Fluid Overload Research Articles

Subcutaneous Pectoral Edema After Arthroscopic Labral Repair Despite Normal Irrigation Fluid Usage and Surgery Duration

ABSTRACTObjectivesEdema after shoulder arthroscopic surgery poses concerns due to its potential complications such as compartment syndrome, nerve damage, and respiratory issues. This study aimed to investigate the acute accumulation of subcutaneous fluid after shoulder arthroscopy.MethodsA prospective cohort study, providing Level III evidence was conducted on 50 patients undergoing arthroscopic shoulder surgery under interscalene block anaesthesia from September to December 2023. The patients were divided into two groups: rotator cuff repair (RCR, n = 29) and labral repair for shoulder instability (LR, n = 21). Subcutaneous fluid levels were measured preoperatively, postoperatively, and at discharge (24 h postsurgery) using the MoistureMeterD Compact at the neck, pectoral region, deltoid area, cubital fossa, and carpal tunnel. Data on surgery duration and irrigation fluid volume were documented. In the statistical analysis, repeated measures ANOVA and the independent‐samples t‐test were applied to compare parametric data, while the Friedman test and Mann–Whitney U test were used for nonparametric data.ResultsThe average operation time was 29.0 ± 12.1 min for RCR and 30.0 ± 10.9 min for LR, with average irrigation fluid use of 3.8 ± 0.9 and 4.0 ± 0.7 L, respectively (both p > 0.05). There was no increase in subcutaneous edema in the neck and deltoid region in both groups. At discharge, the percentage of subcutaneous fluid increased in the cubital fossa (p = 0.04 for RCR; p < 0.001 for LR) and carpal tunnel (both p < 0.001) in oth groups, whereas pectoral edema increased only in the labral repair group (p = 0.04).ConclusionsSubcutaneous pectoral edema can occur following arthroscopic labral repair, and increased fluid levels in the cubital fossa and carpal tunnel were observed in both rotator cuff and labral repairs, even in the absence of prolonged surgery or excessive irrigation fluid use. These findings highlight the need for careful postoperative management of edema after shoulder arthroscopy, particularly for labral repairs, with special attention to the pectoral region, cubital fossa, and carpal tunnel to prevent potential complications.The registry is sponsored by the United States National Library of Medicine (www.clinicaltrials.gov); Registry Name: Examination of Edema After Arthroscopic Shoulder Surgery ID: NCT06014203.

Optimization of Hydrogen Supercritical Oxy-Combustion in Gas Turbines

This study investigates the combustion of hydrogen in supercritical gas turbines, emphasizing the optimization of combustor design through computational fluid dynamics (CFD) simulations. Key parameters analysed include the number of oxygen inlets, operating pressure, excess working fluid in oxygen inlets, power output, and the use of different working fluids: supercritical argon (sAr) and supercritical xenon (sXe). The results highlight how these parameters influence temperature distribution, flame stability, and overall combustion efficiency. Findings suggest that increasing the number of oxygen inlets can significantly affect temperature profiles, while higher operating pressures lead to shorter flames. The dilution of oxygen by argon reduces the peak temperatures, and the choice of working fluid impacts cooling efficiency and flame dynamics. This study provides valuable information on optimizing the design of supercritical combustion chambers for hydrogen combustion in novel supercritical gas turbine systems.

Usefulness of body composition assessment by bioelectrical impedance vector analysis in subacute post-stroke patients in rehabilitation

Bioelectrical Impedance Vector Analysis (BIVA) is a valuable tool for evaluating hydration and body composition, but its application in subacute post-stroke patients remains unexplored. This study aimed to fill this gap by analyzing BIVA in a cohort of 87 subacute post-stroke patients (42 women, mean age 69 ± 12) undergoing rehabilitation. At admission (T0), diagnosis of malnutrition with GLIM criteria and of sarcopenia with EWGSOP2 was done, and patients were analyzed with BIVA. The change in modified Barthel Index (mBIT1-mBIT0) was assessed to evaluate the improvement in functional recovery. BIVA revealed that both adult patients (< 65 years, n = 29) and elderly patients (≥ 65 years, n = 58) exhibited high body fluid overload and low muscle mass. Additionally, BIVA revealed a significant rightward shift of the bioimpedance vectors in malnourished (n = 37) versus non-malnourished patients (T2 = 56.9, p < 0.001, D = 1.68) and in sarcopenic (n = 24) versus non-sarcopenic patients (T2 = 36.4, p < 0.001, D = 1.5). Lastly, the BIVA distinguished patients with greater improvement (n = 53) from patients with lower improvement (n = 34) (T2 = 10.6, p = 0.007, D = 0.7). In conclusion, BIVA is an effective, easy-to-use tool for evaluating hydration, nutritional status, and recovery in post-stroke rehabilitation.

Impact of nursing interventions on hemodialysis patients using the integrated theory of health behavior change.

This study investigated the impact of nursing interventions based on the Integrated Theory of Health Behavior Change on hemodialysis patients. A retrospective analysis of 713 hemodialysis patients' electronic medical records from June 2020 to November 2023 was conducted. Patients were divided into an experimental group, receiving nursing interventions based on the theory, and a control group, receiving regular nursing care. After 1 month, dialysis indices and hospitalization rates were compared. Subgroup analyses based on education level were performed. After basic information matching, the spKt/V values of the experimental group and the control group were 1.62 ± 0.27 and 1.41 ± 0.25, with 198 and 176 individuals meeting the standard, respectively. The urea reduction ratio of the experimental group was 78.26 ± 8.72, with 187 individuals meeting the standard. From the 2 indicators, the dialysis indices of the experimental group were significantly better than those of the control group (P < .05). The numbers of readmissions in the 2 groups were 41 and 61, respectively, with a statistically significant difference (P = .024). We also compared the reasons for readmission between the 2 groups and found significant differences in the reasons. Particularly, the numbers of readmissions due to fluid overload were 13 and 32 in the experimental and control groups, respectively, with significantly fewer in the experimental group than in the control group (P = .033). The education level did not affect the readmission rate of patients, with readmission rates of 12 and 11 in the 2 groups, respectively, with P > .05. The dialysis indices spKt/V and urea reduction ratio increased with increasing BMI, and there was a correlation between the 2, with values of 0.61 and 0.51, respectively, which were statistically significant (P < .05). The extremely satisfied rates were 46% in the experimental group and 36% in the control group, with dissatisfaction rates of 2% and 3% in the 2 groups, respectively, showing a significant statistical difference (P < .01). Nursing interventions based on the Integrated Theory of Health Behavior Change improved dialysis outcomes and patient satisfaction, providing insights for chronic disease management.

Associations of resuscitation fluid load, colloid-to-crystalloid infusion ratio and clinical outcomes in children with dengue shock syndrome.

Severe respiratory distress and acute kidney injury (AKI) are key factors leading to poor outcomes in patients with dengue shock syndrome (DSS). There is still limited data on how much resuscitated fluid and the specific ratios of intravenous fluid types contribute to the development of severe respiratory distress necessitating mechanical ventilation (MV) and AKI in children with DSS. This retrospective study was conducted at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcomes were the need for MV and renal function within 48 h post-admission. A predictive model for MV was developed based on covariates from the first 24 h of PICU admission. Changes in renal function within 48 h were analyzed using a linear mixed-effects model. A total of 1,278 DSS children with complete clinical and fluid data were included. The predictive performance of MV based on the total intravenous fluid volume administered yielded an AUC of 0.871 (95% CI, 0.836-0.905), while the colloid-to-crystalloid ratio showed an AUC of 0.781 (95% CI, 0.743-0.819) (both P < 0.001). The optimal cut-off point of the cumulative fluid infusion was 181 mL/kg, whereas that of the colloid-to-crystalloid ratio was 1.6. Multivariable analysis identified female patients, severe bleeding, severe transaminitis, excessive fluid resuscitation, and a higher proportion of colloid solutions in the first 24 h as significant predictors of MV in DSS patients. The predictive model for MV demonstrated high accuracy, with a C-statistic of 89%, strong calibration, and low Brier score (0.04). Importantly, a more pronounced decline in glomerular filtration rate was observed in DSS patients who required MV than in those who did not. This study provides insights into optimizing fluid management protocols, highlighting the importance of monitoring fluid volume and the colloid-to-crystalloid ratio during early resuscitation to improve the clinical outcomes of DSS patients.

Changes in Antigen Carbohydrate 125 in Patients Receiving Dapagliflozin Following an Admission for Acute Heart Failure.

Antigen carbohydrate 125 (CA125) has emerged as a proxy of fluid overload and inflammation in acute heart failure (AHF). We aimed to evaluate the influence of dapagliflozin on CA125 levels within the first weeks after discharge and whether CA125 changes were related to 6-month adverse clinical outcomes. In this retrospective observational study, data from 956 AHF patients discharged from a tertiary hospital were analyzed. CA125 levels were assessed during the index admission (visit 1) and at a median of 26 (15-39) days after discharge (visit 2). The primary endpoint was changes in CA125 and its correlation with the risk of 6-month death and recurrent readmissions (any or AHF-related). Multivariable mixed regression and a two-equation count model regression were used for the analyses. The mean age of the cohort was 73.1±11.1 years, 54.8% were males, 43.5% showed left ventricular ejection fraction ≥50%, and 18.7% of patients received dapagliflozin at discharge. Dapagliflozin treatment was associated with a greater reduction in CA125 levels at follow-up (-24 U/mL) compared to non-dapagliflozin patients (-14 U/mL, p=0.034). The magnitude of CA125 reduction (per decrease in 10 U/ml) was significantly associated with a lower risk of 6-month death (IRR=0.98, 95% CI=0.96-0.99; p=0.049), all-cause readmissions (IRR=0.99, 95% CI=0.98-0.99; p=0.003), and HF-readmissions (IRR=0.98, 95% CI=0.97-0.99; p<0.001). Dapagliflozin treatment at discharge following an episode of AHF was associated with a greater reduction in CA125 during the first weeks after discharge. The greater CA125 reduction identified patients with a lower risk of 6-month adverse clinical outcomes.

Characteristics and outcomes of children ≤ 10 kg receiving continuous kidney replacement therapy: a WE-ROCK study.

Continuous kidney replacement therapy (CKRT) is often used for acute kidney injury (AKI) or fluid overload (FO) in children ≤ 10kg. Intensive care unit (ICU) mortality in children ≤ 10kg reported by the prospective pediatric CRRT (ppCRRT, 2001-2003) registry was 57%. We aimed to evaluate characteristics associated with ICU mortality using a contemporary registry. The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry is a retrospective, multinational, observational study of children and young adults aged 0-25years receiving CKRT (2015-2021) for AKI or FO. This analysis included patients ≤ 10kg at hospital admission. ICU mortality and major adverse kidney events at 90days (MAKE-90) defined as death, persistent kidney dysfunction, or dialysis within 90days, respectively. A total of 210 patients were included (median age 0.53years (IQR, 0.1, 0.9)). ICU mortality was 46.5%. MAKE-90 occurred in 150/207 (72%). CKRT was initiated at a median 3days (IQR 1, 9) after ICU admission and lasted a median 6days (IQR 3, 16). On multivariable analysis, pediatric logistic organ dysfunction score (PELOD-2) at CKRT initiation was associated with increased odds of ICU mortality (aOR 2.64, 95% CI 1.68-4.16), and increased odds of MAKE-90 (aOR 2.2, 95% CI 1.31-3.69). Absence of comorbidity was associated with lower MAKE-90 (aOR 0.29, 95%CI 0.13-0.65). We report on a contemporary cohort of children ≤ 10kg treated with CKRT for acute kidney injury and/or fluid overload. ICU mortality is decreased compared to ppCRRT. The extended risk of death and morbidity at 90days highlights the importance of close follow-up.

Good practice with fluid management in operative hysteroscopy.

Hysteroscopic surgery requires a balance of continuous controlled irrigation and aspiration to distend the endometrial cavity to a degree that provides the clear and stable visual environment necessary for diagnostic and therapeutic procedures. Whereas the preferred distending solution should be isotonic and isonatremic, radiofrequency (RF) electrosurgery with monopolar instrumentation can only be performed with non-ionic (hyponatremic) solutions. Absorption of as little as 500 mL and certainly more than 1000 mL of non-ionic solutions can result in fluid overload and/or dilutional hyponatremia with potentially serious adverse effects under certain conditions and patient characteristics. Both hysteroscopic RF electrosurgery with bipolar instrumentation and electro-mechanical morcellation and aspiration systems use isotonic and isonatremic solutions. Depending on the clinical context, absorption of more than 1500 mL of isonatremic solutions can also result in serious adverse effects. Automated fluid management systems are preferred and recommended, and surgeons should aim to maintain the maximum allowable intravasation of distending media below 1000 and 1500 mL for non-ionic and ionic fluids, respectively.

Relevance of perioperative fluid dynamics in liver transplantation to acute kidney injury and patient outcomes: a cross-sectional survey.

Fluid administration is a critical component of perioperative management for liver transplant recipients, and excessive fluid infusion can lead to acute kidney injury (AKI) and poor patient outcomes. We conducted a cross-sectional survey on the fluid intake and output of adult liver transplant recipients over a 7-day period. The patients were divided into AKI and non-AKI groups. Multivariate logistic regression analyses were used to evaluate the association between fluid balance (FB) and AKI. A Kaplan-Meier survival analysis was performed to determine the survival of the recipient survival at 180 days. A total of 210 liver transplant recipients were included. The peak FB occurred on the second day after transplantation, which was higher than on the seventh day (0.3 [IQR, -0.2 to 0.8] L vs. -0.4 [IQR, -1.0 to 0.3] L, p < 0.001). The highest incidence of AKI was observed on the second day after transplantation and the lowest on the seventh day (52.4% vs. 15.4%, p < 0.001). Multivariate analysis showed that a cumulative FB > 1 L within the first 2 days postoperatively was an independent risk factor for AKI on the second day after liver transplantation (LT) (OR = 2.66, 95% CI, 1.31-5.41, p = 0.007). Survival analysis indicated significant differences in 180-day survival rates among patients with different grades of AKI [94.0% (grade 1) vs. 91.4% (grade 2) vs. 77.8% (grade 3), χ 2 = 12.93, p < 0.001]. There is a significant correlation between post-LT AKI and perioperative FB. Cumulative FB > 1 L in the first 2 days postoperatively is an independent risk factor for AKI on the second day after LT. AKI after LT is associated with a lower 180-day survival rate in patients.

Brainstem C1 neurons mediate heart failure decompensation and mortality during acute salt loading.

Heart failure (HF) is an emerging epidemic worldwide. Despite advances in treatment, the morbidity and mortality rate of HF remain high, and the global prevalence continues to rise. Common clinical features of HF include cardiac sympathoexcitation, disordered breathing, and kidney dysfunction; kidney dysfunction strongly contributes to sodium retention and fluid overload, leading to poor outcomes of HF patients. We have previously shown that brainstem pre-sympathetic neurons (C1) from the rostral ventrolateral medulla (RVLM) play a key role in sympathetic regulation in experimental models of HF. However, the role of RVLM-C1 neurons during salt-loading in the context of HF is unknown. This study tests whether RVLM C1 neurons drive cardiorespiratory decompensation and ultimately lead to sudden death in HF rats. Adult male Sprague-Dawley rats underwent arteriovenous shunt to induce HF with preserved ejection fraction (HFpEF). Two weeks after HFpEF induction, bilateral selective ablation of RVLM C1 neurons was performed using anti-dopamine β-hydroxylase-saporin toxin. Animals were then fed a high Na+ diet (3% Na+ in food and 2% Na+ in water) for 3 weeks to induce compensated-to-decompensated HF state transition. Echocardiography, cardiac autonomic function, breathing function, and survival were assessed during the progression of HF. Salt loading resulted in marked decompensation in HF rats, as evidenced by a significant decrease in survival rates (survival: 10% vs. 100% HFpEF + Na+ vs. HFpEF). Furthermore, HFpEF + Na+ animals showed a further increase in cardiac sympathetic drive and more severe disordered breathing, including higher hypoxia-related epochs (i.e. apnoeas/hypopnoeas), compared with HF. Ablation of RVLM C1 neurons partly reduced the excessive cardiac sympathoexcitation during salt loading in HF, improved the exaggerated disordered breathing in HFpEF+ Na+ rats, and reduced decompensation-linked mortality. We found that hypoxia, but not high sodium, was the major contributor to impaired calcium handling in isolated adult cardiomyocytes. Our results strongly suggest that RVLM C1 neurons contribute to acute HF decompensation during salt loading by a mechanism encompassing further increases in sympathetic outflow and hypoxia-related breathing disorders. This mechanism may ultimately impact cardiac contractility through cardiomyocyte calcium mishandling, increasing morbidity and mortality.

Permanent tunneled catheter : Audit Analysis of Patients Presenting to A Tertiary Care Hospital.

Vascular access for chronic kidney disease (CKD) patient is vital for a smooth transition from CKD 5 into hemodialysis (HD). Patient resist the idea of early creation of AVF till they manifest complications such as fluid overload, electrolyte or metabolic. This audit report is a review of our patients who had a permanent catheter placed for hemodialysis. Methods: Retrospective analysis of our patient registry data. Results: Majority of the patients had PC placed as permanent access for HD and only 40% of these were due to failure of an already pplaced vascular. Access. Conclusion: Majority of our patients had PC as the only solution left for HD and this may be due to delay in AVF creation. Fistula first policy should be implemented with the help of special CKD clinics and patient education.

Fluid overload trajectories and mortality in hemodialysis patients.

Fluid overload remains critical in managing patients with end-stage kidney disease. However, there is limited empirical understanding of fluid overload's impact on mortality. This study analyzes fluid overload trajectories and their association with mortality in hemodialysis patients. This longitudinal study included 9332 incident hemodialysis patients from the EuCliD database, treated in Fresenius Medical Care NephroCare dialysis centers across seven countries between January 2016 and December 2019, with follow-up until May 2023. Fluid overload was assessed using bioimpedance spectroscopy, and patients were grouped based on fluid overload trajectories using group-based trajectory modeling. Cox regression models, adjusted for potential confounders, were used to investigate the relationship between trajectory groups and mortality. Four distinct fluid overload trajectories were identified. Patients in the highest trajectory group (8.5% of the cohort) had more frequent background cardiovascular complications, lower BMI and serum albumin, and their adjusted mortality risk was 2.20 times higher than the lowest trajectory. There was a dose-response relationship between trajectories and mortality. The incidence rate of death increased with the degree of fluid overload, from 8.6 deaths per 100 person-years in the lowest trajectory to 18.6 in the highest. This longitudinal study highlights the significant risk of chronic fluid overload in hemodialysis patients. Latent trajectory analysis provides novel information into the dynamic nature of fluid overload and its impact on mortality in the hemodialysis population.

Apolipoprotein-L1 G1 variant contributes to hydrocephalus but not to atherosclerosis in apolipoprotein-E knock-out mice.

In USA, six million individuals with Sub-Saharan ancestry carry two APOL1 high-risk variants, which increase the risk for kidney diseases. Whether APOL1 high-risk variants are independent risk factors for cardiovascular diseases is unclear and requires further investigation. We characterized a mouse model to investigate the role of APOL1 in dyslipidemia and cardiovascular diseases. Transgenic mice carrying APOL1 (G0 and G1 variants) on bacterial artificial chromosomes (BAC/APOL1 mice) were crossed with the ApoE knock-out (ApoE-KO) atherosclerosis mouse model. The compound transgenic mice were evaluated for the impact of APOL1 on systemic phenotypes. ApoE-KO mice carrying APOL1-G0 and APOL1-G1 did not show differences in the extent of atherosclerotic lesions or aortic calcification, as evaluated by Sudan IV staining and radiographic examination, respectively. However, ∼20% of ApoE-KO; BAC/APOL1-G1 mice developed hydrocephalus and required euthanasia. The hydrocephalus was communicating and likely was due to excess cerebrospinal fluid produced by the choroid plexus, where epithelial cells expressed APOL1. Single-nuclear RNA-seq of choroid plexus identified solute transporter upregulation and mTORC2 pathway activation in APOL1-G1-expressing epithelial cells. Further, in the All of Us cohort, we found higher hydrocephalus prevalence among individuals with the APOL1-G1 variant in both recessive and dominant models, supporting the mouse findings. While APOL1-G1 expression in ApoE-KO mice did not worsen cardiovascular disease phenotypes, we uncovered hydrocephalus as a novel APOL1 risk allele-mediated phenotype. These findings extend the spectrum of APOL1-associated pathologies.

IN VITRO ASSESSMENT OF ANTIUROLITHIATIC ACTIVITY OF APIGENIN WITH NITRIC ALGINATE VARIATION IN NANOSUSPENSION

Kidney stones are hard kidney material, such as stones that originate from minerals and salts. Alternative therapy using medicinal plants as anticalculi is an option for treating kidney stones. One plant with anticalculi activity is celery, which contains various active chemical compounds, including apigenin. Apigenin is a diuretic that can help the kidneys remove excess fluid and salt from the body. However, apigenin has low solubility in water. To overcome the limited solubility of apigenin, nanosuspensions were prepared. This study aimed to formulate a nanosuspension, evaluate its preparation, and test it in vitro. This formula uses the concentration of the suspending agent, Na. The different alginates were F0 without active substances (0%) and F1 (1%), F2 (2%), and F3 (3%). The evaluation of the preparation includes tests for pH, viscosity, specific gravity, particle size, zeta potential, and adsorption efficiency. The results showed that the preparation had an average pH value of 4-7, an average viscosity value of 78-162 cP, a specific gravity of 0.98-1.02 g/mL, the preparation had a particle size of 928–974 nm, zeta potential of-26, 3 to -41.7, and an average entrapment efficiency of 99.63%-99.64%. Apigenin nanosuspension preparations can dissolve kidney stone calcium at 1800-7800 ppm. The test results showed that the apigenin nanosuspension has the potential to dissolve calcium kidney stones. Keywords: kidney stones, apigenin, in vitro, nanosuspension

Design and rationale of the eLym™ System for Decompensation of Excess Lymphatic Fluid via the Thoracic Duct in Acute Heart Failure (DELTA‐HF)

AbstractAimsThe interstitial space is the major compartment in which the excess fluid is located, forming peripheral congestion in acute decompensated heart failure (ADHF). The lymphatic system is responsible for the constant drainage of the compartment. In ADHF, the inefficiency of this system causes extravascular fluid accumulation, underscoring the crucial role of lymphatic system failure in ADHF's pathophysiology. The eLym™ System is a transcutaneous device designed to facilitate lymph drainage by creating a low‐pressure zone in the thoracic duct area, theoretically allowing more efficient decompression of the lymphatic system.Methods and ResultsThe safety and feasibility of the eLym™ System for the Decongestion of Excess Lymphatic Fluid via the Thoracic Duct in Acute Decompensated Heart Failure: DELTA‐HF Study is a prospective, multicentre, single‐arm study designed to evaluate the safety and feasibility of the WhiteSwell eLym™ System in the treatment of fluid overload in ADHF. A maximum of 50 subjects may be enrolled and undergo the treatment. Inclusion criteria include the presence of congestion, a home diuretic dose ≥80 mg furosemide (or equivalent) and elevated natriuretic peptides. The key exclusion criteria include anatomical abnormalities and the inability to undergo systemic anticoagulation. The study endpoints include the safety (short‐ and long‐term) and feasibility of the procedure. Several congestion indexes will be prospectively assessed. Descriptive statistics will summarize the study results. The study was registered in clinicaltrial.gov (NCT05747196).ConclusionsThe results of the DELTA‐HF study will provide information about the safety and feasibility of the eLym™ System and will provide first‐in‐human clinical signals of its use in ADHF patients.

Fluid management in adult patients undergoing venoarterial extracorporeal membrane oxygenation: A scoping review.

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a cardiocirculatory support has tremendously increased in critically ill patients. Although fluid therapy is an essential component of the hemodynamic management of VA-ECMO patients, the optimal fluid resuscitation strategy remains controversial. We performed a scoping review to map out the existing knowledge on fluid management in terms of fluid type, dosing and the impact of fluid balance on VA-ECMO patient outcomes. A literature search within PubMed and EMBASE was conducted from database inception to April 2024. We included all studies involving critically ill adult patients, supported by VA-ECMO regardless of clinical indication (cardiogenic shock or extracorporeal cardiopulmonary resuscitation) with or without Renal Replacement Therapy and describing fluid resuscitation strategies or focusing on fluid type or reporting the impact of fluid balance on clinical outcomes and mortality. Details of study population, ECMO indications, fluid types, resuscitation strategies, fluid balance and outcome measures were extracted. Sixteen studies met inclusion criteria, including 14 clinical studies and two experimental animal studies. We found a lack of studies comparing restrictive and liberal approaches. No study has compared the efficacy and safety of balanced and saline solutions. The place of albumin, as an alternative fluid, should be investigated. Despite their heterogeneity, studies found a negative impact of both early and cumulative fluid overload on survival and renal outcomes. The available literature on the fluid management in VA-ECMO setting is scarce. More high-quality evidence is needed regarding optimal fluid dosing, type and resuscitation endpoints in order to standardize practice and improve outcomes.

Effect of the use of dapagliflozin in diuresis, natriuriesis, and in ultrafiltration and peritoneal elimination of sodium in patients with refractory heart failure: DAPA-DP study

BackgroundPeritoneal dialysis (PD) has emerged as an effective technique for managing refractory heart failure (HF) in patients unresponsive to diuretics. Previous meta-analyses have demonstrated significant reductions in hospitalization days and improvements in cardiac function among patients with HF treated with PD compared with those receiving standard therapies. However, sodium retention remains a challenge in HF management, as patients often exhibit poor compliance with dietary sodium restrictions. In patients on PD, sodium retention exacerbates fluid overload and cardiovascular complications, highlighting the need for effective sodium elimination strategies.MethodsThis study will investigate the effects of PD on sodium excretion and its impact on mortality and heart failure exacerbations. We will enroll 31 patients with refractory HF in a continuous ambulatory peritoneal dialysis program. The study design includes randomization, a washout period, and an open-label approach to evaluate the impact of dapagliflozin, a sodium-glucose cotransporter-2(SGLT2) inhibitor, on sodium balance and clinical outcomes. Statistical analysis will be performed to assess changes in sodium excretion and the association between sodium removal levels and clinical outcomes.Expected resultsWe hypothesize that dapagliflozin in patients undergoing PD will enhance net sodium loss by combining its known natriuretic efficacy with the hypothesis of increased sodium elimination in the peritoneal effluent. This effect is expected to be observed independently of the patients’ baseline renal function. Additionally, the study will investigate the safety profile of dapagliflozin in PD patients, monitoring for potential adverse effects and overall tolerability.ConclusionsThe study aims to provide valuable insights into optimizing HF management in PD patients through innovative therapeutic approaches. The anticipated findings could significantly impact clinical practice by improving sodium and fluid balance, potentially leading to reduced hospitalizations and better overall health outcomes for HF patients on PD.Trial Registration: This study was approved and authorized by both the Spanish Agency of Drugs and Health Products (AEMPS) and the Hospital Clínico Universitario de Valencia Ethical Committee (CEIM). The investigated drug, dapagliflozin, has received approval from the European Medicines Agency (EMA) and has been authorized for commercialization in Spain (CEIM FILE: 148/23, CODE: DAPA-DP, EUDRACT no.: 2023-505571-78-00).

The Impact of Postoperative Albumin Levels on Furosemide Efficacy in Infants with Congenital Heart Disease.

Postoperative fluid overload is associated with increased mortality and morbidity in infants with congenital heart disease (CHD). Loop diuretics, such as furosemide, are commonly used to prevent fluid overload in the postoperative period. This study aimed to investigate the effect of postoperative albumin levels on the efficacy of furosemide after surgery in infants with CHD. From 1 January 2017 to 31 December 2022, postoperative albumin levels, total furosemide doses, and three-day postoperative diuresis levels were retrospectively analyzed in 186 patients aged 0-1 years who underwent cardiopulmonary bypass at the Pediatric Intensive Care Unit, Diyarbakır Gazi Yaşargil Training and Research Hospital. Demographic and clinical parameters, along with urine output in the first 6 h, first 24 h, 24-48 h, and 48-72 h postoperatively, were recorded. Patients were divided into two groups based on their albumin levels: normal albumin (≥30 g/dL) and hypoalbuminemia (<30 g/dL). A common protein interaction network for albumin and furosemide was constructed using Cytoscape software (version 3.10.2). Of the 186 patients, 79 (42.5%) were male and 107 (57.5%) were female, with a median age of 97.5 days (range 1-360 days). Furosemide doses were higher in hypoalbuminemic patients on postoperative days 1 and 2 compared to normoalbuminemic patients. On postoperative day 1, hypoalbuminemia was more prevalent in patients with oliguria, whereas normoalbuminemia was significantly higher in patients with normouria and polyuria. Furosemide doses were significantly higher in patients with oliguria than in those with normouria in the first 6 h and lower in patients with polyuria compared to those with normouria. A positive correlation was observed between albumin levels and furosemide efficacy on postoperative day 2. Additionally, a positive correlation existed between albumin levels on postoperative day 1 and urine output in the first 6 and 24 h postoperatively. Furosemide efficacy and urine output were positively correlated in the postoperative period. Mortality risk was significantly higher in hypoalbuminemic patients on postoperative days 1 and 2, as well as in patients with oliguria in the first 6 and 24 h postoperatively. Network analysis revealed that albumin was directly involved in furosemide's target network, along with six other proteins within the common interaction network. Diuresis levels were significantly lower in hypoalbuminemic patients. We suggest that the effectiveness of furosemide is reduced because it cannot bind to albumin at sufficient levels. The effective management of albumin levels may enhance furosemide efficacy and improve postoperative outcomes in infants with CHD.

The Association Between Fluid Management and Intraoperative Blood Pressure and Patients’ Outcome After Complex Spine Surgeries

BACKGROUND: Both intraoperative hypotension and excessive fluid administration can lead to detrimental perioperative complications. However, how much fluid is considered excessive and how is intraoperative hypotension related to major postoperative complications? METHODS: We conducted a single-center retrospective cohort study in 6243 patients undergoing complex spine surgery at the Cleveland Clinic Foundation between 2012 and 2022 and studied the relationship between intraoperative net fluid administration and intraoperative hypotension with major postoperative complications. The primary outcome was a collapsed composite of postoperative complications including acute kidney injury (AKI), myocardial infarction (MI), stroke, and intensive care unit (ICU) admissions. Secondary outcomes were in-hospital postoperative pulmonary complications, surgical site infections (SSI), and mortality. RESULTS: The study consisted of 6998 complex spinal surgery cases from 6243 patients. The median net fluid administration was 2100 mL (Interquartile range: 1450 to 3020 mL), and we found a change point in net fluid administration of 1865 mL (95% Confidence Interval: 1228 to 4710 mL). The odds ratio of developing postoperative complications for every 500 mL increase in net fluid administration was 1.16 (95% confidence interval [CI], 1.11–1.21; P &lt; .0001) above and 0.87 (95% CI, 0.77–0.98; P = .026) below the change point. The odds ratio of developing postoperative pulmonary complications was 1.12 (95% CI, 1.07–1.18; P &lt; .0001) for every 500 mL increase in net fluid administration. Intraoperative hypotension was detected in 2052 complex spine surgeries (29%). The odds ratio of developing any postoperative complication was 1.57 (95% CI, 1.37–1.80; P &lt; .0001) and 1.30 (95% CI, 1.04–1.61; P = .019) for postoperative pulmonary complications. CONCLUSIONS: We discovered a change point in net fluid administration of 1,865mL. Above this change point, higher net fluid administration is associated with increased odds of developing postoperative complications. Intraoperative hypotension in complex spine surgeries was associated with increased postoperative complications.

Fabrication and in vivo testing of a sub-mm duckbill valve for hydrocephalus treatment

Hydrocephalus is characterized by the accumulation of excess cerebrospinal fluid (CSF) in the cranium due to an imbalance between production and absorption of CSF. The standard treatment involves the implantation of a shunt to divert excess CSF into the peritoneal cavity, but these shunts exhibit high failure rates over time. In pursuit of improved reliability and performance, this study proposes a miniaturized valve designed to mimic the natural one-way valve function of the arachnoid granulations and thereby replace the shunts. A benchtop testing setup was employed to characterize the behavior of the fabricated valve. Additionally, an animal study was conducted to assess the valve’s in vivo performance. This involved the injection of saline into the lateral ventricle to elevate intracranial pressure (ICP), followed by the drainage of the saline through the valve inserted into the cisterna magna (CM) to reduce pressure. Our prototype features a silicone duckbill valve design combined with a silicone tube as an inlet. Through benchtop testing, the valve exhibited unidirectional flow with negligible reverse leakage, revealing that critical parameters such as the width of the fluid channel (W) and bill length (L) could be controlled to optimize valve performance. Notably, the valve configuration with W= 0.8mm and L < 0.5mm achieved the lowest cracking pressure (2.22 ± 0.07 mmHg) and outflow resistance (22.00 ± 0.70 mmHg/mL/min) within the low cracking pressure range of conventional shunts. Our observations of the in vivo test demonstrated that when untreated states, pressure differences from baseline to peak exceeded 20 mmHg due to the absence of drainage, resulting in sustained pressure elevation. Conversely, upon treating states by removing the clamp, pressure differences from baseline to peak remained below 5 mmHg, indicating effective drainage of injected saline through the valve. These promising results highlight the potential of the miniaturized duckbill valve as an alternative for ICP management in hydrocephalus, offering improved control and reliability compared to conventional shunting systems. Further research is required to evaluate the valve’s performance as a chronic implant.