Fluid Balance Research Articles

Renal Function Markers Predicts Extubation Failure in Critically Ill Patients: A Retrospective Study.

Several studies attempt to identify predictors for weaning and extubation from mechanical ventilation (MV) and none have been shown to be particularly accurate. Therefore, the objective of the study was to evaluate whether markers of renal function may be associated with extubation failure. This retrospective study collected data through electronic medical records for 2 consecutive years. The inclusion criteria were:≥18years old and requiring invasive MV for a period of≥48hours. Extubation failure was determined when subjects needed to return to invasive MV within 48hours of the tracheal tube withdrawal. Acute kidney injury (AKI) was assessed according to the KDIGO classification. From a total of 167 subjects, 15% evolved with extubation failure. Lower creatinine clearance and higher fluid balance was observed in the extubation failure group compared to the successful extubation group (42 mL/min vs 100 mL/min, P =0.01 and 739 mL vs-189 mL, P =0.01, respectively). Subjects with AKI are 51% more likely to evolve with extubation failures than those with normal renal function (OR=2.7; 95% CI: 1.6-4.7; P <0.01). Renal dysfunction was related to the rate of extubation failure. Fluid balance and serum creatinine may be aspects to be considered when making the extubation decision.

764 Fluid balance in infants randomized to receive fortified milk shortly after birth and the risk of bronchopulmonary dysplasia after extremely preterm birth: a secondary analysis

764 Fluid balance in infants randomized to receive fortified milk shortly after birth and the risk of bronchopulmonary dysplasia after extremely preterm birth: a secondary analysis

Acute kidney injury in paediatric kidney transplant recipients.

Acute kidney injury (AKI) in paediatric kidney transplant recipients is common. Infection including urinary tract infection (UTI) and rejection are the most common causes in children. Surgical complications often cause AKI early post-transplant, whereas BK polyomavirus nephropathy rarely occurs in the first month post-transplant. Understanding kidney physiology helps to appreciate the sensitivity of the allograft to AKI, more so than native kidneys. Although the cause of AKI is often multi-factorial, there may be an underlying process that is treatable. Eliciting the aetiology, in this regard, is of paramount importance. Pre-renal and post-renal causes of allograft dysfunction are important to distinguish from intrinsic kidney disease. Clinical information and examination of fluid balance, urine dipstick testing, blood tests, bladder and kidney transplant ultrasound, and kidney transplant biopsy remain vital assessment tools in narrowing the differential diagnosis. A careful prescribed and recreational drug history is always warranted as many drugs including supplements are nephrotoxic. Additional causes such as allograft rejection, recurrent disease, and calcineurin inhibitor toxicity need to be considered in cases of allograft dysfunction, which would not affect the native kidneys. Early detection and assessment of AKI is crucial in promoting recovery. Significant progress has been made in specific pathologies over the last 20years, which has improved kidney allograft survival rates considerably. Research into identifying AKI biomarkers to assist early diagnosis, before the serum creatinine rises, is ongoing.

Prognostic factors for successful extubation in newborns with congenital diaphragmatic hernia

IntroductionNeonates with congenital diaphragmatic hernia (CDH) have an associated high mortality and morbidity. The European CDH EURO consortium has developed guidelines for initial and perioperative ventilatory management. There are, however, no recommendations on how to wean these patients from the ventilator. Extubation failure is more frequent in this group of patients than in other neonates. The aim of this study was to describe patient characteristics and risk factors for failed extubation and to evaluate predictive factors for successful weaning.MethodsWe performed a retrospective study in a single centre tertiary pediatric intensive care unit in Stockholm, Sweden. CDH-patients (n = 38), aged 0–28 days, with extubation events were identified from 2017 to 2019. Eight patients (21.1%) needed reintubation within 24 h after the first extubation attempt. Patient demographics, surgical repair with patch, oxygenation saturation index (OSI), rapid shallow breathing index (RSBI), ventilatory settings, fluid balance and sedation on the day of extubation were recorded.ResultsPatients in the failed extubation group (FE) had lower birth weight (p &amp;lt; 0.05), surgical patch repair (p &amp;lt; 0.05), longer length of stay in intensive care (p &amp;lt; 0.05), longer time on the ventilator (p &amp;lt; 0.05) and other comorbidities (p &amp;lt; 0.001). Using logistic regression we identified OSI, RSBI and inspiratory pressure (Pinsp) as factors predicting a successful extubation, AUCROC 0.95 (95% CI: 0.87 to 1.00). Patients in the FE-group had significantly more often pulmonary hypertension requiring treatment (p &amp;lt; 0.05), a higher fraction of inspired oxygen (FiO2) (p &amp;lt; 0.05) and hypercapnia (p &amp;lt; 0.001) prior to extubation and an oxygen demand exceeding 40% two hours after extubation (p &amp;lt; 0.05).ConclusionUseful predictors of successful extubation in CDH patients are OSI, RSBI and Pinsp. Low birth weight, patch repair and comorbidity also appear to be important factors. Prospective studies are required to confirm findings in the present study.

The Hippo Pathway in Kidney Development

The kidney, a complex organ crucial for a multitude of homeostatic functions, including the maintenance of fluid and electrolyte balance, removal of various metabolic waste products, and hormone production, undergoes intricate developmental processes to form functional nephron units. Understanding the mechanisms behind kidney development is paramount for elucidating the etiology of renal congenital disabilities and acquired diseases. The Hippo pathway is known for its involvement in various cellular functions, including cell fate determination and differentiation, and is a critical player in renal organogenesis. Here, we discuss research findings about the roles that Hippo signaling plays in kidney formation.

Passive dehydration reduces muscle thickness after resistance exercise

ABSTRACT Dehydration-induced increased plasma osmolality (Posmo) alters whole body fluid balance which could alter resistance exercise (RE) induced intramuscular (IM) fluid shift. PURPOSE: The purpose of the current report was to investigate the effect of dehydration on RE-induced change in whole body fluid balance in resistance trained (RT) men. METHODS: Fourteen RT men performed two identical RE sessions, either in a hydrated (EUHY) or dehydrated (DEHY) state induced by a 24 hr fluid restriction. Total body fluid, urine osmolality (Uosmo), urine specific gravity (USG), Posmo, hematocrit (HCT), muscle thickness were measured and plasma volume (%ΔPV) was calculated using HCT. RESULTS: A significant (p < 0.050) condition effect was observed for total body fluid and muscle thickness such that EUHY was 2.6% and 13.0% greater than DEHY, respectively. Significant time × condition effects were observed for Posmo, Uosmo, and USG. At all times, EUHY (collapsing for time: Posmo: 3.9%; Uosmo: 133.5%; USG: 1.6%) was lower than DEHY. A significant time effect was observed for %ΔPV. %ΔPV 5 min after RE was −12.5% lower than PRE. CONCLUSION: Dehydration with RE altered whole body fluid balance indicated by greater fluid retention and efflux of IM fluid could at least partly maintain %ΔPV following DEHY in RT men.

Incidence and outcomes of dysnatremia in crush injury patients admitted to Türkiye’s largest hospital following the Kahramanmaraş earthquake

ObjectivesDysnatremia is a critical electrolyte disturbance that can significantly impact the prognosis of trauma patients by influencing fluid balance, neurological function, and hemodynamics. Although sodium disorder is common in hospitalized patients, few studies have specifically examined the incidence of dysnatremia in patients presenting to the emergency department for post-earthquake trauma. The aim of this study is to evaluate the incidence of dysnatremia and the prognosis of patients with dysnatremia in trauma patients admitted to our center after the Kahramanmaraş earthquake.Materials and methodsBetween February 6th, 2023 and February 20th, 2023, a total of 422 patients with earthquake-related crush injuries after the Kahramanmaras earthquake were retrospectively analyzed. Patients were divided into two groups: the survivor group and the exitus group. Then, patients with dysnatremia were evaluated. Age, gender, the city where patients came from, type of presentation, injured organ systems and extremities, laboratory findings, ward admission, intensive care admission, GCS, MESS, ISS, RTS, TRISS, and hemodialysis sessions were analyzed.ResultsA total of 422 earthquake victims with crush injuries were included in the study. Dysnatremia was present in 28% of the patients, and these patients had a longer hospital stay. GCS was lower, MESS and ISS values were higher, and survival rates according to TRISS were lower. Multiple extremity trauma, crush syndrome, and dialysis rates were more common in the dysnatremia group. Additionally, fasciotomy, amputation and mortality rates were higher in the dysnatremia group.ConclusionDysnatremia is a common finding in patients with crush injuries and is associated with more severe trauma and poorer clinical outcomes. This study highlights the need for close monitoring and management of sodium disturbances in trauma patients, not only in the context of earthquakes but across various disaster scenarios. Recognizing and addressing dysnatremia can contribute to improved patient outcomes in disaster and emergency settings.

Angiotensin II: A novel biomarker in vascular diseases.

The renin-angiotensin system (RAS), composed mainly of renin, angiotensin, and aldosterone, is a key endocrine pathway involved in cardiovascular activity regulation. Under physiological conditions, the RAS plays a vital role in water and salt metabolism, blood pressure regulation, and electrolyte balance. Angiotensin II (Ang II) is the most important active component of the RAS, and its receptors are concentrated in vascular, pulmonary, cardiac, and renal tissues in vivo. Moreover, Ang II is closely associated with the development of vascular lesions. Ang II expression is closely associated with atherosclerosis, aortic aneurysm/dissection, ischemic stroke, hypertension, pulmonary hypertension, and type 2 diabetes mellitus. Given the significant pathophysiological role of Ang II in vascular diseases and the availability of advanced detection methods, Ang II holds promise as a reliable biomarker and therapeutic target in clinical settings. This review summarizes the mechanisms through which Ang II contributes to different vascular diseases and discusses its potential application as a biomarker for disease diagnosis.

Closed-loop ventilation and oxygenation with decision support fluid resuscitation to treat major burn injury with smoke induced acute respiratory distress syndrome.

The understanding of the interaction of closed-loop control of ventilation and oxygenation, specifically fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP), and fluid resuscitation after burn injury and acute lung injury from smoke inhalation is limited. We compared the effectiveness of FiO2, PEEP, and ventilation adjusted automatically using adaptive support ventilation (ASV) and decision support fluid resuscitation based on urine output in a clinically relevant conscious ovine model of lung injury secondary to combined smoke inhalation and major burn injury. Sheep were subjected to burn and smoke inhalation injury under deep anesthesia and analgesia. After injury, sheep were randomly allocated to two groups. 1) Closed-loop group: automated mechanical ventilation (ASV), oxygen FiO2 and PEEP (n = 9); and 2) Control group: mechanically ventilated with standard ASV mode (n = 8). FiO2, PEEP, and the percentage of the minute volume (%MV) were automatically adjusted in group 1, whereas PEEP was held at 5 cmH2O, and FiO2 and %MV were manually adjusted in group 2. Decision support fluid resuscitation was guided based on urine output. Cardiopulmonary hemodynamics were monitored for 48 h. There were no differences in body weight and the severity of smoke injury between the two groups. The Closed-loop group resulted in significantly higher PEEP, %MV, static lung compliance, and survival rate; the driving pressure was significantly lower compared to the Control group. In the Closed-loop group, the net fluid balance at 48 h was significantly greater than in the Control group. Closed-loop ventilation and oxygenation with decision support fluid resuscitation improve lung mechanics and survival in sheep with combined burn and smoke inhalation. There were no negative interactions observed between automated PEEP control and fluid management.

Fluid Management Bundle in Critically Ill Children With Respiratory Failure Is Associated With a Reduced Prevalence of Excess Fluid Accumulation.

To report the feasibility of a fluid management practice bundle and describe the pre- vs. post-implementation prevalence and odds of cumulative fluid balance greater than 10% in critically ill pediatric patients with respiratory failure. Retrospective cohort from May 2022 to December 2022. Quaternary care PICU in Pittsburgh, PA. Children older than 28 days receiving invasive mechanical ventilation for greater than 48 hours. None. We reviewed data from 205 patients; 104 before bundle implementation and 101 after bundle implementation. At the time of implementation in 2022, our PICU clinicians were educated on the use of the fluid management practice bundle, which included the following during daily rounds: goal-setting for daily fluid balance; assessing transition to enteral nutrition; and fluid conservation measures such as concentrating infusions or using enteral formulations of medications. A cumulative fluid balance greater than 10% occurred in 46 of 104 patients (44%) pre-implementation and 26 of 101 patients (26%) post-implementation. We failed to identify an association between implementation epoch grouping (pre- and post-) and adverse outcomes, including mortality, duration of mechanical ventilation, acute kidney injury, and ICU length of stay. In a multivariable logistic regression model, management during the fluid management bundle was associated with lower odds of a cumulative fluid balance greater than 10% (adjusted odds ratio, 0.35 [95% CI, 0.18-0.68]). In our PICUs 2022 peri-implementation testing of a fluid management bundle in critically ill children with respiratory failure, we have first found that such a practice change is feasible. Second, we identified an associated decrease in the prevalence and lower odds of fluid accumulation. We continue to use this fluid management bundle in our center but more widespread prospective studies are needed to test the benefit in clinical practice.

Incidence, Risk Factors, and Outcomes of Acute Kidney Injury in Major Burn Patients: A 7-Year Experience in Ramathibodi Hospital

Objective: To identify the incidence of acute kidney injury (AKI) in patients with major burn injuries within the first week of intensive care unit (ICU) admission at Ramathibodi Hospital and to identify risk factors associated with AKI. Materials and Methods: The present study was a retrospective observational study of the patients with major burn injuries in the burn intensive care unit (BICU) at Ramathibodi Hospital. All data were retrieved from the scanned medical records of the patients admitted to the BICU between January 1, 2016 and December 31, 2022. The patients were diagnosed and graded according to the Kidney Disease Improving Global Outcomes (KDIGO) recommendation. Independent risk factors associated with AKI were identified by multivariable logistic regression. Results: Eight of the 50 patients (16%) had AKI within the first week of admission. The baseline international normalized ratio (INR) level of 1.5 or greater was independently associated with AKI with an odds ratio (OR) of 32.42 (95% confidence interval [CI] 2.194 to 478.608). No independent risk factor was identified for 28-day mortality. Fluid balance in the first week had an area under receiver operating characteristics (ROC) of 0.856 (95% CI 0.747 to 0.964) to diagnose 28-day mortality. A cutoff point of 22,761 mL or more provided a sensitivity of 90.91% and a specificity of 61.54%. Conclusion: The incidence of AKI in the first seven days of BICU admission was 16%. Coagulopathy, defined as INR of 1.5 or greater, was identified as an independent risk factor associated with early AKI in patients with major burns. Utilizing a simple value of INR could be a practical way to identify patients with major burns that may require further workup. Furthermore, the fluid balance cutoff point could be used as a warning signal of high risk for mortality during a weekly review of patients’ clinical rounds.

Volume kinetic analysis of 2 crystalloid fluid bolus rates in anesthetized cats.

To investigate the volume kinetic between 2 crystalloid fluid bolus rates in anesthetized cats. Prospective, randomized, dose-response study. University laboratory. Ten convenience-sample, purpose-bred domestic shorthair and medium hair cats. Intravenous 20mL/kg balanced crystalloid fluid over 10 (G10) or 40 (G40) minutes under anesthesia in a randomized order with at least a 5-day washout period. Serial measurements of hemoglobin (Hb) concentration and PCV were performed up to 60 minutes after conclusion of the fluid bolus. Plasma dilution was calculated with the Hb dilution method and fitted to a 2-compartment microconstant kinetic model using nonlinear mixed-effect models. The apparent central plasma volume (Vc) was similar between the 2 groups (G10: 81.2±23.8mL/kg and G40: 78.8±10.2mL/kg). The apparent peripheral volume (Vp) of G10 (4.81E+8±2.66E+8mL/kg) was twice that of G40 (2.36E+8±6.44E+7mL/kg). The rate constant from Vc to Vp (K12) of G10 (0.057±0.0196/min) was almost twice that of G40 (0.0302±0.00807/min). The elimination constant of G10 (0.0113±0.00672/min) was almost twice that of G40 (0.00534±0.00279/min). The peak plasma expansion was similar between G10 and G40 (20.7±1.9 and 19.1±5.1mL/kg). Area under the curve for plasma dilution versus time of the first 90 minutes from the beginning of the boluses was not statistically different between G10 and G40. The volume expansion over time was not different likely due to the slow elimination. The plasma dilution to crystalloid bolus between subjects is varied in anesthetized cats. Clinicians should consider the slow elimination and return of crystalloid fluid from the Vp to Vc when prescribing fluid therapy in anesthetized cats.

Adrenomedullin 2/Intermedin Exerts Cardioprotective Effects by Regulating Cardiomyocyte Mitochondrial Function.

Adrenomedullin 2 (AM2) plays critical roles in regulating blood pressure and fluid balance. However, the specific involvement of AM2 in cardiac hypertrophy has not been comprehensively elucidated, warranting further investigation into its molecular mechanisms and therapeutic implications. Cardiac hypertrophy was induced in adult mice lacking AM2 (AM2-/-) using transverse aortic constriction surgery. Comprehensive cardiac morphology, function, histology, and transcriptome/metabolome analyses were conducted. Signal transduction underlying AM2 stimulation in the cardiomyocytes was explored. The absence of endogenous AM2 led to the development of severe heart failure after transverse aortic constriction surgery, which was characterized by alterations in the mitochondrial morphology and function associated with glycolysis and the tricarboxylic acid cycle in the heart and cardiomyocytes of transverse aortic constriction-operated AM2-/- mice. AM2 stimulation was associated with the receptor-modifying factor RAMP2 (receptor activity-modifying protein 2), which primarily transduces signals through the MAPK pathway and affects the expression of genes involved in glycolysis, β-oxidation, and oxidative phosphorylation. The administration of exogenous AM2 alleviated heart failure following transverse aortic constriction. AM2 crucially regulates mitochondrial functions associated with the glycolysis and tricarboxylic acid cycles in the cardiomyocytes, thereby exerting a protective effect on the heart under pressure overload conditions.

Dynamic Reconstruction of Fluid Interface Manipulated by Fluid Balancing Agent for Scalable Efficient Perovskite Solar Cells.

Laboratory-scale spin-coating techniques are widely employed for fabricating small-size, high-efficiency perovskite solar cells. However, achieving large-area, high-uniformity perovskite films and thus high-efficiency solar cell devices remain challenging due to the complex fluid dynamics and drying behaviors of perovskite precursor solutions during large-area fabrication processes. In this work, a high-quality, pinhole-free, large-area FAPbI3 perovskite film is successfully obtained via scalable blade-coating technology, assisted by a novel bidirectional Marangoni convection strategy. By incorporating methanol (MeOH) as a fluid balance agent, the direction of Marangoni convection is effectively regulated, mitigating the disordered motion of colloidal precursor particles during the printing process. As a result, champion power conversion efficiencies (PCEs) of 24.45% and 20.32% are achieved for small-area FAPbI3 devices (0.07cm2) and large-area modules (21cm2), respectively. Notably, under steady illumination, the device reached a stabilized PCE of 24.28%. Furthermore, the unencapsulated device exhibited remarkable operational stability, retaining 92.03% of its initial PCE after 1800h under ambient conditions (35±5% relative humidity, 30°C). To demonstrate the universality of this strategy, a blue perovskite light-emitting diode is fabricated, showing an external quantum efficiency (EQE) of 14.78% and an electroluminescence wavelength (EL) of 494nm. This work provides a significant technique for advancing solution-processed, industrial-scale production of high-quality and stable perovskite films and solar cells.

Identifying Opportunities for Fluid Balance Optimization in Critically Ill Children.

Fluid overload (FO), a state of pathologic positive cumulative fluid balance (CFB), is common in Pediatric Intensive Care Units (PICU) and associated with morbidity and mortality. Because different PICUs may have unique needs, barriers, and limitations to accurately report fluid balance (FB) and reduce FO, understanding the drivers of positive FB is needed. We hypothesize CFB >5% and >10% is common within initial days of PICU admission, but that reasons for high %CFB will vary across sites, as will barriers to accurate FB recording and opportunities to improve FB recording and management. Concurrent mixed methods study utilizing a retrospective observational cohort design and prospective interview and survey design performed at four tertiary pediatric ICUs. FB data was extracted from the electronic health record. A federated data collection framework allowed for rapid data aggregation. The primary outcome was %CFB on PICU days 1 and 2, defined as total intake minus total output divided by PICU admission weight. Chi-square test and Wilcoxon rank sum tests compared results across and within sites. Amongst 3,071 PICU encounters, day 2 CFB >5% varied from 39% to 54% (p=0.03) and day 2 CFB >10% varied from 16% to 25% (p=0.04) across sites. Urine occurrence recordings and patients receiving >100% Holliday-Segar fluids on Day 1 differed across sites (p<0.001). Sites discussed overall FB and specific FB goals on rounds with differing frequency (42-73% and 19-39%, respectively), but they reported similar barriers to accurate FB reporting and achievable opportunities to improve FB measurements. Day 2 CFB >5% and >10% was common among PICU encounters but proportion of patients varied significantly across PICUs. Individual ICUs have different drivers of FO that must be targeted to improve FB management.

Associations Between Daily-Use Products and Urinary Biomarkers of Endocrine-Disrupting Chemicals in Adults of Reproductive Age.

Daily-use products, including personal care products, household products, and dietary supplements, often contain ingredients that raise concerns regarding harmful chemical exposure. Endocrine-disrupting chemicals (EDCs) found in daily-use products are associated with numerous adverse health effects. This pilot study explores the relationship between concentrations of EDCs in urine samples and products used 24 h prior to sample collection, and ingredients of concern in those products, in 140 adults of reproductive age in Northern Nevada. Having higher numbers of products and ingredients of concern, especially in the personal care category, was associated with higher levels of mono-(-ethyl-5-carboxypentyl) phthalate (MECPP). Similarly, taking more supplements was associated with higher levels of methylparaben (MePB). In contrast, using household products with more ingredients of concern was associated with lower levels of monobutyl phthalate (MBP). Generally, women used more products, were exposed to more ingredients of concern and had higher urinary metabolites than men. Participants who rated themselves as being in poor/fair health were exposed to more personal care and supplement ingredients of concern than those in better health. Interestingly, those in excellent health also took supplements with more ingredients of concern. Greater product use and more ingredients of concern are associated with urinary metabolites of known EDCs and self-ratings of poor health. Women and people who take supplements are at greater risk, and even people who consider themselves to be healthy can be highly exposed. More education among the general public is needed to make people aware of the presence of these chemicals in their everyday products so they can make efforts to avoid them.

Electroactive Asymmetric Dressing for Spatiotemporal Deep Burn Scarless Healing and Management.

Burn care and treatment differ markedly from other types of wounds, as they are significantly more prone to infections and struggle to maintain fluid balance post-burn. Moreover, the limited self-healing abilities exacerbate the likelihood of scar formation, further complicating the recovery process. To tackle these issues, an asymmetric wound dressing comprising a quercetin-loaded poly(3-hydroxybutyrate-co-4-hydroxybutyrate) (P34HB@Qu) hydrophilic layer and a zinc oxide nanoparticle-loaded, thermally treated polyvinylidene fluoride (HPVDF@ZnO) hydrophobic layer is designed. This dressing provided antibacterial property and exudate management in the early stages of burn treatment, preventing infection and maintaining moisture balance at the wound site. As healing progresses, the electroactive properties of HPVDF@ZnO and quercetin from P34HB@Qu synergistically regulate cell migration and differentiation, accelerating wound healing and facilitating scar-free regeneration. Furthermore, the wound dressing assisted in the regeneration of skin appendages. This study underscores the full-cycle strategy of versatile wound dressings for spatiotemporal burn wound management from injury to scarless healing.

Understanding the Current Practice in Chest Tube Management Following Lung Resection-A Canadian National Survey.

Timing of chest tube removal post lung resection is variable in practice and often based on personal experience rather than evidence. The current practice in chest tube management among thoracic surgeons across Canada is so far unknown. Our primary aim was to assess the current status of chest tube removal in Canada in order to uncover potential shortcomings. An online anonymous survey was emailed to members of Canadian Association of Thoracic Surgeons in order to better understand the status quo of the chest tubes' removal policy in the different departments preparing the grounds for suggesting a future uniformity. Data were collected and analysed with descriptive statistics. A linear regression analysis was performed in order to understand the factors related to chest tube removal. Sixty responses were received (44.4% response rate). Most surgeons place a single chest tube in both open (75%, 45/60) and minimally invasive lobectomies (93.3%, 56/60). Digital drainage systems are used by half of the surgeons surveyed. A quarter of the respondents report removing chest tubes regardless of drainage output. This practice was independent of the surgeons' number of years in practice (p = 0.127), number of lobectomies performed annually (p = 0.877), proportion of lobectomies performed minimally invasively (p = 0.259), whether digital drainage system is used (p = 0.141) and whether the surgeon is aware of the Enhanced Recovery after Surgery (ERAS) guideline (p = 0.374). Of those who remove chest tubes based on fluid output, thresholds vary widely; a significant proportion (86%, 37/43) uses a volume lower than the 450 mL/24 h threshold set out ERAS. Most respondents (77%) were interested in a clinical trial studying chest tube removal independent of drainage volume. This study demonstrated ongoing diverse practice amongst thoracic surgeons in Canada with regards to post-operative chest tube management, indicating a much-needed area of research.

Real World Testing of a Clinical Strategy to Start Early Peritoneal Dialysis for High-Risk Newborns Following Cardiac Surgery.

The beneficial impact of peritoneal dialysis (PD) catheter placement following cardiopulmonary bypass in young infants has been demonstrated. But the indications to start early peritoneal dialysis are not agreed upon. This retrospective single center study was conducted to evaluate the performance of a clinical strategy for early PD start. PD catheters were placed in the operating room (OR) following cardiopulmonary bypass (CPB). Those with prolonged CPB times (>180 minutes), post-operative (post-op) oligo-anuria and/or inability to achieve negative fluid balance in post-op 24 hours were evaluated as high-risk and selected for early PD start (PD +). All PD + were started within the first post-op 24 hours. Primary outcomes were 5% fluid accumulation at post-op 48 hours and severe acute kidney injury (AKI) at post-op day 5. There were forty-nine newborns. Twenty-nine subjects were early PD (PD +) starts and twenty used the PD catheter as an abdominal drain (PD -). Baseline demographic data were similar. Both groups were oliguric during post-op first 8 hours (p= 0.906). The Early PD (+) group produced significantly less urine output during post-op day 1 (0.98 vs 3.02 ml/kg/hour; p= 0.001). At post-op 48 hours, early PD (+) group had similar prevalence of 5% fluid accumulation as early PD (-), 5 (16.7%) vs. 2 (7.41%), respectively (p= 0.427). Severe AKI incidence at post-op day 5 was similar between the groups (17.3% vs 5.0%; p=0.204). Time to extubation was longer for early PD (+) group compared to PD (-) group, 10.0 days [7.0;16.0] vs. 4.0 days [4.0;10.0] (p=0.017). Persistent oliguria and inability to achieve negative fluid balance during initial post-op 24 hours may identify those newborns who will benefit from early PD. The first post-operative 8 hours was indiscriminative for this strategy. PD start may ameliorate the disadvantage for the designated group.

Left ventricular diastolic dysfunction is prevalent but not associated with mortality in patients with septic shock.

Prognostic impact of left ventricular diastolic dysfunction (LVDD) in septic shock patients has not been determined using current diagnostic guidelines. We assessed the relation between LVDD during the first 3days following intensive care unit (ICU) admission for septic shock and Day-28 mortality. This prospective, multicenter, observational study enrolled 402 patients (age: 63 ± 13year; 59% male; SAPS II: 59 ± 20; SOFA: 9.4 ± 3.6; mechanical ventilation: 74%) with septic shock (Sepsis-3 definition). Patients were echocardiographically assessed within 12h after admission (Day 1), on Day 2, Day 3, at ICU and at hospital discharge (or Day 28 whichever occurred first), using 2016 American-European guidelines. LVDD was present at least once between Day 1 and 3 in 304 patients (76%), and in 56% and 44% of patients at ICU discharge and on Day 28 (or hospital discharge), respectively (43% of patients with follow-up). Seventy-eight of 172 patients (45%) exhibited similar LV diastolic properties throughout the study period while 58 patients (34%) improved their LVDD at follow-up (lower grade: n = 9, regression: n = 49). Day-28 mortality was not statistically different between patients with and without LVDD (80/304 [26%] vs. 25/88 [28%]; OR: 0.900 [0.530-1.527]; p = 0.696). Similar results were obtained when adjusting the multivariate model on SAPSII or SOFA score on admission, together with fluid balance during the first three days of ICU stay (OR: 0.838 [0.471-1.491]: p = 0.547 and OR: 0.887 [0.513-1.534]: p = 0.668, respectively). LVDD was highly prevalent in patients with septic shock but not associated with mortality. It appeared improving in one-third of survivors. PRODIASYS study registered on ClinicalTrials (September 27, 2016, number NCT02918214).