Fluid Balance Research Articles

Mini PINCHME multidisciplinary team (MDT) meetings improve fluid balance documentation for orthopaedic patients with delirium: A quality improvement project

Orthopaedic patients are at risk of delirium, which is managed according to the mnemonic PINCHME and involves monitoring hydration. Fluid balance measures hydration, therefore we aimed to improve fluid balance documentation using ward round plans, posters and mini PINCHME multidisciplinary team meetings. Results demonstrated improved fluid balance documentation for patients with delirium from 63.33% to 100%. The most significant intervention was mini PINCHME multidisciplinary team meetings, which may also reduce rates of delirium; however, further work is required.

Bioimpedance-Guided Fluid Removal in Continuous Kidney Replacement Therapy: The VENUS Randomized Clinical Trial.

Ultrafiltration with continuous kidney replacement therapy (CKRT) can be used to manage fluid balance in critically ill patients with acute kidney injury (AKI). We aimed to assess whether bioimpedance analysis (BIA)-guided volume management was more efficacious than conventional management for achieving estimated euvolemia (e-euvolemia) in CKRT-treated patients. In a multi-center randomized controlled trial from July 2017 to July 2020, the patients with AKI requiring CKRT were eligible if the weight at the start of CKRT had increased by ≥5% compared to the weight at the time of admission, or total body water (TBW)/ height (H)2 ≥13 L/m2. We randomly assigned 208 patients to the control (conventional fluid management; N=103) and intervention groups (BIA-guided fluid management; N=105). Primary outcome was the proportion of attaining e-euvolemia seven days post-randomization. E-euvolemia was defined as the difference between TBW/H2 D7 and D0 was <-2.1 L/m2, or when TBW/H2 measured on D7 was <13 L/m2. The 28-, 60-, and 90-day mortality rate were secondary outcomes. The primary outcome occurred in 34 patients in the intervention group and 27 in the control group (47% versus 41%; P=0.50). The mean value of TBW/H2 measured on D7 was the same at 13.9 L/m2 in both groups. The differences between TBW/H2 D7 and D0 were -1.13 L/m2 in the intervention group and -1.08 L/m2 in the control group (P=0.84). Patients in the intervention group had a significantly higher proportion of reaching e-euvolemia on D1 than those in the control group (13% versus 4%, P=0.02). Adverse events did not differ significantly between the groups. BIA-guided volume management did not affect the proportion of reaching the estimated euvolemia at seven days of the start of CKRT. ClinicalTrials.gov, ID: NCT03330626 (Registered on 6 November 2017; Seven study participants were retrospectively registered; nonetheless, IRB approval of each institution was completed before study participant registration).

Characteristics and Outcomes of Children and Young Adults With Sepsis Requiring Continuous Renal Replacement Therapy: A Comparative Analysis From the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK).

Pediatric sepsis-associated acute kidney injury (AKI) often requires continuous renal replacement therapy (CRRT), but limited data exist regarding patient characteristics and outcomes. We aimed to describe these features, including the impact of possible dialytrauma (i.e., vasoactive requirement, negative fluid balance) on outcomes, and contrast them to nonseptic patients in an international cohort of children and young adults receiving CRRT. A secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), an international, multicenter, retrospective study. Neonatal, cardiac and PICUs at 34 centers in nine countries from January 1, 2015, to December 31, 2021. Patients 0-25 years old requiring CRRT for AKI and/or fluid overload. None. Among 1016 patients, 446 (44%) had sepsis at CRRT initiation and 650 (64%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (defined as a composite of death, renal replacement therapy [RRT] dependence, or > 25% decline in estimated glomerular filtration rate from baseline at 90 d from CRRT initiation). Septic patients were less likely to liberate from CRRT by 28 days (30% vs. 38%; p < 0.001) and had higher rates of MAKE-90 (70% vs. 61%; p = 0.002) and higher mortality (47% vs. 31%; p < 0.001) than nonseptic patients; however, septic survivors were less likely to be RRT dependent at 90 days (10% vs. 18%; p = 0.011). On multivariable regression, pre-CRRT vasoactive requirement, time to negative fluid balance, and median daily fluid balance over the first week of CRRT were not associated with MAKE-90; however, increasing duration of vasoactive requirement was independently associated with increased odds of MAKE-90 (adjusted OR [aOR], 1.16; 95% CI, 1.05-1.28) and mortality (aOR, 1.20; 95% CI, 1.1-1.32) for each additional day of support. Septic children requiring CRRT have different clinical characteristics and outcomes compared with those without sepsis, including higher rates of mortality and MAKE-90. Increasing duration of vasoactive support during the first week of CRRT, a surrogate of potential dialytrauma, appears to be associated with these outcomes.

Blood pressure alteration associated with abnormal body electrolyte and water balance in colitis mice.

Previous studies reported that there is an association between abnormal body fluid balance and prognosis in colitis patients. However, it remains to be clarified the effects of colitis on characteristics of body electrolytes or water content, including alternation in blood pressure. In this study, we examined the effects of colon injury on body water balance and blood pressure in the dextran sodium sulfate (DSS)-induced colitis mouse model. We evaluated body electrolytes and water content, blood pressure, and urea-associated water conservation in DSS mice. By 5 days after the treatment, DSS mice exhibited diarrhea but relatively maintained body weight and total body sodium, potassium, and water content by increases in water intake and hepatic ureagenesis. On 7 days after DSS treatment, when colitis becomes severe, DSS mice significantly decreased food and water intake, and body weight but significantly increased relative total body sodium, potassium, and water content per dry mass. Notably, DSS induced more total body dry mass loss relative to water loss. These body electrolytes and water accumulation on day 7 were associated with a reduction in urinary osmole excretion and urine volume accompanied by renal urea accumulation. DSS mice significantly increased blood pressure by day 5 and then decreased on day 7. These findings suggest that body electrolyte and fluid imbalance and alternations in blood pressure in colitis vary with the stage and severity of the condition. Assessment and correction of electrolyte and water content at the tissue level would be important to improve the prognosis of colitis.

RhoprCAPA-2 acts as a gonadotropin regulating reproduction in adult female, Rhodnius prolixus

CAPA peptides play diverse roles in insects, modulating muscle contraction, regulating fluid balance, and reproduction. In Rhodnius prolixus, a hematophagous insect and a vector for human Chagas disease, three CAPA peptides are encoded by the capability gene, including RhoprCAPA-1, RhoprCAPA-2, and RhoprCAPA-PK-1. RhoprCAPA-2 is an anti-diuretic hormone in R. prolixus. Here, we explore the involvement of RhoprCAPA-2 in reproduction in adult female R. prolixus. Double-label immunohistochemistry reveals co-localization of RhoprCAPA-2-like and the glycoprotein hormone (GPA2/GPB5) subunit GPB5-like immunoreactivity in neurosecretory cells in the mesothoracic ganglionic mass and in their neurohemal sites, suggesting these peptides can be co-released to regulate physiological processes. qPCR analysis reveals changes in transcript expression levels of the RhoprCAPA receptor (CAPAR) in the fat body and reproductive tissues after feeding in adult female R. prolixus. RNA interference-mediated knockdown of CAPAR transcript decreases egg production and reduces hatching rate and survival rate in female R. prolixus. Downregulation of CAPAR decreases vitellogenin RhoprVg1 transcript expression in the fat body and deceases its receptor RhoprVgR transcript level in the ovaries; accompanied by a reduction in vitellogenin content in the fat body and hemolymph. Incubation of fat body and ovaries in vitro with RhoprCAPA-2 increases RhoprVg1 transcript expression in the fat body, vitellogenin content in the fat body culture medium, and increases RhoprVgR transcript in the ovaries. These findings implicate the CAPA signaling pathway in reproduction, with RhoprCAPA-2 acting as a gonadotropin in adult female R. prolixus.

Conservative fluid resuscitation protocol does not reduce the incidence of reoperation for bleeding after emergency CABG

Reoperation for bleeding (ROB) after emergency coronary artery bypass grafting (eCABG) has been identified as an independent risk factor for mortality. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. This retrospective single-center study included 265 patients undergoing eCABG between 2011 and 2020. From 2018, postoperative hemodynamic management was performed with lower volume administration and higher vasoactive support. The primary outcome measure was the incidence of ROB within 48 h according to altered fluid resuscitation strategy. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. Incidence of ROB was independent from the volume resuscitation protocol (P = .3). The ROB group had a higher perioperative risk, which was observed in EuroSCORE II. Fluid intake (P = .021), fluid balance (P = .001), and norepinephrine administration (P = .004) were associated with ROB. Fluid output and blood loss were not associated with ROB (P = .22). Post-test probability was low among all variables. Although fluid management might have an impact on specific postoperative complications, different fluid resuscitation protocols did not alter the incidence of ROB after emergency CABG.Trial registration: www.clinicaltrials.gov registration number NCT04533698; date of registration: August 31, 2020 (retrospectively registered due to nature of the study); URL: https://classic.clinicaltrials.gov/ct2/show/NCT04533698

Impact of different intravenous bolus rates on fluid and electrolyte balance and mortality in critically ill patients.

The effect of intravenous bolus rates on patient outcomes is a complex and crucial aspect of critical care. Fluid challenges are commonly used in critically ill patients to manage their hemodynamic status, but there is limited information available on the specifics of when, how much, and at what rate fluids should be administered during these challenges. The aim of this review is to thoroughly examine the relationship between intravenous bolus rates, fluid-electrolyte balance, and mortality and to analyze key research findings and methodologies to understand these complex dynamics better. Fluid challenges are commonly employed in managing hemodynamic status in this population, yet there is limited information on the optimal timing, volume, and rate of fluid administration. Utilizing a narrative review approach, the analysis identified nine relevant studies that investigate these variables. The findings underscore the importance of a precise and individualized approach in clinical settings, highlighting the need to tailor intravenous bolus rates to each patient's specific needs to maximize outcomes. This review provides valuable insights that can inform and optimize clinical practices in critical care, emphasizing the necessity of meticulous and exact strategies in fluid administration.

A Possible Link between Cell Plasticity and Renin Expression in the Collecting Duct: A Narrative Review.

The hormone renin is produced in the kidney by the juxtaglomerular cells. It is the rate-limiting factor in the circulating renin-angiotensin-aldosterone system (RAAS), which contributes to electrolyte, water, and blood pressure homeostasis. In the kidneys, the distal tubule and the collecting duct are the key target segments for RAAS. The collecting duct is important for urine production and also for salt, water, and acid-base homeostasis. The critical functional role of the collecting duct is mediated by the principal and the intercalated cells and is regulated by different hormones like aldosterone and vasopressin. The collecting duct is not only a target for hormones but also a place of hormone production. It is accepted that renin is produced in the collecting duct at a low level. Several studies have described that the cells in the collecting duct exhibit plasticity properties because the ratio of principal to intercalated cells can change under specific circumstances. This narrative review focuses on two aspects of the collecting duct that remain somehow aside from mainstream research, namely the cell plasticity and the renin expression. We discuss the link between these collecting duct features, which we see as a promising area for future research given recent findings.

The mineralocorticoid system, cardiometabolic health and its interplay with adipose tissue.

The mineralocorticoid system, comprising the renin-angiotensin-aldosterone system (RAAS) and associated receptors, is traditionally viewed as a regulator of sodium and fluid balance and blood pressure (BP), with the main mineralocorticoid hormone aldosterone acting via the mineralocorticoid receptor (MR) in distal renal tubules. Over the past few decades, there has been a wider understanding of the role of the mineralocorticoid system in regulating both classical BP-dependent and non-BP-dependent systemic effects. Mounting evidence indicates the novel role of the mineralocorticoid system in cardiometabolic health with excess mineralocorticoid system activity being associated with adiposity, diabetes, insulin resistance and cardiovascular diseases independent of its effect on BP, and RAAS blockade and MR antagonists offering protection against cardiometabolic dysfunction. The metabolic manifestations of mineralocorticoid system overactivation are mainly mediated by their interactions with adipose tissue which orchestrates energy, lipids and glucose homeostasis via effects on the functions of brown and white adipocytes and immune cells. Adipose tissue can in turn influence mineralocorticoid system activity by harbouring its own RAAS system and by releasing mineralocorticoid-secretory factors/adipokines, with resultant further progression of cardiometabolic dysfunction. This article discusses the interplay between the mineralocorticoid system and adipose tissue in the pathophysiology of cardiometabolic diseases.

Abstract P422: Neuropeptide FF and Its Receptor NPFFR2 Decrease Renal Sodium Excretion and Increase Blood Pressure in Mice

The kidney is critical in the overall regulation of fluid and electrolyte balance and blood pressure. Neuropeptide FF (NPFF), a morphine-modulating peptide, regulates cardiovascular function through its interaction with two receptors, NPFFR1 and NPFFR2. We now report that NPFF and its receptors, mainly NPFFR2, are expressed in the kidney. NPFF (9.25 mmol, 0.5 mL/hr, 0.05 nmol/day, 7 days) chronically infused underneath the renal capsule, decreased renal sodium excretion (UNaV) from 0.68±0.07 mEq/day, n=5 to 0.43±0.06 mEq/day (n=6/group) in conscious C57BL/6 mice. This was accompanied by an increase in systolic blood pressure (SBP, 114.5±5.0 mm Hg, n=4); the infusion of vehicle (saline) did not affect the blood pressure (96.4±3.0 mm Hg, n=4). The renal subcapsular injection of a single dose (10 µg in 100 µL) of NPFF also increased SBP within 15-35 min (NPFF: 105.5±3.44 mm Hg, n=6); saline injection did not affect SBP (82.6±5.65 mm Hg, n=4). RF-9 (10 µg in 100 µL), an antagonist of NPFF receptors prevented the NPFF-mediated increase in SBP (NPFF alone: 105.5±3.44 mm Hg, n=6; RF+NPFF: 88.5±5.90 mm Hg, n=5), whereas RF-9, alone, had no effect (Baseline: 97.6±2.70 mmHg; RF-9: 90.9±4.70 mm Hg, n=5). The renal subcapsular injection of scrambled peptide (10 µg in 100 µL) had no effect on SBP (86.1±1.83 mm Hg, n=4). However, SBP was decreased by the renal subcapsular infusion of Npffr2 siRNA (98±4 vs 113±3 mmHg; P &lt; 0.05; n=3-5/group) in C57Bl/6 mice fed with a high salt diet (4% NaCl). Furthermore, the SBP of conventional germline Npffr2 knockout (KO) mice fed a high salt (4% NaCl) diet was lower than the SBP of wild-type (WT) littermates (WT: 105.6±2.9 mm Hg, n=5; KO: 90.5±5.5 mm Hg, n=4, P &lt; 0.05). By contrast, in mice fed normal salt (0.8% NaCl) diet, SBP was not different between Npffr2 KO mice and WT littermates (WT: 96.5±4.5 mm Hg, n=5; KO: 98.7±11.7 mm Hg, n=4, P &gt; 0.05). Taken together, NPFF and its receptor, NPFFR2, in the kidney cause salt-sensitive hypertension in mice. Uncovering the functional relevance of renal NPFF in the dynamic regulation of renal sodium transport will lead to a better understanding of blood pressure homeostasis.

Skimmed, Lactose-Free Milk Ingestion Postexercise: Rehydration Effectiveness and Gastrointestinal Disturbances Versus Water and a Sports Drink in Physically Active People.

Postexercise hydration is fundamental to replace fluid loss from sweat. This study evaluated rehydration and gastrointestinal (GI) symptoms for each of three beverages: water (W), sports drink (SD), and skimmed, lactose-free milk (SLM) after moderate-intensity cycling in the heat. Sixteen college students completed three exercise sessions each to lose ≈2% of their body mass. They drank 150% of body mass loss of the drink assigned in randomized order; net fluid balance, diuresis, and GI symptoms were measured and followed up for 3hr after completion of fluid intake. SLM showed higher fluid retention (∼69%) versus W (∼40%; p < .001); SD (∼56%) was not different from SLM or W (p > .05). Net fluid balance was higher for SLM (-0.26kg) and SD (-0.42kg) than W (-0.67kg) after 3hr (p < .001), resulting from a significantly lower diuresis with SLM. Reported GI disturbances were mild and showed no difference among drinks (p > .05) despite ingestion of W (1,992 ± 425ml), SD (1,999 ± 429ml), and SLM (1,993 ± 426ml) in 90min. In conclusion, SLM was more effective than W for postexercise rehydration, showing greater fluid retention for the 3-hr follow-up and presenting with low-intensity GI symptoms similar to those with W and SD. These results confirm that SLM is an effective option for hydration after exercise in the heat.

Postoperative Fluid Accumulation is Associated With Underestimation of AKI Severity in Lung Transplant Recipients.

Post-lung transplantation (LTx) fluid accumulation can lead to dilution of serum creatinine (SCr). We hypothesized that fluid accumulation might impact the diagnosis, staging, and outcome of posttransplant acute kidney injury (AKI). In this retrospective study, we analyzed data from 131 adult LTx patients at a single German lung center between 2005 and 2018. We assessed the occurrence of AKI within 7 days posttransplant, both before and after SCr-adjustment for fluid balance (FB), and investigated its impact on all-cause mortality. Transient and persistent AKIs were defined as return to baseline kidney function or continuation of AKI beyond 72h of onset, respectively. AKI was diagnosed in 58.8% of patients according to crude SCr values. When considering FB-adjusted SCr values, AKI severity was underestimated in 20.6% of patients, that is, AKI was detected in an additional 6.9% of patients and led to AKI upstaging in 23.4% of cases. Patients initially underestimated but detected with AKI only after FB adjustment had higher mortality compared to those who did not meet AKI criteria (hazard ratio [HR] 2.98; 95% confidence interval [CI] 1.06, 8.36; p=0.038). Persistent AKI was associated with higher mortality than transient AKI, regardless of using crude or adjusted SCr values (p < 0.05). Persistent AKI emerged as an independent risk factor for mortality (HR 2.35; 95% CI 1.29, 4.30; p=0.005). Adjusting for FB and evaluating renal recovery patterns post-AKI may enhance the sensitivity of AKI detection. This approach could help identify patients with poor prognosis and potentially improve outcomes in lung transplant recipients. ClinicalTrials.gov identifier: NCT03039959, NCT03046277.

Torsemide in the Management of Essential Hypertension.

Torsemide, a loop diuretic, is increasingly recognized for its role in managing essential hypertension. Its mechanism of action involves inhibiting the reabsorption of sodium and chloride ions in the ascending loop of Henle in the kidneys. By doing so, torsemide promotes diuresis, which refers to increased urine production, and subsequently lowers blood pressure. Studies have shown that torsemide is comparably effective to other antihypertensive agents in lowering blood pressure, with the added benefit of potentially improving renal function. However, while torsemide shows promise in hypertensive management, further research is necessary to fully understand its long-term effects and to establish optimal dosing strategies. Future research should focus on clarifying its role in long-term blood pressure control and refining its use in clinical practice to maximize efficacy and minimize adverse effects.

Research on Experimental Hypertension in Prague (1966-2009).

The study of ontogenetic aspects of water and electrolyte metabolism performed in the Institute of Physiology (Czechoslovak Academy of Sciences) led to the research on the increased susceptibility of immature rats to salt-dependent forms of hypertension since 1966. Hemodynamic studies in developing rats paved the way to the evaluation of hemodynamic mechanisms during the development of genetic hypertension in SHR. A particular attention was focused on altered renal function and kidney damage in both salt and genetic hypertension with a special respect to renin-angiotensin system. Renal damage associated with hypertension progression was in the center of interest of several research groups in Prague. The alterations in ion transport, cell calcium handling and membrane structure as well as their relationship to abnormal lipid metabolism were studied in a close cooperation with laboratories in Munich, Glasgow, Montreal and Paris. The role of NO and oxidative stress in various forms of hypertension was a subject of a joint research with our Slovak colleagues focused mainly on NO-deficient hypertension elicited by chronic L-NAME administration. Finally, we adopted a method enabling us to evaluate the balance of vasoconstrictor and vasodilator mechanisms in BP maintenance. Using this method we demonstrated sympathetic hyperactivity and relative NO deficiency in rats with either salt-dependent or genetic hypertension. At the end of the first decennium of this century we were ready to modify our traditional approach towards modern trends in the research of experimental hypertension. Keywords: Salt-dependent hypertension o Genetic hypertension o Body fluids o Hemodynamics o Ion transport o Cell membrane structure and function o Renal function o Renin-angiotensin systems.

Primerjava ultrazvočnega merjenja premera spodnje votle vene in merjenja sestave telesa z metodo bioelektrične impedance za oceno tekočinskega stanja pri novorojenčkih

Background: Neonatal medical conditions often disrupt the physiological processes that regulate fluid balance, so assessing fluid status in sick neonates is important for clinical management. In clinical practice we use clinical signs, which, however, on their own, do not provide a reliable assessment of fluid status. We aimed to compare two methods: i) diameters and collapsibility index of vena cava inferior (VCI) measured by ultrasonography and ii) analysis of body composition by bioelectrical impedance (BIA) and to evaluate their relation to changes in body mass. Methods: In a cohort-prospective clinical trial we included 27 neonates aged 1–7 days with various pathologies. Ultrasound measurements of VCI transversely and longitudinally, measurements of body composition by BIA and measurements of body mass were performed in each subject at least three times with an interval of 24–72 hours. Simultaneous measurements of the same subject were then analysed and evaluated. Results: The average proportion of total body water (TBW) decreased in the first days after birth, from 80.3% (Day 1) to 73.1% (Day 8) (p = 0.006). The decrease in the average proportion of extracellular water (ECW) in the first days after birth was not statistically significant. The association between ECW and body mass over time was statistically significant (p &lt; 0.001). The association between transversely measured large VCI diameter during inspiration, body mass, and ECW was statistically significant (p = 0.024). No statistically significant association with ECW or body mass was proven for the other ultrasound-measured variables. Conclusions: By measuring body composition with BIA, we confirmed the reduction of the average proportions of TBW after birth and the association between body mass, ECW, and transversely measured maximal diameter of VCI during inspiration. BIA is an appropriate method for monitoring fluid status in a newborn. Additional research on a larger number of subjects is needed to define the significance of VCI measurements for assessing fluid status.

Impact of device variability and protocol differences on kidney function during normothermic machine perfusion: A comparative study using porcine and human kidneys.

A growing interest in renal normothermic machine perfusion (NMP) has resulted in more clinically available perfusion devices. While all perfusion systems have the same aim, there are significant differences in their circuits, pumps, sensors, and software. Therefore, our objective was to assess the impact of different perfusion protocols and devices on kidney function and perfusion parameters during NMP. Porcine kidneys were subjected to 30 min of warm ischemia, 24 h of static cold storage, and subsequently perfused for 6 h using (1) the Kidney Assist (KA) machine with a pressure of 75 mm Hg, (2) the KA device incorporating several adjustments and a pressure of 85 mm Hg (modified KA), or (3) the Perlife (PL) perfusion device (n = 4). Consecutively, discarded human kidneys were perfused using the KA or modified KA (n = 3) protocol. The PL group quickly reached the device's upper flow limit and consequently received a significantly lower pressure compared to the KA groups. The arterial pO2 was significantly lower in the PL group. Yet, hemoglobin concentration increased over time, and oxygen consumption was significantly higher compared to the KA groups. Fractional sodium excretion was significantly lower in the PL group. Tissue ATP levels, urine production, and creatinine clearance rates did not differ between groups. In human kidneys, the modified KA group showed significantly lower vascular resistance, higher oxygen delivery, and lower levels of lactate in the perfusate compared to the KA group. This study shows that perfusion characteristics and kidney function are significantly influenced by the perfusion protocol and the device and its settings during normothermic machine perfusion and therefore should be interpreted with caution.

Common foot and ankle disorders in pregnancy: the role of diagnostic ultrasound.

Foot and ankle disorders are common during pregnancy, driven by significant physiological changes including weight distribution, hormonal fluctuations, and fluid balance. These changes often result in conditions such as varicose veins, thrombophlebitis, deep vein thrombosis (DVT), edema, overpronation, ankle sprains, metatarsalgia, stress fractures, ligament tears, synovitis, tendon tears, tenosynovitis, paratenonitis, plantar fasciitis, and Morton's neuroma. This paper emphasizes the diagnostic utility of ultrasound for these conditions, given its safety, non-invasiveness, and real-time imaging capabilities without ionizing radiation. Ultrasound is particularly effective for diagnosing venous disorders like varicose veins and thrombophlebitis, leveraging Doppler ultrasound to assess vein structure and function. It is also instrumental in identifying DVT, detecting vein dilation, reflux, and thrombosis. For conditions such as edema, ultrasound helps differentiate physiological from pathological causes, ensuring accurate diagnosis and management. In cases of musculoskeletal issues like overpronation, ankle sprains, ligament tears, and tendon pathologies, ultrasound provides detailed images of soft tissues, allowing for precise diagnosis and effective treatment planning. It is equally useful for detecting metatarsalgia, plantar fasciitis, and Morton's neuroma, offering insights into soft tissue abnormalities and guiding therapeutic interventions. Ultrasound's role extends to diagnosing foreign bodies in the foot and ankle, where it demonstrates high sensitivity and specificity. The accessibility and cost-effectiveness of ultrasound make it an invaluable tool in various healthcare settings, ensuring timely and accurate diagnosis and management of foot and ankle disorders during pregnancy, ultimately enhancing patient outcomes and quality of life.

Preload responsiveness–guided fluid removal in mechanically ventilated patients with fluid overload: A comprehensive clinical–physiological study

This study investigated fluid removal strategies for critically ill patients with fluid overload on mechanical ventilation. Traditionally, a negative fluid balance (FB) is aimed for. However, this approach can have drawbacks. Here, we compared a new approach, namely removing fluids until patients become fluid responsive (FR) to the traditional empiric negative balance approach.Twelve patients were placed in each group (n = 24). FR assessment was performed using passive leg raising (PLR). Both groups maintained stable blood pressure and heart function during fluid management. Notably, the FR group weaned from the ventilator significantly faster than negative FB group (both for a spontaneous breathing trial (14 h vs. 36 h, p = 0.031) and extubation (26 h vs. 57 h, p = 0.007); the difference in total ventilator time wasn't statistically significant (49 h vs. 62 h, p = 0.065). Additionally, FR group avoided metabolic problems like secondary alkalosis and potential hypokalemia seen in the negative FB group.FR-guided fluid-removal in fluid overloaded mechanically ventilated patients was a feasible, safe, and maybe superior strategy in facilitating weaning and disconnection from mechanical ventilation than negative FB-driven fluid removal. FR is a safe endpoint for optimizing cardiac function and preventing adverse consequences during fluid removal.

Hypopituitarism, Diabetes Insipidus, and Syndrome of Inappropriate Antidiuretic Hormone Secretion after Pituitary Macroadenoma Surgery with Indocyanine Green Dye.

(1) Background: Pituitary adenomas are benign tumors comprising about 18% of all intracranial tumors, and they often require surgical intervention. Differentiating pituitary tissue from adenoma during surgery is crucial to minimize complications. We hypothesized that using ICG dye would reduce the hormonal complication rates. (2) Methods: A prospective randomized study (February 2019-October 2023) included 34 patients with non-functional macroadenomas of the pituitary gland randomly assigned to receive intraoperative ICG or be in the control group. All underwent endoscopic endonasal transsphenoidal surgery. Pituitary function was assessed preoperatively, immediately postoperatively, and 3-6 months postoperatively. Adenohypophysis function was evaluated with hormonal tests (Cosyntropin stimulation test, TSH, fT3, fT4, prolactin, IGF-1, FSH, LH, and testosterone in men) and neurohypophysis function with fluid balance, plasma and urine osmolality, and serum and urinary sodium. (3) Results: Of the 34 patients (23 men, 11 women; average age 60.9 years), 5.9% in the ICG group developed diabetes insipidus postoperatively, compared to 23.5% in the control group. Adenohypophysis function worsened in 52.9% of the ICG group and in 35.3% of the control group. (4) Conclusions: Our study did not confirm the benefits of using ICG in these surgeries. Further research with a larger sample is needed.

Correlation between elevated neutrophil lymphocyte ratio, vasotropic inotropic score, cumulative fluid balance and level of reactive oxygen species in septic patients

Introduction. Reactive oxygen species (ROS) serve as a biomarker in sepsis, while neutrophil lymphocyte ratio (NLR), vasotropic inotropic score (VIS), and cumulative fluid balance (CFB) correlate with inflammation and mortality. Understanding the correlation between elevated ROS levels and these markers aids in prognostication.The objective is to study the correlation between the increased level of neutrophil/lymphocyte ratio, vasotropic and inotropic index, total fluid balance and reactive oxygen species level in patients with sepsis.Materials and methods. A prospective cohort study in RSUD Dr. Moewardi’s ICU/HCU from June to August 2023 employed univariate, bivariate (Spearman correlation), and multivariate logistic regression analyses.Results. Among 34 sepsis patients, NLR and VIS showed significant positive correlations on day one, and NLR, VIS, and FB on day three. Delta changes in NLR and VIS significantly correlated with ROS.Conclusion. NLR and VIS changes predict ROS levels, while CFB exhibits weak correlations, which deserve additional investigation. This underscores the importance of NLR and VIS as prognostic indicators in sepsis.