Excessive Fluid Administration Research Articles

Intraoperative fluid management in adult spinal deformity surgery: variation analysis and association with outcomes.

To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS). Multicenter comparative cohort study. Patients ≥ 18years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input-output difference (IOD), and normalized input-output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes. Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = -0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004). Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes. III.

Understanding fluid dynamics and renal perfusion in acute kidney injury management.

Acute kidney injury (AKI) is associated with an increased risk of morbidity, mortality, and healthcare expenditure, posing a major challenge in clinical practice, and affecting about 50% of patients in the intensive care unit (ICU), particularly the elderly and those with pre-existing chronic comorbidities. In health, intra-renal blood flow is maintained and auto-regulated within a wide range of renal perfusion pressures (60-100 mmHg), mediated predominantly through changes in pre-glomerular vascular tone of the afferent arteriole in response to changes of the intratubular NaCl concentration, i.e. tubuloglomerular feedback. Several neurohormonal processes contribute to regulation of the renal microcirculation, including the sympathetic nervous system, vasodilators such as nitric oxide and prostaglandin E2, and vasoconstrictors such as endothelin, angiotensin II and adenosine. The most common risk factors for AKI include volume depletion, haemodynamic instability, inflammation, nephrotoxic exposure and mitochondrial dysfunction. Fluid management is an essential component of AKI prevention and management. While traditional approaches emphasize fluid resuscitation to ensure renal perfusion, recent evidence urges caution against excessive fluid administration, given AKI patients' susceptibility to volume overload. This review examines the main characteristics of AKI in ICU patients and provides guidance on fluid management, use of biomarkers, and pharmacological strategies.

Prehospital treatment of severely burned patients: a retrospective analysis of patients admitted to the Berlin burn centre

BackgroundPrehospital management of severely burned patients is extremely challenging. It should include adequate analgesia, decision-making on the necessity of prehospital endotracheal intubation and the administration of crystalloid fluids. Guidelines recommend immediate transport to specialised burn centres when certain criteria are met. To date, there is still insufficient knowledge on the characteristics of prehospital emergency treatment. We sought to investigate the current practice and its potential effects on patient outcome.MethodsWe conducted a single centre, retrospective cohort analysis of severely burned patients (total burned surface area > 20%), admitted to the Berlin burn centre between 2014 and 2019. The relevant data was extracted from Emergency Medical Service reports and digital patient charts for exploratory data analysis. Primary outcome was 28-day-mortality.ResultsNinety patients (male/female 60/30, with a median age of 52 years [interquartile range, IQR 37–63], median total burned surface area 36% [IQR 25–51] and median body mass index 26.56 kg/m2 [IQR 22.86–30.86] were included. The median time from trauma to ED arrival was 1 h 45 min; within this time, on average 1961 ml of crystalloid fluid (0.48 ml/kg/%TBSA, IQR 0.32–0.86) was administered. Most patients received opioid-based analgesia. Times from trauma to ED arrival were longer for patients who were intubated. Neither excessive fluid treatment (> 1000 ml/h) nor transport times > 2 h was associated with higher mortality. A total of 31 patients (34,4%) died within the hospital stay. Multivariate regression analysis revealed that non-survival was linked to age > 65 years (odds ratio (OR) 3.5, 95% CI: 1.27–9.66), inhalation injury (OR 3.57, 95% CI: 1.36–9.36), burned surface area > 60% (OR 5.14, 95% CI 1.57–16.84) and prehospital intubation (5.38, 95% CI: 1.92–15.92).ConclusionWe showed that severely burned patients frequently received excessive fluid administration prehospitally and that this was not associated with more hemodynamic stability or outcome. In our cohort, patients were frequently intubated prehospitally, which was associated with increased mortality rates. Further research and emergency medical staff training should focus on adequate fluid application and cautious decision-making on the risks and benefits of prehospital intubation.Trial registrationGerman Clinical Trial Registry (ID: DRKS00033516).

Role of inferior vena cava assessment in volume management in acute kidney injury patients

BackgroundIntravascular volume assessment is critical to guiding volume management in patients with acute kidney injury (AKI). This study aimed to compare the impact of using inferior vena cava (IVC) diameter and collapsibility index (IVC-CI) measurements versus clinical assessment on the management of volume status and improvement of renal function in patients with AKI.MethodsThis prospective comparative study included 88 patients with AKI or AKI on top of chronic kidney disease (CKD) who were randomly allocated into two groups: In group 1, volume status was managed according to IVC assessment, while in group 2, volume status was managed according to clinical assessment. In addition, group 1 patients were assessed clinically and compared with IVC measurements in the same group.ResultsThere was moderate agreement between the IVC and clinical methods in diagnosing 86.4% of patients (P < 0.001) within group 1. The percentage of patients with edema increased post-treatment in group 2. There was no statistically significant difference between the two groups regarding renal recovery and survival.ConclusionBedside ultrasonographic IVC assessment is a non-invasive method that can facilitate volume management in AKI patients, helping to administer fluids more wisely without unintended excess fluid administration.

MAN VERSUS MACHINE: PROVIDER DIRECTED VERSUS PRECISION AUTOMATED CRITICAL CARE MANAGEMENT IN A PORCINE MODEL OF DISTRIBUTIVE SHOCK.

Background: Critical care management of shock is a labor-intensive process. Precision Automated Critical Care Management (PACC-MAN) is an automated closed-loop system incorporating physiologic and hemodynamic inputs to deliver interventions while avoiding excessive fluid or vasopressor administration. To understand PACC-MAN efficacy, we compared PACC-MAN to provider-directed management (PDM). We hypothesized that PACC-MAN would achieve equivalent resuscitation outcomes to PDM while maintaining normotension with lower fluid and vasopressor requirements. Methods : Twelve swine underwent 30% controlled hemorrhage over 30 min, followed by 45 min of aortic occlusion to generate a vasoplegic shock state, transfusion to euvolemia, and randomization to PACC-MAN or PDM for 4.25 h. Primary outcomes were total crystalloid volume, vasopressor administration, total time spent at hypotension (mean arterial blood pressure <60 mm Hg), and total number of interventions. Results : Weight-based fluid volumes were similar between PACC-MAN and PDM; median and IQR are reported (73.1 mL/kg [59.0-78.7] vs. 87.1 mL/kg [79.4-91.8], P = 0.07). There was no statistical difference in cumulative norepinephrine (PACC-MAN: 33.4 μg/kg [27.1-44.6] vs. PDM: 7.5 [3.3-24.2] μg/kg, P = 0.09). The median percentage of time spent at hypotension was equivalent (PACC-MAN: 6.2% [3.6-7.4] and PDM: 3.1% [1.3-6.6], P = 0.23). Urine outputs were similar between PACC-MAN and PDM (14.0 mL/kg vs. 21.5 mL/kg, P = 0.13). Conclusion : Automated resuscitation achieves equivalent resuscitation outcomes to direct human intervention in this shock model. This study provides the first translational experience with the PACC-MAN system versus PDM.

A Narrative Review on Diabetic Ketoacidosis in Children.

Diabetic ketoacidosis (DKA) is a life-threatening complication in children with diabetes mellitus. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. This is based on the concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration. However, in recent years, new clinical studies suggest that there is no causal relationship between intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians. The purpose of this article is to provide a narrative review on the management of DKA. A PubMed search was performed with clinical queries using the key term "diabetic ketoacidosis". The search strategy included randomized controlled trials, clinical trials, meta-analyses, observational studies, guidelines, and reviews. The search was restricted to English literature and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines. The management of DKA involves early recognition, accurate diagnosis, meticulous fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal function, and neurological status. There is still limited clinical evidence to support either a restrictive or permissive approach in the fluid management of paediatric DKA patients. Clinicians should exercise caution when applying different guidelines in their clinical practice, considering the specific circumstances of individual paediatric patients.

Permissive Hypotension Has No Deleterious Impact on Fluid Balance or Kidney Function.

Mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely in the absence of tissue hypoperfusion, but the consequences on fluid balance and kidney function remain unknown. During a 1-year period, we retrospectively collected data of consecutive septic patients admitted for sepsis with a mean arterial pressure (MAP) less than 65 mm Hg despite fluid resuscitation. Medical 18-bed ICU in a tertiary teaching hospital. Septic patients with a MAP less than 65 mm Hg despite initial resuscitation. In our ICU, MAP between 55 and 65 mm Hg was tolerated in the absence of peripheral hypoperfusion (permissive hypotension) or corrected using norepinephrine (septic shock group) when peripheral tissue hypoperfusion was present. Ninety-four consecutive septic patients were included, 15 in the permissive hypotension group and 79 in the septic shock group. Median age was 66 years (57-77 yr) and 42% were women. The main sources of infection were respiratory (45%) and abdominal (18%). Severity was more important in septic shock group with higher Sequential Organ Failure Assessment score (7 [5-10] vs. 4 [1-6]; p < 0.0001), more frequent organ support therapy and ultimately higher mortality (38 vs. 0%; p < 0.01). The total volume of crystalloids infused before ICU admission was not different between groups (1930 ± 250 vs. 1850 ± 150 mL; p = 0.40). Within the 6 first hours of ICU stay, patients in the permissive hypotension group received less fluids (530 ± 170 vs. 1100 ± 110 mL; p = 0.03) and had higher urinary output (1.4 mL [0.88-2.34 mL] vs. 0.47 mL/kg/hr [0.08-1.25 mL/kg/hr]; p < 0.001). In addition, kidney injury evaluated using KDIGO score was lower in the permissive hypotension group at 48 hours (0 hr [0-1 hr] vs. 1 hr [0-2 hr]; p < 0.05). In septic patients without clinical peripheral hypoperfusion, mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely without vasopressor infusion and was not associated with excessive fluid administration or kidney damage.

Assessing the venous system: Correlation of mean systemic filling pressure with the venous excess ultrasound grading system in cardiac surgery.

Evaluation of the venous system has long been underestimated as an important component of the circulatory system. As systemic venous pressure increases, the perfusion pressure to the tissues is compromised. During initial resuscitation in cardiac surgery, excessive fluid administration is associated with increased morbidity and mortality. We conducted a cross-sectional study of 60 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain the venous excess ultrasound (VExUS) grading system and mean systemic filling pressure (Pmsf) in the postoperative period upon admission, at 24 and 48h. We then determined the correlation between VExUS grading and Pmsf. On admission, patients with VExUS grading 0 predominated, with a progressive increase in venous congestion and an increase in Pmsf over the course of the first 48h. There was a strong positive correlation between VExUS grading and the invasive measurement of Pmsf at 24 and 48h after arrival. The presence of grade 2 or grade 3 venous congestion in the postoperative period poses an increased risk of developing acute kidney injury. The VExUS grading system indicates a high degree of systemic venous congestion in the first 48h of the postoperative period after cardiac surgery and correlates with the Pmsf, which is the best surrogate of stressed circulatory volume.

Can the OSA patient be managed within an ERAS protocol? A narrative review

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder among surgical patients and is associated with an increased risk of perioperative cardiopulmonary complications leading to increased health expenses. Therefore, preoperative OSA screening should be instituted to inform patients of their increased perioperative risk and measures can be taken in to decrease this risk. Meanwhile ERAS (Enhanced recovery after surgery) guidelines are becoming standard of care and being widely implemented. The purpose of these recovery programs is to standardize medical care, enhance outcomes and decrease health care expenses using evidence-based protocols. According to the current evidence it is unclear if OSA patients could benefit from these protocols. The first part of this narrative review states the current evidence on OSA definition, classification, pathophysiology and risk factors, postoperative complications, endotypes and their relevance for the anesthesiologist. The second part investigated the feasibility of ERAS measures within the OSA-population. Preoperatively there are many parallels to be drawn between the ERAS measures and Society of Anesthesia and Sleep Medicine (SASM) guidelines on OSA management: Risk stratification by OSA-screening, information counselling on the increased perioperative risk and optimization of preoperative health conditions by initiation of CPAP-therapy. Perioperatively the use short acting anesthetics allows for both early mobilization and avoid postoperative respiratory compromise by sustained drug effect. ERAS measures to maintain the patient in the zone of normovolaemia are advantageous for OSA patients as excessive fluid administration can worsen OSA. The use of multimodal analgesia sparing opioids might be the most important element beneficial for OSA patients they are more prone to develop opioid induced respiratory depression (OIRD). As OSA patients are at risk for venous thromboembolism appropriate thromboprophylaxis should be applied. Postoperatively OSA patients should be closely monitored in the prevention of OIRD. In conclusion many ERAS measures seem to be applicable or of benefit for OSA patients. However, large prospective randomized controlled trials are needed to evaluate if these patients can be managed within an ERAS protocol.

Goal-directed fluid therapy compared to liberal fluid therapy in patients subjected to colorectal surgery

ABSTRACT Background The best technique to manage intraoperative fluids during colorectal surgery has never been universally agreed upon. Key organ function is hampered by excessive intraoperative fluid administration: It lengthens and raises the expense of hospitalization by increasing the risk of heart failure that goes along with it, causing gastrointestinal membrane edema, and impeding the recovery of gastrointestinal functions. Aim and objectives Thestudy’s objective was to evaluate the impacts of goal-directed fluid therapy (GDFT) and liberal fluid therapy (LFT) using cardiometry in candidates with colorectal abnormalities. Subjects and methods 100 patients were allocated into two equal groups in a random pattern for this prospective, randomized, controlled trial at the Mansoura oncology center; GDFT group) 50 patients): by using stroke volume optimization and the LFT group (50 patients): by using the traditional technique of fluid administration. Results Crystalloid and total fluids were significantly lower among GDFTgroup compared to LFT group. Both lactate and creatinine levels were slightly higher among the GDFT group than the LFT group but without a statistically significant difference. Postoperative complications were comparable between the studied groups. Conclusions However, GDFT needs lower total volume of fluids given to the patients it may not enhance patients’ postoperative outcomes after colorectal surgery compared to liberal fluid treatment. Moreover, both studied strategies did not affect organ perfusion, although serum lactate and serum creatinine were slightly higher with GDFT.

The Impact of Rocuronium and Sugammadex on Length of Stay in Patients Undergoing Open Spine Surgery: A Propensity Score-Matched Analysis.

Enhanced Recovery After Surgery (ERAS), an all-encompassing perioperative care approach, has been demonstrated to enhance surgical results, mitigate postoperative issues, and decrease the length of hospital stay (LOS) in diverse surgical specialties. In this retrospective study, our objective was to examine the influence of muscle relaxant selection on LOS and perioperative results in adult patients undergoing open spine surgery. Specifically, we compared 201 patients who received cisatracurium and neostigmine with 201 patients who received rocuronium and sugammadex, after 1:1 propensity score matching. The utilization of the rocuronium and sugammadex combination in anesthesia for open spinal surgery did not lead to a reduction in the LOS but was associated with a decreased incidence of postoperative chest radiographic abnormalities, including infiltration, consolidation, atelectasis, or pneumonia (p = 0.027). In our secondary analysis, multivariate analysis revealed multiple determinants influencing the prolonged LOS (>7 days) during open spine surgery. Bispectral index-guided anesthesia emerged as a protective factor, while variables such as excessive intraoperative blood loss and fluid administration as well as postoperative chest radiographic abnormalities independently contributed to prolonged LOS.

Association between cumulative fluid balance and clinical outcome in patients with septic shock: A retrospective observational study

Abstract Introduction: Aggressive fluid replacement is done in septic shock to compensate for the decreased stressed volume in view of peripheral vasodilatation. However, excessive fluid administration may lead to fluid overload, edema formation, and organ damage such as renal congestion and acute kidney injury. Hence, this study was conducted to estimate the effect of fluid balance in the 1st week of septic shock on mortality. Materials and Methods: We conducted a retrospective analysis of the use of intravenous fluids and cumulative fluid balance (CFB) during the first 7 days of septic shock in a 25-bed multidisciplinary intensive care unit (ICU) in Northern India at a tertiary care teaching hospital. Results: Based on the CFB, we classified patients as low CFB when CFB is &lt;20 mL/kg and high CFB when it is &gt;20 mL/kg. The 28-day mortality in the low CFB group was 4.7% and in the high CFB group 26.15%, which was statistically significant. With an odds ratio of 7.17, CFB in septic shock was a predictor of ICU mortality (confidence interval of 3.87–13). The length of stay between the two groups was also found to be statistically significant (11.7 ± 3.2 vs. 12.6 ± 3.8; P = 0.02). Conclusions: In patients with septic shock, a higher CFB on day 7 of ICU admission is independently associated with an increased risk of mortality and a longer ICU stay. The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge.

PRECISION AUTOMATED CRITICAL CARE MANAGEMENT (PACC-MAN): CLOSED-LOOP CRITICAL CARE FOR THE TREATMENT OF DISTRIBUTIVE SHOCK IN A SWINE MODEL OF ISCHEMIA-REPERFUSION.

Goal-directed blood pressure management in the intensive care unit can improve trauma outcomes but is labor-intensive. Automated critical care systems can deliver scaled interventions to avoid excessive fluid or vasopressor administration. We compared a first generation automated drug and fluid delivery platform, Precision Automated Critical Care Management (PACC-MAN), to a more refined algorithm, incorporating additional physiologic inputs and therapeutics. We hypothesized that the enhanced algorithm would achieve equivalent resuscitation endpoints with less crystalloid utilization in the setting of distributive shock. Twelve swine underwent 30% hemorrhage and 30 min of aortic occlusion to induce an ischemia-reperfusion injury and distributive shock state. Next, animals were transfused to euvolemia and randomized into a standardized critical care (SCC) of PACC-MAN or an enhanced version (SCC+) for 4.25 hrs. SCC+ incorporated lactate and urine output to assess global response to resuscitation and added vasopressin as an adjunct to norepinephrine at certain thresholds. Primary and secondary outcomes were decreased crystalloid administration and time at goal blood pressure, respectively. Weight-based fluid bolus volume was lower in SCC+ compared to SCC (26.9 ml/kg vs. 67.5 ml/kg, p = 0.02). Cumulative norepinephrine dose required was not significantly different (SCC+: 26.9 mcg/kg vs. SCC: 13.76 mcg/kg, p = 0.24). Three of 6 animals (50%) in SCC+ triggered vasopressin as an adjunct. Percent time spent between 60-70 mmHg, terminal creatinine and lactate, and weight-adjusted cumulative urine output were equivalent. Refinement of the PACC-MAN algorithm decreased crystalloid administration without sacrificing time in normotension, reducing urine output, increasing vasopressor support, or elevating biomarkers of organ damage. Iterative improvements in automated critical care systems to achieve target hemodynamics in a distributive-shock model are feasible. Level IIIJTACS Study Type: Therapeutic/care management.

Intraoperative vasopressor use does not increase complications in microvascular post-mastectomy breast reconstruction: Experience in 1729 DIEP flaps at a single center

Vasopressors are traditionally avoided in microsurgery due to concerns about their effect on free flap survival. We examine the impact of intraoperative vasopressors on microsurgical outcomes in a large series of DIEP flap breast reconstructions. A retrospective chart review was performed of patients who underwent DIEP breast reconstruction between January 2010 and May 2020. Intraoperative and postoperative microsurgical outcomes were compared in patients who received vasopressors and those who did not. The study included 1102 women who underwent 1729 DIEP. 878 patients (79.7%) received intraoperative phenylephrine, ephedrine, or a combination of both. There was no significant difference in overall complications, intraoperative microvascular events, takebacks for microvascular complications, or partial or total flap loss between groups. Outcomes were not affected by vasopressor type, dose, or timing of administration. The vasopressor group received significantly lower intraoperative fluid volumes. Multivariate logistic regression found a significant association between overall complications and excessive fluids (OR 2.03, 99% CI 0.98-5.18, p=0.03) but not vasopressor use (OR 0.79, 99% CI 0.64-3.16, p=0.7) CONCLUSION: This study demonstrates that vasopressors do not adversely affect clinical outcomes after DIEP breast reconstruction. Withholding vasopressors results in excessive intravenous fluid administration and increased postoperative complications.

Effects of excess fluid administration and dehydration treatment on venous return in canine model of septic shock.

Effects of excess fluid administration and dehydration treatment on venous return in canine model of septic shock.

Guidance of Ultrasound in Critical Illness to Direct Euvolemia Trial: A Cluster-Randomized, Crossover, Comparative Effectiveness Trial

INTRODUCTION: Acute kidney injury (AKI) after trauma is common and associated with poor outcomes. Both inadequate resuscitation and excess fluid administration increase incidence and duration of AKI. We hypothesized that adding ultrasound (US) assessments of inferior vena cava diameter and collapsibility index to usual care would result in shorter AKI duration. METHODS: The Guidance of Ultrasound in Critical Illness to Direct Euvolemia (GUIDE) trial was a sequential, cluster-randomized, crossover comparative effectiveness trial designed to account for care team clusters. ICU teams were randomized to usual care with or without the addition of 24 hours of serial inferior vena cava diameter and inferior vena cava diameter and collapsibility index measurements from September 2019 to June 2020. The primary outcome was AKI duration. Univariate and multivariate analyses were performed. RESULTS: Of 411 patients, 222 were randomized to the US group. Demographics were similar between groups. Patients had a median Injury Severity Score of 26 (interquartile range 16 to 34) and a median age of 38 (interquartile range 26 to 60). The incidence of AKI was similar between groups (US 54% vs usual care 58%, p = 0.46), and the median duration of AKI was 1 day in both groups (interquartile range 0 to 2, p = 0.34). Fluid balances were similar at 24 hours; however, at 48 hours, patients in the US group had a higher fluid balance (Figure). Other complications and mortality were similar between groups.FigureCONCLUSION: This comparative effectiveness trial demonstrated that addition of inferior vena cava diameter and inferior vena cava diameter and collapsibility index assessments to routine care did not affect the duration of AKI but increased patients’ fluid balance at 48 hours. Routine application of US assessments of fluid status in severely injured trauma patients is not recommended.

Acid-Base Disorders in the Critically Ill Patient.

Acid-base disorders are common in the intensive care unit. By utilizing a systematic approach to their diagnosis, it is easy to identify both simple and mixed disturbances. These disorders are divided into four major categories: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Metabolic acidosis is subdivided into anion gap and non-gap acidosis. Distinguishing between these is helpful in establishing the cause of the acidosis. Anion gap acidosis, caused by the accumulation of organic anions from sepsis, diabetes, alcohol use, and numerous drugs and toxins, is usually present on admission to the intensive care unit. Lactic acidosis from decreased delivery or utilization of oxygen is associated with increased mortality. This is likely secondary to the disease process, as opposed to the degree of acidemia. Treatment of an anion gap acidosis is aimed at the underlying disease or removal of the toxin. The use of therapy to normalize the pH is controversial. Non-gap acidoses result from disorders of renal tubular H + transport, decreased renal ammonia secretion, gastrointestinal and kidney losses of bicarbonate, dilution of serum bicarbonate from excessive intravenous fluid administration, or addition of hydrochloric acid. Metabolic alkalosis is the most common acid-base disorder found in patients who are critically ill, and most often occurs after admission to the intensive care unit. Its etiology is most often secondary to the aggressive therapeutic interventions used to treat shock, acidemia, volume overload, severe coagulopathy, respiratory failure, and AKI. Treatment consists of volume resuscitation and repletion of potassium deficits. Aggressive lowering of the pH is usually not necessary. Respiratory disorders are caused by either decreased or increased minute ventilation. The use of permissive hypercapnia to prevent barotrauma has become the standard of care. The use of bicarbonate to correct the acidemia is not recommended. In patients at the extreme, the use of extracorporeal therapies to remove CO 2 can be considered.

Fluid overload as a predictor of morbidity and mortality in pediatric patients following congenital heart surgery.

Patients undergoing congenital heart surgery with cardiopulmonary bypass frequently require the administration of intravenous fluids and blood products due to hemodynamic instability. Correctly performed fluid resuscitation can revert the state of tissue hypoperfusion in the different organs. However, excessive fluid administration and acute kidney injury may promote fluid overload (FO) and increase the risk of complications, hospital stay, and mortality. We conducted a prospective longitudinal study of pediatric patients with congenital heart surgery and cardiopulmonary bypass in the Pediatric Cardiac Intensive Care Unit (PCICU), Instituto Nacional de Pediatría, from July 2018 to December 2019. Fluid overload was quantified every 24 hours during the first 3 days of stay at the PCICU and expressed as a percentage. We recorded PCICU stay, days of mechanical ventilation, and mortality as outcome variables. We included 130 patients. The main factors associated with fluid overload were age < 1 year (p < 0.001), weight < 5 kg (p < 0.001), and longer cardiopulmonary bypass time (p = 0.003). Patients with fluid overload ≥ 5% had higher inotropic score (p < 0.001), higher oxygenation index (p < 0.001), and longer mechanical ventilation time (p < 0.001). Fluid overload ≥ 5% was associated with higher postoperative mortality (odds ratio 89, p = 0.004). Fluid overload can be used as a prognostic factor in the evolution of pediatric patients undergoing congenital heart surgery since it is associated with increased morbidity and mortality.

Postoperative Delirium in Patients with Oral Cancer: Is Intraoperative Fluid Administration a Neglected Risk Factor?

Simple SummarySquamous cell carcinoma is the most typical malignant tumor of the oral cavity (OSCC) and surgery, including tumor resection and neck dissection with an appropriate reconstruction, remains the first line of treatment. Postoperative complications delay the healing process, and can have negative consequences for the patient. This study aimed to evaluate the impact of intraoperative fluid administration on developing postoperative delirium, and to identify other parameters leading to an increased risk of delirium.Squamous cell carcinoma (SCC) is a malignant tumor derived from squamous cells and can be found in different localizations. In the oral cavity especially, it represents the most common type of malignant tumor. First-line therapy for oral squamous cell carcinoma (OSCC) is surgery, including tumor resection, neck dissection, and maybe reconstruction. Although perioperative mortality is low, complications such as delirium are very common, and may have long-lasting consequences on the patient’s quality of life. This study examines if excessive fluid administration, among other parameters, is an aggravating factor for the development of postoperative delirium. A total of 198 patients were divided into groups concerning the reconstruction technique used: group A for primary wound closure or reconstruction with a local flap, and group B for microsurgical reconstruction. The patients with and without delirium in both groups were compared regarding intraoperative fluid administration, fluid balance, and other parameters, such as blood loss, duration of surgery and overall ventilation, alcohol consumption, and creatinine, albumin, natrium, and hematocrit levels. The logistic regression for group A shows that fluid intake (p = 0.02, OR = 5.27, 95% CI 1.27–21.8) and albumin levels (p = 0.036, OR = 0.22, CI 0.054–0.908) are independent predictors for the development of delirium. For group B, gender (p = 0.026, OR = 0.34, CI 0.133–0.879) with a protective effect for females, fluid intake (p = 0.003, OR = 3.975, CI 1.606–9.839), and duration of ventilation (p = 0.025, OR = 1.178, CI 1.021–1.359) are also independent predictors for delirium. An intake of more than 3000 mL for group A, and 4150 mL for group B, increases the risk of delirium by approximately five and four times, respectively. Fluid management should be considered carefully in patients with OSCC, in order to reduce the occurrence of postoperative delirium. Different factors may become significant for the development of delirium regarding different surgical procedures.

Genesis of Antibiotic Resistance (AR) LXXXI: Turbulence Modeling of Simplified Severe Sepsis Protocol‐2 (SSSP‐2), NCT01663701: ERP Induced Fluid Volume Expansion Confer Transition from Laminar to Turbulence by Discontinuity

NCT01663701(PMID:28973227) observed that a primary outcome of in‐hospital mortality (ihm) occurred in 51 of 106 patients (48.1%) in the sepsis protocol group vs 34 of 103 patients (33.0%) in the usual care group while the vital status after hospital discharge at day 28 reported for 97 patients in each study group; 28‐day mortality was 67.0% with the sepsis protocol vs 45.3% with usual care. Hypothesis: Based on the data on risk of ihm by subgroup for patients treated with the sepsis protocol vs usual care (Fig3), compared to elements of sepsis resuscitation (Table 2), and baseline characteristics of the patients (Table 1), we hypothesize that the discontinuity in fluid volume due to ERP is the pivotal determining factor for an exacerbated mortality rate in NCT0166370. Relevance of Central Venous Pressure(CVP) or Jugular Venous Pressure (JVP) for the Determination of Fluid Overload(PMID: 23774337, PMID: 24132054):NCT01663701, p1237, Table 1: The JVP data indicate that the baseline: by proximity to the sternal angle, ≥4cm below: sepsis protocol cohort: 32.1% vs usual care: 40.8%; 1‐3cm below:sepsis protocol cohort: 28.3% vs usual care 21.4%; At the sternal angle, 20.8% vs 27.2%; ≥1 cm above: sepsis protocol 20.8% vsusual care 10.7%. Cause(s) of elevated CVP or JVP:A plausible cause would be RV failure (pulmonary edema!) due to fluid volume overload by excessive fluid administration. Geometry, Governing Eq. &amp; Analysis: The mass continuity eq: 2.17, (p14‐ISBN‐13:978‐0521598866); where V1= fluid velocity, ρ1= fluid density, at terminal arteriole (cross‐sectional area) = A1and tis time interval dt, prior to ERP, length dl1=V1dt mass that enters the A1in the time interval is: dm1=ρ1dV1= ρ1A1dl1=ρ1A1v1dt. After the ERP, the expanded fluid volume passing through metarteriole (cross‐sectional area) =A2and length dl2=V2dt in the time interval dt is=dm2=ρ2dV2=ρ2A2dl2=ρ2A2v2dt. As per the mass continuity equation, (flow at any given point in a closed hydraulic system will be equal to flow at any other points) an equal amount of mass that enters the area A1in the time interval dt, must pass through area A2,therefore, dm1=dm2or ρ1A1v1dt=ρ2A2v2dt.Dividing by dt, will result ρ1A1v1=ρ2A2v2for a steady flow pattern referred to as mass continuity equation for steady flow. Our simulation analysis implicates that for the ERP induced fluid volume overload fluid flow is A1v1≠A2v2 . The rationale is that, the laminar fluid flow is in streamlines with equal space but ERP induced will not be in streamline but widely spaced, ⬆viscosity, ⬆ rate of LPE aggregation and ⬇velocity, ⬆torque &amp; drag with an unknown angular momentum, on endothelial layer in terminal arteriole. Prospects: It is suggested that the total mass of expanded fluid vol. within 6 hrs, entering/exiting the terminal arteriole (Cerebral BBB) elicit CCP rupturing the pre‐capillary vessels due to an adverse pressure gradient (APG). Differential shear stress due to APG, induce temporal regulation of ARGR expression in clinical persisters in vivo w/ orw/o vasoplegia may have been the cause for an exacerbated mortality in NCT01663701.