events in Patients Who Are Given Balanced Crystalloids

What is the right crystalloid for fluid resuscitation? Because limited data guide this decision, choices traditionally have been driven by culture:

Early Goal-Directed Therapy: The History and Ongoing Impact on Management of Severe Sepsis and Septic Shock.

The use of early goal-directed therapy (EGDT) for the management of severe sepsis and septic shock, a practice put forth by Dr. Rivers et al. in 2001, ushered in a new era of targeted sepsis therapy. After its publication, several further studies helped validate the protocolized approach to sepsis management, ultimately leading to its incorporation into the Surviving Sepsis Campaign guidelines. Since that time, however, a trio of large multi-center randomized controlled trials have taken place to evaluate the efficacy of EGDT when compared with usual care and have demonstrated that strict adherence to the entirety of the original EGDT protocol is unnecessary for improved outcomes. Some recommendations, such as higher goal hemoglobin and hematocrit levels and liberal crystalloid fluid resuscitation, are likely harmful. Despite controversy over a number of the recommendations, early identification of sepsis, source control, and prompt empiric antibiotic administration remain the mainstay of treatment for patients with sepsis and septic shock.

388 Sepsis Fun Facts: A Simple Way to Increase Sepsis Bundle Compliance

To design a quality improvement project to improve sepsis bundle compliance in our emergency department. This was a before and after study. Historical data on sepsis bundle compliance was obtained from our quality officer. In our institution, the sepsis bundle consists of 1) blood cultures before antibiotics, 2) antibiotics within 1 hr of recognition, 3) serum lactate level at presentation with 3hr repeat if elevated >2, and 4) crystalloid fluid resuscitation of 30cc/kg. Start date was determined by our department’s QI launch; we collected data for 30 consecutive days and compared sepsis bundle compliance rates before and after the intervention. Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance. The intervention was two-fold: 1) a bright yellow card with sepsis criteria listed was posted on all ED workstation computers; and 2) daily email blast for 1 month with “sepsis fun facts.” These email blasts were short pearls that highlighted the importance of recognizing and treating sepsis. The sepsis bundle compliance rates in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (P=0.0399). We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived our intervention as helping them increase compliance with ordering the sepsis bundle. The response rate was 94%. To the question “Did you feel the SEPSIS cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?” 70% answered agree or strongly agree. To the question “Were you more likely to order the SEPSIS bundle after receiving the daily Sepsis “Fun Facts”?” 29% were neutral while 59% answered agree or strongly agree. Finally, to the question “Did you feel the Sepsis Cards and “Fun Facts” help you improve the care of Septic patients in the emergency department?” 76% answered agree or strongly agree. Simple interventions such as sepsis criteria reminders and email blasts highlighting the importance of treating and recognizing sepsis can improve compliance with sepsis bundle ordering within the emergency department. A post-intervention survey suggests that such reminders do influence emergency physicians and increase their awareness of sepsis.