Fluid Bolus Research Articles

Blood pressure trends following birth in infants born under 25 weeks’ gestational age: a retrospective cohort study

ObjectiveThe aim of our study was to describe postnatal blood pressure (BP) trends and evaluate relevant dynamics and outcomes for a subgroup of extremely preterm (EPT) infants.DesignRetrospective observational cohort study.SettingPatients...

Effect of intravenous lipid therapy in critically ill pediatric patients with calcium channel blocker toxicity.

Overdose with calcium-channel blockers (CCBs) still maintain their importance with a high lethality rate after exposure. We report the intravenous lipid emulsion therapy (ILE) therapy in our CCB overdose patients. We retrospectively analyzed the records of 6 patients with CCB intoxication from Batman Training and Research Hospital PICU between March 2021 and September 2022. Patients aged 0-18 years who received ILE treatment for CCB poisoning were included. All six patients ingested CCB with the intention of committing suicide and were followed up in the pediatric intensive care unit (PICU). All patients received ILE therapy due to hemodynamic instability despite intravenous fluid boluses, calcium, glucagon, insulin-dextrose, and vasoactive agents. Vasoactive-Inotropic Score (VIS) decreased after ILE treatment. All patients were transferred from the PICU after recovery. ILE therapy should be kept in mind as a salvage therapy in hemodynamically unstable CCB poisoning cases that do not respond to initial and advanced options.

Catalytic effects on peristaltic flow of Jeffrey fluid through a flexible porous duct under oblique magnetic field: Application in biomimetic pumps for hazardous materials

Homogenous and heterogeneous reactions play an essential role in polymer production, combustion, ceramic production, catalysis, distillation, and biochemical procedures. As a result of this advancement, a mathematical model is developed to examine the role of catalytic chemical reaction effects on the magneto-hydrodynamic peristaltic transport in a flexible divergent duct containing a non-deformable porous medium as a model for complex hazardous waste bio-inspired pumping mechanisms. The Jeffrey model is utilized to simulate strong non-Newtonian characteristics. Additional multi-physical features included in the model are heat generation, thermal radiation, Hall current, and complaint wall properties along with an inclined (oblique) magnetic field. The long wavelength and low Reynolds number approximations are deployed to transform the primitive conservation equations from a moving boundary problem to a fixed frame. Appropriate transformations are then utilized to render the model dimensionless. The exact solutions are obtained for stream function and velocity. Further, the R-K-Fehlberg integration scheme is applied to solve the energy and concentration equations. Velocity, temperature, concentration, skin friction, and Nusselt number profiles are visualized graphically. Streamline patterns are also included to capture bolus dynamics. Validation with previous simpler studies has been included. A detailed appraisal of key control parameters on transport characteristics is conducted. It is found that velocity is suppressed with elevation in the damping force parameter while it is enhanced with an increment in regime permeability i. e. Darcy number. Both homogeneous and heterogeneous reactions are observed to exert a significant impact on the species concentration. The volume of the trapped fluid bolus size is shown to be an increasing function of the peristaltic wave amplitude ratio. The present work generalizes existing studies to consider catalytic effects on dissipative peristaltic pumping of the Jeffrey fluid with heat generation and radiative flux, aspects which have been neglected in a single model previously. The simulations are relevant to better characterize the complex transport phenomena in nuclear reactor waste transport via biologically inspired pumping designs.

Assessment of Outcomes in Patients with Heart Failure and End-Stage Kidney Disease after Fluid Resuscitation for Sepsis and Septic Shock

BackgroundSepsis fluid resuscitation is controversial, especially for patients with volume overload risk. The Surviving Sepsis Campaign recommends a 30-mL/kg crystalloid fluid bolus for patients with sepsis-induced hypoperfusion. Criticism of this approach includes excessive fluid resuscitation in certain patients. ObjectiveThe aim of this study was to assess the efficacy and safety of guideline-concordant fluid resuscitation in patients with sepsis and heart failure (HF) or end-stage kidney disease (ESKD). MethodsA retrospective cohort study was conducted in patients with sepsis who qualified for guideline-directed fluid resuscitation and concomitant HF or ESKD. Those receiving crystalloid fluid boluses of at least 30 mL/kg within 3 h of sepsis diagnosis were placed in the concordant group and all others in the nonconcordant group. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS); vasoactive medications and net volume over 24 h; new mechanical ventilation, new or increased volume removal, and acute kidney injury within 48 h; and shock-free survival at 7 days. ResultsOne hundred twenty-five patients were included in each group. In-hospital mortality was 34.4% in the concordant group and 44.8% in the nonconcordant group (p = 0.1205). The concordant group had a shorter ICU LOS (7.6 vs. 10.5 days; p = 0.0214) and hospital LOS (12.9 vs. 18.3 days; p = 0.0163), but increased new mechanical ventilation (37.6 vs. 20.8%; p = 0.0052). No differences in other outcomes were observed. ConclusionsReceipt of a 30-mL/kg fluid bolus did not affect outcomes in a cohort of patients with mixed types of HF and sepsis-induced hypoperfusion.

Goal-directed fluid therapy guided by plethysmographic variability index versus conventional liberal fluid therapy in neonates undergoing abdominal surgery: A prospective randomized controlled trial.

Intraoperative fluid therapy maintains normovolemia, normal tissue perfusion, normal metabolic function, normal electrolytes, and acid-base status. Plethysmographic variability index has been shown to predict fluid responsiveness but its role in guiding intraoperative fluid therapy is still elusive. The aim of the present study was to compare intraoperative goal-directed fluid therapy based on plethysmographic variability index with liberal fluid therapy in term neonates undergoing abdominal surgeries. A prospective randomized controlled study was conducted in a tertiary care centre, over a period of 18 months. A total of 30 neonates completed the study out of 132 neonates screened. Neonates with tracheoesophageal fistula, congenital diaphragmatic hernia, congenital heart disease, respiratory disorders, creatinine clearance <90 mL/min and who were hemodynamically unstable were excluded. Neonates were randomized to goal-directed fluid therapy group where the plethysmographic variability index was targeted at <18 or liberal fluid therapy group. Primary outcome was comparison of total amount of fluid infused intraoperatively in both the groups. Secondary outcomes included intraoperative and postoperative arterial blood gas parameters, biochemical parameters, use of vasopressors, number of fluid boluses, complications and duration of hospital stay. There was no significant difference in total intraoperative fluid infused [90 (84-117.5 mL) in goal-directed fluid therapy and 105 (85.5-144.5 mL) in liberal fluid therapy group (p = .406)], median difference (95% CI) -15 (-49.1 to 19.1). There was a decrease in serum lactate levels in both groups from preoperative to postoperative 24 h. The amount of fluid infused before dopamine administration was significantly higher in liberal fluid therapy group (58 [50.25-65 mL]) compared to goal-directed fluid therapy group (36 [22-44 mL], p = .008), median difference (95% CI) -22 (-46 to 2). In postoperative period, the total amount of fluid intake over 24 h was comparable in two groups (222 [204-253 mL] in goal-directed fluid therapy group and 224 [179.5-289.5 mL] in liberal fluid therapy group, p = .917) median difference (95% CI) cutoff -2 (-65.3 to 61.2). Intraoperative plethysmographic variability index-guided goal-directed fluid therapy was comparable to liberal fluid therapy in terms of total volume of fluid infused in neonates during perioperative period. More randomized controlled trials with higher sample size are required. Central Trial Registry of India (CTRI/2020/02/023561).

Term Neonate Born With Right Upper Extremity Skin Necrosis at Birth: A Case Report.

Congenital skin and soft tissue necrosis is a rare condition associated with significant morbidity and mortality in neonates. The authors treated a neonate born with significant skin necrosis of the right forearm. The case report is followed by a literature review and discussion of previously published reports of neonatal skin necrosis. A term female neonate was admitted to our hospital at 24 h of age for skin necrosis of the right forearm with sloughing and edema below the right elbow and contractures of her fingers. Topical treatment with cleansing and antibiotic application was initiated. The LUNA florescent microangiography showed superficial perfusion defects in the arm and dorsum of the hand along with overt ischemia over the dorsal aspect of the forearm. She was treated with intravenous antibiotics following a sepsis evaluation. Subsequently, she developed hypotension treated with fluid boluses, dopamine, and stress dose steroids. Concerns of wound infection and sepsis led to debridement of the necrotic area within the first 24 h post-admission. Wet-to-dry dressing changes using Vashe wound solution were begun postoperatively.; followed by placement of Integra on postoperative day-of-life (DOL) 7; dressing takedown on DOL 12; and autografting of the right hand and forearm with disarticulation of the 4th distal interphalangeal joints and right 5th distal interphalangeal transection on DOL 24. Postoperative dressing care was continued during the remainder of the hospital stay, she remained stable without any further complications and was discharged home on DOL 34 with outpatient clinic follow-up.

Improving the precision of shock resuscitation by predicting fluid responsiveness with machine learning and arterial blood pressure waveform data

Fluid bolus therapy (FBT) is fundamental to the management of circulatory shock in critical care but balancing the benefits and toxicities of FBT has proven challenging in individual patients. Improved predictors of the hemodynamic response to a fluid bolus, commonly referred to as a fluid challenge, are needed to limit non-beneficial fluid administration and to enable automated clinical decision support and patient-specific precision critical care management. In this study we retrospectively analyzed data from 394 fluid boluses from 58 pigs subjected to either hemorrhagic or distributive shock. All animals had continuous blood pressure and cardiac output monitored throughout the study. Using this data, we developed a machine learning (ML) model to predict the hemodynamic response to a fluid challenge using only arterial blood pressure waveform data as the input. A Random Forest binary classifier referred to as the ML fluid responsiveness algorithm (MLFRA) was trained to detect fluid responsiveness (FR), defined as a ≥ 15% change in cardiac stroke volume after a fluid challenge. We then compared its performance to pulse pressure variation, a commonly used metric of FR. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), confusion matrix metrics, and calibration curves plotting predicted probabilities against observed outcomes. Across multiple train/test splits and feature selection methods designed to assess performance in the setting of small sample size conditions typical of large animal experiments, the MLFRA achieved an average AUROC, recall (sensitivity), specificity, and precision of 0.82, 0.86, 0.62. and 0.76, respectively. In the same datasets, pulse pressure variation had an AUROC, recall, specificity, and precision of 0.73, 0.91, 0.49, and 0.71, respectively. The MLFRA was generally well-calibrated across its range of predicted probabilities and appeared to perform equally well across physiologic conditions. These results suggest that ML, using only inputs from arterial blood pressure monitoring, may substantially improve the accuracy of predicting FR compared to the use of pulse pressure variation. If generalizable, these methods may enable more effective, automated precision management of critically ill patients with circulatory shock.

Assessing fluid responsiveness with ultrasound in the neonatal intensive care setting: the mini-fluid challenge.

The mini-fluid challenge (MFC) can guide individualised fluid therapy and prevent fluid overload and associated morbidity in adult intensive care patients. This ultrasound test is based on the Frank-Starling principles to assess dynamic fluid responsiveness, but limited MFC data exists for newborns.This brief report describes the feasibility of the MFC in 12 preterm infants with late onset sepsis and 5 newborns with other pathophysiology. Apical views were used to determine the changes in left ventricular stroke volume before and after a 3ml/kg fluid bolus was given over 5min. Four out of the 17 infants were fluid responsive, defined as a post-bolus increase in stroke volume of 15% or more. Conclusion: The MFC was feasible and followed the physiological principles of stroke volume and extravascular lung water changes and 24% were fluid responsive. The MFC could enable future studies to examine whether adding fluid responsiveness to guide fluid therapy in newborns can reduce the risk of fluid overload. What is Known: • Fluid overload is associated with morbidity and mortality. • The mini-fluid challenge (MFC) provides a personalised approach to fluid therapy. What is New: • The MFC is feasible in newborns. • The MFC followed the physiological principles of stroke volume and extravascular lung water changes.

Correlation Study of Inferior Venacava Collapsibility Index And Perfusion Index as Predictors of Fluid Responsiveness in Critically ill Patients

Introduction: Fluid responsiveness assessment is crucial in managing critically ill patients. This study evaluates the correlation and efficacy of Inferior Vena Cava Collapsibility Index (IVCCI) and Perfusion Index (PI) in predicting fluid responsiveness.&#x0D; Objectives: The primary objective was to evaluate the correlation between the IVCCI and PI as predictors fluid responsiveness in critically ill patients. Secondary objectives involved studying the individual accuracy of the IVCCI and PI in predicting of fluid responsiveness and exploring whether their combined use improves overall accuracy in predicting fluid responsiveness in this patient population.&#x0D; Methodology: This prospective study enrolled 80 critically ill patients requiring hemodynamic monitoring and fluid resuscitation. IVCCI was measured using bedside ultrasonography, and PI was derived from pulseoximetry. Hemodynamic parameters were recorded before and after a standardized fluid bolus. Receiver Operating Characteristic (ROC) curves were generated to assess the predictive performance of IVCCI and PI.&#x0D; Results: Among 80 enrolled patients, responders (N=35) demonstrated significantly lower baseline cardiac output (4.5 ± 0.23 vs 4.76 ± 0.22, p&lt;0.01) and higher IVCCI (35.13 ± 13.41 vs 28.53 ± 10.17, p=0.015) compared to non-responders. After a standardized fluid bolus, responders exhibited higher cardiac output (5.31 ± 0.24 vs 4.9 ± 0.27, p&lt;0.01) and lower IVCCI (22.01 ± 15.84 vs 28.88 ± 11.71, p=0.029). IVCCI and PI before fluid bolus showed a very weak positive correlation (r = 0.080, p = 0.478). Moreover, IVCCI before fluid bolus had better sensitivity (0.745) and specificity (0.727) than PI before fluid bolus (sensitivity: 0.574, specificity: 0.485), with AUC values of 0.693 and 0.455, respectively.&#x0D; Conclusion: IVCCI demonstrates efficacy in predicting fluid responsiveness, with a very weak positive correlation to PI. Notably, IVCCI before fluid bolus outperforms PI before fluid bolus in sensitivity and specificity, highlighting its superior predictive accuracy in critically ill patients.

Mathematical modeling of blood flow in an annulus porous region between two coaxial deformable tubes: An advancement to peristaltic endoscope

In the present work, the electromagnetohydrodynamic peristaltic flow of blood through an annulus region between two concentric circular tubes has been investigated for the advancement of a peristaltic endoscope. In this model, the viscous and incompressible blood is assumed as non-Newtonian Jeffery fluid, and tubes are inclined at an angle β with the horizontal. The governing equations for the considered problem are simplified under the assumption of a low Reynolds number and long wavelength approximations. An analytical expression for various flow variables such as axial velocity, radial velocity, time mean flow rate, volumetric flow rate, frictional force at the surface of the inner tube, and mechanical efficiency is obtained. In this work, we discussed the impact of various flow parameters like the Hartmann number M, electric field strength parameter H, Jeffery fluid parameter λ1, radius ratio n, occlusion ϕ=ba, angle of inclination β, and Darcy number Da on the above flow variables. The streamlines are also made to discuss the trapping phenomena of a fluid bolus inside the tubes. The comparison of pressure rise for the various endoscopes and the validation of the present result with the previously established results are discussed.

Analysis of two layered peristaltic-ciliary transport of Jeffrey fluid and in vitro preimplantation embryo development

The analysis of peristaltic-ciliary transport in the human female fallopian tube, specifically in relation to the growing embryo, is a matter of considerable physiological importance. This paper proposes a biomechanical model that incorporates a finite permeable tube consisting of two layers, where the Jeffrey fluid model characterizes the viscoelastic properties of the growing embryo and continuously secreting fluid. Jeffrey fluid entering with some negative pressure gradient forms the core fluid layer while continuously secreting Jeffrey fluid forms the peripheral fluid layer. The resulting partial differential equations are solved for closed-form solutions after employing the assumption of long wavelength. The analysis delineated that increasing the constant secretion velocity, Darcy number, and Reynolds number leads to a decrease in the appropriate residue time of the core fluid layer and a reduction in the size of the secreting fluid bolus in the peripheral fluid layer. Eventually, the boluses completely disappear when the constant secretion velocity exceeds 3.0 Progesterone (P4\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$P_4$$\\end{document}) and estradiol (E2\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$E_2$$\\end{document}) directly regulate the transportation of the growing embryo, while luteinizing hormone (LH) and follicle-stimulating hormone (FSH), prolactin, anti-mullerian hormone (AMH), and thyroid-stimulating hormone (TSH) have an indirect effects. Based on the number and size of blastomeres, the percentage of fragmentation, and the presence of multinucleated blastomeres two groups were formed in an in vitro experiment. Out of 50 patients, 26 (76.5%) were pregnant in a group of the good quality embryos, and only 8 (23.5%) were in a group of the bad quality embryos. The transport of growing embryo in the human fallopian tube and preimplantation development of human embryos in in vitro are constraint by baseline hormones FSH, LH, prolactin, E2\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$E_{2}$$\\end{document}, AMH, and TSH.

Early red blood cell transfusion and the occurrence of intraventricular hemorrhage in very preterm infants

BackgroundPreterm infants are at risk of developing both intraventricular hemorrhage (IVH) and anemia of prematurity. Several studies reported an association between early postnatal red blood cell (RBC) transfusion and IVH, however the timing and causality between these two remains unclear. AimsTo describe the temporal sequence between administration of early RBC transfusion (within the first week of life) and diagnosis of IVH in very preterm infants. Study designRetrospective single center case-series. Subjects132 very preterm infants (<32 weeks' gestation), admitted to a level III neonatal intensive care unit, studied with serial cranial ultrasound (CUS), and diagnosed with any grade of IVH. Outcome measuresNumber and timing of early RBC transfusions in relation to the timing of IVH. ResultsMedian time of IVH diagnosis was 20.5 h after birth (interquartile range [IQR], 6.25–49.00 h). Of those who received an early RBC transfusion (36 %, 47/132), only 15 % (20/132) received it before the IVH diagnosis. Infants with RBC transfusion before IVH more frequently had lower birth weight, received less fequently antenatal steroids, required more often invasive mechanical ventilation and surfactant administration, had more often hypo- and hypercapnia, and received more fluid boluses, NaHCO3, and inotropes compared to the rest. ConclusionsIn the majority of infants, IVH was already present at the time of the first RBC transfusion. Studies including pre- and post RBC transfusion CUS are needed to assess the effect of early RBC transfusions on the development of IVH in preterm neonates.

Hemodynamic assessment and management of septic shock in children

Abstract The three main pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative &gt; absolute), vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses (FBs), vasopressors ± inotropic agents. The three goals of hemodynamic resuscitation include an adequate cardiac output (CO)/clinical perfusion markers, pressure parameters (adequate mean arterial pressure [MAP] and diastolic blood pressure [DBP]) for organ perfusion, and avoiding congestion (worse filling) parameters. Fluid bolus-induced CO improvements are variable (33%–50%) and ill-sustained on account of sepsis-mediated glycocalyx injury. A pragmatic approach is to administer a small bolus (10 mL/kg over 20–30 min) as a test and judge the response based on clinical perfusion markers, pressure parameters, and congestive features. Vasoplegia is characterized by low DBP, which is a major contributor to hypotension in septic shock; furthermore, FBs may exacerbate vasoplegia. A strategy of restricted FB with early low-dose norepinephrine (NE) (0.05–0.1 µg/kg/min) can be helpful. NE has press or effects and also mild inotropy and can be a useful first-line vasoactive even in patients with mild-moderate septic myocardial dysfunction (SMD) to maintain adequate coronary perfusion and DBP while minimizing tachycardia. Severe SMD may benefit from additional inotropy (epinephrine/dobutamine). Except vasopressin, most vasoactive drugs may safely be administered via a peripheral route. The lowest MAP (5th centile for age) may be an acceptable target, provided that end-organ perfusion and organ function (mentation and urine output) are satisfactory. An individualized rather than protocolized approach combining the history, physical examination, laboratory analyses, available monitoring tools, and re-assessments can improve outcomes.

Partial Exchange Transfusion in the Management of a Preterm Neonate with Severe Anaemia from Acute Foetomaternal Haemorrhage: A Case Report

Foetomaternal Haemorrhage (FMH) refers to the passage of foetal blood into the maternal circulation. FMH is rarely diagnosed antenatally as clinical findings are subtle and non specific. Massive FMH is suspected when foetal movements are decreased, and Cardiotocographic (CTG) findings are abnormal with decreased heart rate variability, saw-tooth or a sinusoidal pattern. Massive FMH can lead to foetal demise, stillbirth, hydrops, or the birth of a severely anaemic infant with hypovolaemic shock. A 35-week pregnant woman presented with decreased foetal movements, and an emergency caesarean section was performed due to late deceleration on the cardiotocograph. The baby was very pale at birth and in shock. The Kleihauer-Betke (KB) test performed on the mother’s blood shortly after delivery showed 2.7% foetal red cells, suggesting 135 cc of FMH. The clinical features and outcome of FMH depend on the gestational age, volume, and rapidity of FMH, as well as, whether it is acute or chronic. Packed cell transfusion is recommended, but in babies with severe anaemia and cardiac failure, partial exchange transfusion is performed. The baby was managed with a fluid bolus, inotropic support, respiratory support, and partial exchange transfusion, resulting in a successful outcome. A high index of suspicion enables the obstetrician to undertake diagnostic tests, cordocentesis, plan for intrauterine transfusion or delivery, and alert the neonatal team for a better outcome.

A prospective observational study to compare and evaluate delta down, aortic velocity time integral variability, and superior vena cava collapsibility index as predictors of fluid responsiveness in patients with supratentorial brain tumors undergoing elective neurosurgery.

Patients undergoing surgical resection of brain tumors frequently exhibit a spectrum of hemodynamic fluctuations necessitating careful fluid management. This study aimed to evaluate the feasibility of dynamic predictors of fluid responsiveness, such as delta down (DD), aortic velocity time integral variability (VTIAoV), and superior vena cava collapsibility index (SVCCI), in patients undergoing neurosurgery for brain tumors. In this prospective study, 30 patients scheduled to undergo elective neurosurgery for brain tumor resection were enrolled. Baseline measurements of vitals, anesthetic parameters, and study variables were recorded post-induction. Subsequently, patients received a fluid bolus of 10 mL/kg of colloid over 20 min, and measurements were repeated post-loading. Data were presented as mean ± standard deviation. The normally distributed continuous variables were compared using Student's t-test, with P < 0.05 considered statistically significant. The predictive capability of variables for fluid responsiveness was assessed using Pearson's coefficient analysis (r). Of the 30 patients, 22 were identified as volume responders (R), while eight were non-responders (NR). DD >5 mmHg effectively distinguished between R and NR (P < 0.001), with a good predictive ability (r = 0.759). SVCCI >38% differentiated R from NR (P < 0.001), with excellent predictability (r = 0.994). Similarly, VTIAoV >20% was also a good predictor (P < 0.05; r = 0.746). Our study revealed that most patients undergoing surgical resection of brain tumors exhibited fluid responsiveness. Among the variables assessed, SVCCI >38% emerged as an excellent predictor, followed by VTIAoV >20% and DD >5 mm Hg, for evaluating fluid status in this population.

Aortic peak flow variation as a predictor of fluid responsiveness in pediatric septic shock patients under mechanical ventilation

Introduction: effective fluid management is crucial in pediatric critical care, particularly for patients with septic shock. Aortic Peak Flow Variation (APFV) has emerged as a potential predictor of fluid responsiveness, yet its utility in pediatric septic shock patients under mechanical ventilation remains underexplored.Objective: to evaluate the predictive accuracy of APFV for fluid responsiveness in pediatric septic shock patients undergoing mechanical ventilation and to establish optimal APFV cutoff values for clinical application.Methods: in this prospective observational study conducted from January to September 2023 at the PICU of Hospital Padre Carollo "Un Canto a la Vida," 26 pediatric septic shock patients were enrolled. Hemodynamic variables were measured before and after a standard fluid bolus of 10 ml/kg. APFV was calculated using transthoracic echocardiography, with fluid responsiveness defined as a ≥10 % increase in stroke volume index post-fluid administration. Sensitivity, specificity, and ROC curve analyses were employed to evaluate APFV's predictive capability.Results: out of 26 patients, 17 (65,4 %) responded to fluid administration. The mean APFV across all patients was 12,5 %. ROC curve analysis determined an APFV cutoff of 13,4 % for predicting fluid responsiveness, yielding a sensitivity of 82 % and specificity of 83 %, with an AUROC of 0,83.Conclusions: APFV demonstrated a moderate to high level of accuracy in predicting fluid responsiveness in pediatric septic shock patients under mechanical ventilation. The identified APFV cutoff provides a practical reference for clinicians in fluid management decisions within this patient population

Focused Cardiac Ultrasound Findings of Fluid Tolerance and Fluid Resuscitation in Septic Shock.

Compliance with the fluid bonus component of the SEP-1 (severe sepsis and septic shock management) bundle remains poor due to concerns for iatrogenic harm from fluid overload. We sought to assess whether patients who received focused cardiac ultrasound (FCU) and were found to be fluid tolerant (FT) were more likely to receive the recommended 30 mL/kg fluid bolus within 3 hours of sepsis identification. Retrospective, observational cohort study. University-affiliated, tertiary-care hospital in the United States. Emergency department patients presenting with septic shock from 2018 to 2021. The primary exposure was receipt of FCU with identification of fluid tolerance 3 hours from onset of septic shock. None. Two hundred ninety-two of 1,024 patients with septic shock received FCU within 3 hours of sepsis onset. One hundred seventy-seven were determined to be FT. One hundred fifteen patients were determined to have poor fluid tolerance (pFT). FT patients were more likely to reach the recommended 30 mL/kg fluid bolus amount compared with pFT (FT 52.0% vs. pFT 31.3%, risk difference: 20.7%, [95% CI, 9.4-31.9]). Patients who did not receive FCU met the bolus requirement 34.3% of the time. FT patients received more fluid within 3 hours (FT 2,271 mL vs. pFT 1,646 mL, mean difference 625 mL [95% CI, 330-919]). Multivariable logistic regression was used to estimate the association between fluid tolerance FCU findings and compliance with 30 mL/kg bolus after adjustment for patient characteristics and markers of hemodynamic instability. FT with associated with a higher likelihood of meeting bolus requirement (odds ratio 2.17 [1.52-3.12]). Patients found to be FT by FCU were more likely to receive the recommended 30 mL/kg bolus in the SEP-1 bundle when compared with patients found with pFT or those that did not receive FCU. There was no difference between groups in 28-day mortality, vasopressor requirement, or need for mechanical ventilation.

Identification of Risk Factors for Sickle Cell Crisis Readmissions: A Community Center Experience

Introduction: Sickle cell disease (SCD) exerts a significant morbidity and mortality burden worldwide, with 300,000 infants being diagnosed with SCD annually. The term sickle cell crisis (SCC) encompasses several acute conditions under its umbrella, namely vaso-occlusive crisis, aplastic crisis, splenic sequestration crisis, dactylitis, and acute chest syndrome. SCC has been established to be a known cause of readmissions across the year with studies showing 17% of the population returning two to three times annually. This has resulted in a high mean length of stay for this diagnosis (5.3 days) in comparison to an index hospitalization (4.9 days), with a mean cost of $8485 per admission. Readmissions owing to SCC have relayed a significant burden of 95,445 hospitalization days and a total charge of $609 million in the US. Despite the high morbidity and financial burden it imposes, limited studies have been performed studying the risk factors for readmissions in these patients. Despite the establishment of a framework of recommendations and guidelines, there appears to be a high incidence of readmissions and discrepancies in adherence to evidence based recommendations. We performed a retrospective study to evaluate the risk factors for patients hospitalized in three community hospitals between October 2021 and August 2022. Methods: The admissions database of a community health system across three hospitals was scanned for admissions with SCC between the time period October 2021 and August 2022. ICD9 and ICD-10 codes of SCC were used. 50 patients found with the admitting diagnosis code of SCC and 103 encounters were included. After excluding patients who left against medical advice before initiation of treatment, those with the wrong diagnosis and incomplete documentation, a cohort of 47 patients with 100 encounters was attained. Patient charts were reviewed and demographic variables such as age, gender and race were studied. Readmissions and the length of stay were assessed for risk factors with the help of a chi square test. Risk factors assessed included use of pain medications (opioids with non-steroid anti-inflammatory medications versus monotherapy), use of IV Fluid Boluses, placement of Hematology consult, having an established primary care physician and the use of hydroxyurea as a home medication. Results: 87% of the patient population was African American with equal gender distribution (Males 51%; Females 49%). 59% of the patient population lay in the age group of 18-35. 49% of the patient population was noted to have readmissions within the time frame studied with 29% of the patient population having a length of stay of more than 3 days. 100% of the patients without an established primary care physician (PCP) were noted to have readmissions in comparison to 3.6% of the patients with an established PCP (p&amp;lt; 0.01). Length of stay was less than 3 days for 91.3% of the patients treated with the combination of opioids and NSAID's for pain in comparison to 64.9% of the patients that were not treated with this combination (p= 0.014). It was noted however, that 37% of the population was on hydroxyurea outpatient and 44% of the cases had involved hematology for the inpatient management of these patients. IV Fluid boluses and their association with length of stays in our patient population was unequivocal. 52.7% of the patients on hydroxyurea had readmissions within 30 days as opposed to 28.6% of the patients not on the drug. This was likely explained by non-compliance to the medication. No deaths were reported in this patient cohort. Conclusion: Several risk factors for readmissions in SCC patients exist in the community setting. Our findings reported that lack of close outpatient follow up is associated with higher readmission rates. In addition, we also observed that the type of medical pain management (combination vs monotherapy) played a role in length of stay with combination therapy being linked to shorter hospitalization stay. Integrated education for various medicine specialties regarding management guidelines should be instituted. In addition, maximum utilization of social work and case management for ensuring close follow ups for this patient population may further mitigate readmissions of SCC patients in the community setting.

1325. Neurodevelopmental outcomes in preschoolers following viral meningitis is Canterbury, New Zealand

Abstract Background Most childhood meningitis nowadays is caused by viruses in countries with widespread use of conjugate vaccines. There is limited knowledge about outcomes following childhood viral meningitis, necessary to inform clinical guidelines. Methods Children aged 19-42 months in Canterbury New Zealand, who had enterovirus (EV) or human parechovirus (HPEV) meningitis as infants were included. Clinical data was collected. Comprehensive neurodevelopmental assessments were completed using the Bayley Scale for Infant Development (BSID) Third Edition. Mean composite and scaled scores, and proportion below cutoff were assessed in each domain. Normative mean composite scores for any domain is 100. Expected scaled score range is 8-12. Mean scores between EV and HPEV meningitis were compared by t-tests, with P&amp;lt; 0.05 considered significant. Results BSID assessments were completed for 33 children (55% male) of mean age 31 months, from 2019-22, including 23 with EV and 10 with HPEV meningitis. There were 24 children of NZ European, 4 Māori, 4 Asian, and 1 Middle Eastern ethnicity. Mean age at diagnosis was 43 days, and mean length of admission was 2.79 days (CI 1.74-3.15). Of 33 children, 32 (97%) received intravenous or intramuscular antibiotics, 6 (18%) received a fluid bolus on arrival at hospital, and 9 (27%) required high dependency or intensive care. Following viral meningitis, parents reported developmental speech concerns in 6 children, and delayed motor milestones in 1 child. There was no reported sensorineural hearing loss. BSID mean composite scores were in expected range for cognition 102 (CI 98-106), language 96 (93-100) and motor 102 (98-106) domains. Mean scaled scores were in expected range for receptive language 9 (9-10), expressive language 9 (9-10), fine motor 11 (11-12) and gross motor 9 (9-10) domains. Overall, 12/33 (36%) children had below expected scores in one area of development including cognition (2/33; 6%), receptive language (6/33; 18%), expressive language (5/33; 15%), and gross motor (6/33; 18%). There were no significant differences between BSID scores in EV and HPEV meningitis. Conclusion Following viral meningitis, 36% percent of preschool children had findings below expected in at least one developmental domain, suggesting targeted follow-up should be considered. Disclosures Manish Sadarangani, BM BCh, FRCPC, DPhil, GlaxoSmithKline: Grant/Research Support|Merck: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Sanofi Pasteur: Grant/Research Support|Seqirus: Grant/Research Support|Symvivo: Grant/Research Support|VBI Vaccines: Grant/Research Support

Are dynamic measurements of central venous pressure in Fontan circulation during exercise or volume loading superior to resting measurements?

The main objective measure to assess the health of the Fontan circulation is the pressure measurement of the superior vena cava or pulmonary arteries. We reviewed the literature for benefits of measuring resting pressure in the Fontan circuit and explored whether dynamic measurement by volume loading or exercise has the potential to refine this diagnostic tool. PubMed was searched for articles showing a relationship between resting post-operative central venous pressure or pulmonary artery pressure and Fontan failure. Relationships between post-operative central venous pressure or pulmonary artery pressure and volume loading changes, such as during exercise or volume loading during cardiac catheterization, were also queried. A total of 44 articles mentioned relationships between resting central venous pressure or pulmonary artery pressure and Fontan failure. Only 26 included an analysis between the variables and only seven of those articles found pressure to be predictive of Fontan failure. Ten articles examined the relationship between exercise or volume loading and outcomes and demonstrated a large individual variation of pressures under these dynamic conditions. Based on current literature, there is not a lot of strong evidence to show that elevated resting central venous pressure or pulmonary artery pressure is predictive of Fontan failure. Some individuals experience dramatic increases in central venous pressure or pulmonary artery pressure under increased loading conditions with exercise or bolus fluid infusion, while others experience increases closer to that of a healthy control population. Further studies are needed to examine whether more dynamic and continuous monitoring of systemic venous pressures might better predict outcomes in patients with Fontan circulation.