Early Fluid Resuscitation Research Articles

Practice and effect evaluation of early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department: a retrospective cohort study.

To explore the practice and effect evaluation of the early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department. A total of 239 sepsis patients, who were treated in the emergency department of our hospital from January to September 2020, were selected as the participants of this study, and a retrospective analysis was performed. According to different fluid resuscitation, they were divided into an improved group and a control group. One hundred and twelve patients who received restrictive fluid resuscitation were in the improved group; another 127 patients who received adequate fluid resuscitation were in the control group. The ICU stay time, ventilator use time and 28-day mortality rate of the two groups were observed. The hemodynamic indexes, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score and complications of the two groups before and after treatment were compared. After treatment, in the improved group, the APACHE II and SOFA scores were lower than in the control group, fluid replacement decreased, lactate clearance increased, ICU admission time shortened and the proportion of ventilator time to ICU admission time decreased. The incidence of acute respiratory distress syndrome (ARDS), cTn I and brain natriuretic peptic in the improved group were significantly lower than those in the control group. From the dimension within the group, the APACHE II score, SOFA score, heart rate and shock index were lower after treatment than before treatment in the improved and control groups. Restricted fluid resuscitation can effectively alleviate the condition of emergency sepsis patients, improve haemodynamics, reduce the incidence of ARDS and prevent patient deaths. It is worthy of clinical application.

Comparative Study between Restrictive versus Liberal Intravenous Fluid Administration in Severe Sepsis and Septic Shock; A Randomized Clinical Trial

Abstract Background Sepsis is an inflammatory response to severe infection characterized by hypovolemia and vasodilation and treated with early antibiotics and fluid resuscitation. In-hospital mortality rates have decreased from 80% in the early years of intensive care to 20-30% in the modern era through improved surveillance, early treatment of underlying infection, and advances in support for failing organs. Despite the central role intravenous (IV) fluid administration has played in sepsis management for the last 15 years, fundamental questions regarding “which fluid” and “in what amount” remain unanswered. Objective To compare between the outcomes of fluid administration strategies in the form of restricted or usual fluid administration in patient with severe sepsis and septic shock, and to detect the optimal strategy of fluid administration which decreases morbidity and mortality. Patients and Methods This was a Prospective controlled; randomized, comparative study was conducted in the intensive care units at Ain-Shams University Hospitals and Gamal Abdelnaser Hospital. This study was conducted on 80 adult patients divided into two groups: Group A: 40 adult patients taking the Usual Care, and Group B: 40 adult patients taking the Restrictive Care. Results The restrictive fluid group received significantly less resuscitative IV fluid than the usual care group prior to randomization, over 24 hours, over 48 hours, over 72 hours and total, Moreover; the restrictive fluid group also received a lower fraction of non-resuscitative IV fluid than the usual care group. In addition, the restrictive fluid group also received less amount of total forms IV fluid than the usual care group. There were no statistically significant differences between the two groups in adjunct resuscitative measures administered including albumin, blood transfusion, or stress dose steroids. By day 30, 9 participants (22.5%) in the restrictive fluid group and 7 participants (17.5%) in the usual care had died with no statistical significant difference between the both groups (p = 0.29). Conclusion A restrictive resuscitation strategy that significantly limited the amount of IV fluid administered to patients with severe sepsis and septic shock show slight improvement as regard mean arterial blood pressure, urine output and lactate level. at the same time did not appear to increase mortality, organ dysfunction, or adverse events. Our data contribute to the current state of clinical equipoise surrounding the use of IV fluids in sepsis, support a larger multicenter trial addressing this topic, and inform future study design. This study demonstrates that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care. Although limited by the sample size, we observed no increase in mortality, organ failure, or adverse events.

Relationship between the rate of fluid resuscitation and acute kidney injury: A retrospective cohort study.

Septic shock is the leading cause of acute kidney injury (AKI) in critically ill patients. The foundation of early septic shock management includes early fluid resuscitation, but the association between fluid resuscitation rates and kidney outcomes remains unclear. This investigation examines the association between fluid resuscitation rate and AKI recovery. In the medical intensive care unit of Mayo Clinic Rochester, adult patients with AKI and septic shock were retrospectively studied from January 1, 2006 to May 31, 2018. The surviving sepsis campaign recommends an initial fluid bolus of 30 ml/kg for sepsis resuscitation. The cohort of patients was divided into three groups based on the average fluid resuscitation time (<1 h, 1.1-3 h, >3 h) and the corresponding fluid rate ≥0.5, 0.17-0.49, and <0.17 ml/kg/min, respectively. The primary outcome was the recovery of AKI on day 7. To account for potential confounders, multivariable regression analyses were conducted. After meeting the eligibility, 597 patients were included in the analysis. The AKI recovery was considerably different among the groups (P = 0.006). Patients in group 1 who received fluid resuscitation faster had a higher rate of AKI recovery (53%) compared to group 2 and group 3 (50% and 37.8%). In septic shock patients with AKI, a higher fluid resuscitation rate of 30 ml/kg IV fluids within the 1st-h sepsis diagnosis (i.e., >0.50 ml/kg/min) lead to higher AKI recovery compared with slower infusion rates.

The Effect of Fluid Resuscitation Timing in Early Sepsis Resuscitation.

The dose and timing of early fluid resuscitation in sepsis remains a debated topic. The objective of this study is to evaluate the effect of fluid timing in early sepsis management on mortality and other clinical outcomes. Single-center, retrospective cohort study of emergency-department-treated adults (>18 years, n = 1032) presenting with severe sepsis or septic shock. Logistic regression evaluating the impact of 30 mL/kg crystalloids timing and mortality-versus-time plot controlling for mortality in emergency department sepsis score, lactate, antibiotic timing, obesity, sex, systemic inflammatory response syndrome criteria, hypotension, and heart and renal failures. This study is a subanalysis of a previously published investigation. Mortality was 17.1% (n = 176) overall and 20.4% (n = 133 of 653) among those in septic shock. 30 mL/kg was given to 16.9%, 32.2%, 16.2%, 14.5%, and 20.3% of patients within ≤1, 1 ≤ 3, 3 ≤ 6, 6 ≤ 24, and not reached within 24 h, respectively. A 24-h plot of adjusted mortality versus time did not reach significance, but within the first 12 h, the linear function showed a per-hour mortality increase (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.02-1.67) which peaks around 5h, although the quadratic function does not reach significance (P = .09). When compared to patients receiving 30 mL/kg within 1 h, increased mortality was observed when not reached within 24 h (OR 2.69, 95% CI 1.37-5.37) but no difference when receiving this volume between 1 and 3 (OR 1.11, 95% CI 0.62-2.01), 3 and 6 (OR 1.83, 95% CI 0.97-3.52), or 6 and 24 h (OR 1.51, 95% CI 0.75-3.06). Receiving 30 mL/kg between 1 and 3 versus <1 h increased the incidence of delayed hypotension (OR 1.83, 95% CI 1.23-2.72) but did not impact need for intubation, intensive care unit admission, or vasopressors. We observed weak evidence that supports that earlier is better for survival when reaching fluid goals of 30 mL/kg, but benefits may wane at later time points. These findings should be viewed as hypothesis generating.

Update on the strategy for intravenous fluid treatment in acute pancreatitis.

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.

Current recommendations for management of paediatric diabetic ketoacidosis.

Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients. Protocols and clinical practice guidelines are being adjusted, with a particular focus on recommendations for initial and ongoing fluids and electrolyte monitoring and replacement. Initial isotonic fluid resuscitation is now recommended for all patients in the first 20 to 30 minutes after presentation, followed by repletion of volume deficit over 36 hours in association with an insulin infusion, electrolyte supplementation, and careful monitoring for and management of potential CI.

Early fluid and norepinephrine resuscitation in septic acute kidney injury diminishes pro-inflammatory cytokine levels and kidney hypoperfusion in newborn pigs

Background and Objective: Sepsis is the most frequent risk factor for acute kidney injury (AKI) in critically ill infants. Whereas sepsis-induced AKI has been studied in several animal models, alterations in renal microcirculation are unclear. The objective of this study was to use the translational swine model to evaluate the changes in renal hemodynamics during the early phase of sepsis in the first week of life. We also examined the impact of early fluid and norepinephrine (NE) resuscitation on renal hemodynamics in newborn septic AKI. Methodology: Newborn pigs (3-7 days old) were randomly allocated to three groups; 1) Sham, 2) Sepsis (cecal ligation and puncture; CLP) without subsequent resuscitation, and 3) CLP-induced sepsis with fluid and vasopressor NE resuscitation. All animals underwent standard anesthesia induction, mechanical ventilation, and intravenous fluid. Cardiac output (COP) and GFR were measured non-invasively using electrical velocimetry and a transdermal system. The pigs were instrumented to measure the mean arterial pressure (MAP), total renal blood flow (tRBF), cortical perfusion (coPf), and medullary perfusion (mePf). Also, a fiber-optic probe was placed in the medulla to measure medullary tissue oxygen tension (tPO2). Baseline values were recorded for the above indices in all groups. In resuscitated animals, fluid bolus and NE infusion were started at the 4-h to maintain MAP within 15 mmHg from baseline. The pigs were euthanized after twelve hours. Results: Compared to baseline values, MAP and COP decreased by more than two-thirds in non-resuscitated sepsis, with a proportional increase in RVR and reduction in tRBF, coPf, mePf, and tPO2 in contrast to sham. CLP also decreased GFR and increased serum creatinine, BUN, and NGAL. A few tubular coagulative necroses were observed in the septic pigs. Changes in all these parameters, except tPO2, were ameliorated in resuscitated pigs. Resuscitation also attenuated sepsis-induced increase in the levels of serum C-reactive protein, inflammatory cytokines (IL-6, IL-8, IL-12, and IL-18), liver enzymes (aspartate aminotransferase and alanine aminotransferase), and renal NLRP3 inflammasome. Conclusions: Early implementation of resuscitation to maintain MAP, COP, and kidney perfusion lessens the degree of inflammation, AKI, and liver injury in newborn pigs. The discrepancy between medullary perfusion and oxygenation indicates that optimizing perfusion and blood flow does not always correlate with improved medullary oxygen delivery in newborns, especially in cases of increased metabolic demand, as in sepsis. Sepsis is a dynamic illness with phases of hypodynamic and hyperdynamic renal perfusion; therefore, management strategies would differ based on hemodynamic status. NIH R01DK120595 and R01DK127625 This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Effect of early fluid balance on the prognosis in severe acute pancreatitis

To observe the correlation between early fluid resuscitation and prognosis in patients with severe acute pancreatitis (SAP). SAP patients admitted to the department of critical care medicine of the People's Hospital of Chuxiong Yi Autonomous Prefecture of Yunnan Province from June 2018 to December 2020 were enrolled and analyzed retrospectively. All patients were given the routine treatment according to their condition and relevant diagnostic According to their different prognosis, enrolled patients were divided into death group and survival group. The differences in gender, age, acute physiology and chronic health evaluation II (APACHE II) and Ranson score on admission between the two groups were analyzed. Taking 24 hours as an observation day, the fluid inflow, outflow, and net balance at the first, second, and third 24 hours after admission were recorded, and the ratio of the fluid inflow at the first 24 hours to the total fluid inflow in 72 hours (FV24 h-1 st) was calculated as a study index. Using 33% as the standard, compare the proportion of patients in the two groups who achieved FV24 h-1 st < 33%. The differences of various indicators between the two groups were compared, and the effect of early fluid balance on the prognosis of SAP patients was analyzed. Eighty-nine patients were included in the study (41 in the death group, 48 in the survival group). There were no statistically significant differences on age (years old: 57.6±15.2 vs. 49.5±15.2), gender (male: 61.0% vs. 54.2%), APACHE II score (18.0±2.4 vs. 17.3±2.3), and Ranson score (6.3±1.4 vs. 5.9±1.2) between the death group and the survival group at the time of admission on the intensive care unit (ICU) (all P > 0.05). The fluid intake of the death group in the first 24 hours, the second 24 hours and the third 24 hours after admission to ICU was significantly higher than that of the survival group, and the difference was statistically significant (mL: 4 138±832 vs. 3 535±1 058, 3 883±729 vs. 3 324±516, 3 786±490 vs. 3 212±609, all P < 0.05), and the fluid inflow in the death group at the first 24 hours was greater than 4 100 mL. After treatment, the fluid outflow of the death group at the three 24-hour periods after admission on the ICU was an increasing trend, but it was still significantly less than that of the survival group at the three 24-hour periods (mL: 1 242±465 vs. 1 795±819, 1 536±579 vs. 2 080±524, 1 610±585 vs. 2 932±752, all P < 0.01). Due to the fact that the total fluid inflow and total fluid outflow in the three 24-hour periods in the death group were more than those in the survival group, the net fluid balances in the three 24-hour periods in the death group were still significantly more than those in the survival group finally (mL: 2 896±782 vs. 1 740±725, 2 347±459 vs. 1 243±795, 2 176±807 vs. 338±289, all P < 0.01). There was no difference in FV24 h-1 st between the death group and survival group [FV24 h-1 st > 33%: 56.1% (23/41) vs. 54.2% (26/48), P > 0.05]. Fluid resuscitation is an important method for early treatment of SAP, but it also has many adverse reactions. Fluid resuscitation indexes such as fluid inflow, outflow, net balance, and FV24 h-1 st within 24 to 72 hours after admission are related to the prognosis of patients with SAP, and can be used as indicators to evaluate the prognosis of SAP. The optimized fluid resuscitation strategy can improve the prognosis of patients with SAP.

Aggressive versus controlled fluid resuscitation in acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials.

Early fluid resuscitation is one of the fundamental treatments for acute pancreatitis (AP), but there is no consensus on the optimal fluid rate. This systematic review and meta-analysis aimed to compare the efficacy and safety of aggressive vs. controlled fluid resuscitation (CFR) in AP. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science databases were searched up to September 30, 2022, for randomized controlled trials (RCTs) comparing aggressive with controlled rates of early fluid resuscitation in AP patients without organ failure on admission. The following keywords were used in the search strategy: "pancreatitis," "fluid therapy,""fluid resuscitation,"and "randomized controlled trial." There was no language restriction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the certainty of evidence. Trial sequential analysis (TSA) was used to control the risk of random errors and assess the conclusions. A total of five RCTs, involving 481 participants, were included in this study. For primary outcomes, there was no significant difference in the development of severe AP (relative risk [RR]: 1.87, 95% confidence interval [CI] 0.95-3.68; P = 0.07; n = 437; moderate quality of evidence) or hypovolemia (RR: 0.98, 95% CI: 0.32-2.97; P = 0.97; n = 437; moderate quality of evidence) between the aggressive and CFR groups. A significantly higher risk of fluid overload (RR: 3.25, 95% CI: 1.53-6.93; P <0.01; n = 249; low quality of evidence) was observed in the aggressive fluid resuscitation (AFR) group than the controlled group. Additionally, the risk of intensive care unit admission ( P = 0.02) and the length of hospital stay ( P <0.01) as partial secondary outcomes were higher in the AFR group. TSA suggested that more studies were required to draw precise conclusions. For AP patients without organ failure on admission, CFR may be superior to AFR with respect to both efficacy and safety outcomes. PROSPERO; https://www.crd.york.ac.uk/PROSPERO/ ; CRD 42022363945.

Association between the volume of fluid resuscitation and mortality modified by disease severity in patients with sepsis in ICU: a retrospective cohort study

ObjectiveThe important effect modifiers of high disease severity on the relationship between the different volumes of early fluid resuscitation and prognosis in septic patients are unknown. Thus, this study was...

Research progress of hypertonic saline in early resuscitation of acute pancreatitis

Local inflammatory reaction and microcirculation disturbance are the early manifestations of acute pancreatitis (AP). Studies have shown that early and reasonable fluid resuscitation of patients with AP can reduce related complications and prevent the deterioration to severe acute pancreatitis (SAP). Traditional isotonic crystalloid (such as Ringer solution) is considered to be a safe and reliable resuscitation solution, but too much and too fast infusion in the early stage of shock will increase the risk of complications such as tissue edema and abdominal compartment syndrome (ACS). Many scholars have found that hypertonic saline resuscitation solution has the advantages of reducing tissue and organ edema, rapidly restoring hemodynamics, inhibiting oxidative stress and inflammatory signal transduction, thereby improving the prognosis of AP patients and reducing the incidence of SAP and mortality. This article summarizes the mechanisms of hypertonic saline in the resuscitation treatment of AP patients in recent years, in order to provide reference for the clinical application and research of AP patients.

Efficacy and safety of early enteral and intravenous fluid resuscitation in severe acute pancreatitis: a systematic review and meta-analysis.

To compare the efficacy and safety of enteral fluid resuscitation (via nasointestinal tube or colorectal tube) and intravenous fluid resuscitation (via intravenous route) in the early treatment of severe acute pancreatitis. In this study, 8 electronic databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, China HowNet database, Wanfang database, and VIP database) were searched to collect clinical studies from inception to June 12, 2022. After the quality evaluation and data extraction of the included studies, the RevMan 5.3 software was used for analysis. A total of seven studies including 580 patients were studied in this meta-analysis, in which 291 cases were treated with enteral fluid resuscitation and 289 cases were treated with intravenous fluid resuscitation. Compared with the intravenous route group, the enteral route resuscitation group reduced the incidence of new organ failure (OR = 0.23, 95% CI: 0.12-0.43, P < 0.00001), the incidence of persistent organ failure (OR = 0.38, 95% CI: 0.22-0.64, P = 0.0003), the incidence of mechanical ventilation (OR = 0.15, 95% CI: 0.03-0.69, P = 0.01), the incidence of ICU care (OR = 0.49, 95% CI: 0.27-0.88, P = 0.02), and the incidence of pancreatic infection (OR = 0.38, 95% CI: 0.17-0.83, P = 0.02). There were no statistically significant differences in mortality (OR = 0.77, 95% CI: 0.35-1.66, P = 0.50), surgical intervention rate (OR = 0.47, 95% CI: 0.19-1.18, P = 0.11), and incidence of localized ascites (OR = 0.65, 95% CI: 0.25-1.73, P = 0.39). Early enteral fluid resuscitation is safe and effective for in severe pancreatitis. But this conclusion needs to be verified by more additional multi-centre randomized controlled trials with large samples.

The efficacy of prehospital IV fluid management in severely injured adult trauma patients: a systematic review and meta-analysis.

The most widely used prehospital strategy for the management of hemorrhagic shock or trauma accompanied by hypotension is fluid resuscitation. Though current guidelines suggest early and aggressive fluid resuscitation, contemporary literature suggests a more restrictive approach. Our objective was to evaluate the effectiveness of low/ no IV fluids in comparison to standard resuscitation in reducing mortality for trauma patients in the prehospital setting. Population-adults with blunt or penetrating trauma in the prehospital setting with severe injury (defined as SBP < 90mm Hg and/or a shock index > (1). Intervention-low-dose/no IV fluids. Comparison-standard resuscitation. Outcome-mortality. A librarian-assisted search of five databases (Medline, Embase, Web of Science, and CINAHL, Cochrane trials) was completed in June 2021 (updated in November 2022). ROBINS-1 and ROB-2 tools were used to assess risk of bias in observational and randomized studies, respectively. An inverse variance method and random-effects model of statistical analysis were utilized, with data reported as risk ratios with related 95% confidence intervals. Heterogeneity of studies was assessed through analysis of the I2 RESULTS: Seven studies (six observational and one randomized trial) were included, with three thousand and fifty study participants included for analysis. Four studies compared high- to low-dose fluids, and three compared fluids to no fluids. We found no difference in mortality when comparing standard resuscitation to restricted resuscitation (RR 0.99, 95% CI [0.80-1.22], I2 = 54%). Weak, primarily observational evidence suggests that standard fluid resuscitation has no significant mortality benefit over restricting/withholding IV fluids in severe/hypotensive trauma. This review adds evidence to questioning the requirement for IV fluids in trauma given the lack of mortality benefit, in addition to demonstrating the need for more randomized studies in this area.

Comparison of early aggressive versus nonaggressive fluid resuscitation in acute pancreatitis: a meta-analysis.

Early fluid resuscitation is one of the main therapeutic strategies for acute pancreatitis (AP). This study investigated the effects of early aggressive and nonaggressive hydration on AP. The aim of this meta-analysis is to investigate the differences between aggressive and nonaggressive intravenous fluid resuscitation in AP. This study was based on publicly available data, all of which have been extracted from previous ethically approved studies. Two authors systematically searched PubMed, Embase (via OVID), Web of Science, and Cochrane Library to find all published research before February 2023. In-hospital mortality were set as primary endpoints. This meta-analysis included seven randomized controlled trials (RCTs) and eight cohort studies with 4072 individuals in nonaggressive (n = 2419) and aggressive (n = 1653) hydration groups. The results showed that patients in the nonaggressive group had a lower mortality rate than those in the aggressive hydration group [relative risks (RR), 0.66; p = 0.02]. Subgroup analysis results showed that patients in the nonaggressive hydration group had lower mortality rates in RCTs (RR, 0.39; p = 0.001), studies conducted in Eastern countries (RR, 0.63; p = 0.002), and studies with severe pancreatitis (RR, 0.65; p = 0.02). In addition, the nonaggressive hydration group had lower rates of infection (RR, 0.62; p < 0.001), organ failure (RR, 0.65; p = 0.02), and shock (RR, 0.21; p = 0.02), as well as a shorter hospital stay (weighted mean difference, -1.63; p = 0.001) than the aggressive hydration group. Early nonaggressive fluid resuscitation is associated with lower mortality, lower risk of organ failure and infection, and shorter hospital stays than aggressive fluid resuscitation. CRD42023396388.

Retracted: Effects of Different Types of Early Restrictive Fluid Resuscitation on Immune Function and Multiorgan Damage on Hemorrhagic Shock Rat Model in a Hypothermic Environment.

[This retracts the article DOI: 10.1155/2022/4982047.].

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Interaction effect between prehospital hydration and initial cardiac rhythm in traumatic out-of-hospital cardiac arrest: a nationwide observational study

Traumatic cardiac arrest (TCA) is different in etiology compared to medical cardiac arrest. In case of TCA, it is important to initiate early fluid resuscitation. Initial cardiac rhythm serves as an indicator of outcomes in case of cardiac arrest. We aimed to find the association between prehospital hydration and outcomes of TCA according to initial cardiac rhythm. This is a retrospective, observational, cross-sectional study. An examination was undertaken involving patients afflicted with TCA within the timeframe of 2014 to 2019. Exposure was defined to encompass prehospital hydration; interactive exposure was categorized by initial cardiac rhythm (non-shockable vs. shockable); the primary outcome was defined as good neurological status at discharge, whereas the secondary outcome was defined as survival to discharge. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). A comprehensive analysis was conducted on a cumulative of 20,247 patients. Rates of good neurological status and survival to discharge were 0.2% and 8.3% (non-shockable rhythm group) and 3.0% and 16.7%(shockable rhythm group), respectively. However, rates of good neurological status and survival to discharge were 0.2% and 7.9% (non-prehospital hydration group) and 0.3% and 10.0% (hydration group), respectively. Compared to the non-hydration group, the AORs for good neurological status at discharge was 1.44 (95% CI: 0.77–2.69) for the hydration group. Moreover, compared to the non-shockable rhythm group, the AORs for good neurological status at discharge was 19.74 (95% CI: 10.46–27.26) in the shockable rhythm group. The interaction analysis conducted between prehospital hydration and initial rhythm unveiled the efficacy of prehospital hydration in promoting favorable survival to discharge outcomes in the non-shockable rhythm group. Therefore, prehospital hydration is recommended for those with TCA characterized by a non-shockable rhythm before transport from the incident location.

Acute infectious purpura fulminans: case report of a medical emergency

Abstract Background Purpura fulminans (PF), characterized by the sudden onset of large, rapidly spreading hemorrhagic skin infarctions and associated disseminated intravascular coagulation, is an uncommon medical emergency. Early recognition, prompt antibiotic therapy, and intensive supportive care are essential to reduce the mortality rate of this disease. Case Presentation We report the case of a 28-year-old Chinese man with acute infectious PF. He initially presented with a fever, which rapidly progressed to septic shock, followed by skin lesions and disseminated intravascular coagulation. Computed tomography imaging revealed superior and inferior mesenteric vein thromboses. Although the etiology of the patient’s infection was unclear, the patient received early fluid resuscitation, empiric antibiotic therapy, and blood product replacement, which resulted in gradual clinical improvement. Conclusion Sepsis-associated PF may be reversible with timely empirical therapeutic interventions; however, the severity of PF should not be underestimated, and treatment should be tailored to individual patients.

Dynamic parameters for fluid responsiveness in mechanically ventilated children: A systematic review.

Fluid administration is the initial step of treatment of unstable pediatric patients. Evaluation of fluid responsiveness is crucial in mechanically ventilated children to avoid fluid overload, which increases mortality. We aim to review and compare the diagnostic performance of dynamically hemodynamic parameters for predicting fluid responsiveness in mechanically ventilated children. A systematic review was performed using four electronic databases, including PubMed, EMBASE, Scopus, and Central, for published articles from 1 January 2010 to 31 December 2020. Studies were included if they described diagnostic performance of dynamic parameters after fluid challenge was performed in mechanically ventilated children. Pediatric intensive and cardiac intensive care unit, and operative room. Children aged 1 month to 18 years old who were under mechanical ventilation and required an intravenous fluid challenge. Twenty-seven studies were included in the systematic review, which included 1,005 participants and 1,138 fluid challenges. Respiratory variation in aortic peak velocity was reliable among dynamic parameters for predicting fluid responsiveness in mechanically ventilated children. All studies of respiratory variation in aortic peak velocity showed that the area under the receiver operating characteristic curve ranged from 0.71 to 1.00, and the cutoff value for determining fluid responsiveness ranged from 7% to 20%. Dynamic parameters based on arterial blood pressure (pulse pressure variation and stroke volume variation) were also used in children undergoing congenital heart surgery. The plethysmography variability index was used in children undergoing neurological and general surgery, including the pediatric intensive care patients. The respiratory variation in aortic peak velocity exhibited a promising diagnostic performance across all populations in predicting fluid responsiveness in mechanically ventilated children. High sensitivity is advantageous in non-cardiac surgical patients and the pediatric intensive care unit because early fluid resuscitation improves survival in these patients. Furthermore, high specificity is beneficial in congenital heart surgery because fluid overload is particularly detrimental in this group of patients. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206400.

Penalized Spline-Involved Tree-based (PenSIT) Learning for estimating an optimal dynamic treatment regime using observational data.

Dynamic treatment regimes are a set of time-adaptive decision rules that can be used to personalize treatment across multiple stages of care. Grounded in causal inference methods, dynamic treatment regimes identify variables that differentiate the treatment effect and may be used to tailor treatments across individuals based on the patient's own characteristics - thereby representing an important step toward personalized medicine. In this manuscript we introduce Penalized Spline-Involved Tree-based Learning, which seeks to improve upon existing tree-based approaches to estimating an optimal dynamic treatment regime. Instead of using weights determined from the estimated propensity scores, which may result in unstable estimates when weights are highly variable, we predict missing counterfactual outcomes using regression models that incorporate a penalized spline of the propensity score and other covariates predictive of the outcome. We further develop a novel purity measure applied within a decision tree framework to produce a flexible yet interpretable method for estimating an optimal multi-stage multi-treatment dynamic treatment regime. In simulation experiments we demonstrate good performance of Penalized Spline-Involved Tree-based Learning relative to competing methods and, in particular, we show that Penalized Spline-Involved Tree-based Learning may be advantageous when the sample size is small and/or when the level of confounding of the outcome is high. We apply Penalized Spline-Involved Tree-based Learning to the retrospectively-collected Medical Information Mart for Intensive Care dataset to identify variables that may be used to tailor early fluid resuscitation strategies in septic patients.