Fluid Management Strategy Research Articles

Risk factors for postoperative acute kidney injury after radical cystectomy for bladder cancer in the era of ERAS protocols: A retrospective observational study.

Radical cystectomy (RC) is a major surgery associated with a high morbidity rate. Perioperative fluid management according to enhanced recovery after surgery (ERAS) protocols aims to maintain patients in an optimal euvolemic state while exposing them to acute kidney injury (AKI) in the event of hypovolemia. Postoperative AKI is associated with severe morbidity and mortality. Our main objective was to determine the association between perioperative variables, including some component of ERAS protocols, and occurrence of postoperative AKI within the first 30 days following RC in patients presenting bladder cancer. Our secondary objective was to evaluate the association between a postoperative AKI and the occurrence or worsening of a chronic kidney disease (CKD) within the 2 years following RC. We conducted a retrospective observational study in a referral cancer center in France on 122 patients who underwent an elective RC for bladder cancer from 01/02/2015 to 30/09/2019. The primary endpoint was occurrence of AKI between surgery and day 30. The secondary endpoint was survival without occurrence or worsening of a postoperative CKD. AKI and CKD were defined by KDIGO (Kidney Disease: Improving Global Outcomes) classification. Logistic regression analyse was used to determine independent factors associated with postoperative AKI. Fine and Gray model was used to determine independent factors associated with postoperative CKD. The incidence of postoperative AKI was 58,2% (n = 71). Multivariate analysis showed 5 factors independently associated with postoperative AKI: intraoperative restrictive vascular filling < 5ml/kg/h (OR = 4.39, 95%CI (1.05-18.39), p = 0.043), postoperative sepsis (OR = 4.61, 95%CI (1.05-20.28), p = 0.043), female sex (OR = 0.11, 95%CI (0.02-0.73), p = 0.022), score SOFA (Sequential Organ Failure Assessment) at day 1 (OR = 2.19, 95%CI (1.15-4.19), p = 0.018) and delta serum creatinine D1 (OR = 1.06, 95%CI (1.02-1.11), p = 0.006). During the entire follow-up, occurrence or worsening of CKD was diagnosed in 36 (29.5%). A postoperative, AKI was strongly associated with occurrence or worsening of a CKD within the 2 years following RC even after adjustment for confounding factors (sHR = 2.247, 95%CI [1.051-4.806, p = 0.037]). A restrictive intraoperative vascular filling < 5ml/kg/h was strongly and independently associated with the occurrence of postoperative AKI after RC in cancer bladder patients. In this context, postoperative AKI was strongly associated with the occurrence or worsening of CKD within the 2 years following RC. A personalized perioperative fluid management strategy needs to be evaluated in these high-risk patients.

The effect of intraoperative goal-directed fluid therapy in patients under anesthesia for gastrointestinal surgery.

Intraoperative fluid management is an important aspect of anesthesia management in gastrointestinal surgery. Intraoperative goal-directed fluid therapy (GDFT) is a method for optimizing a patient's physiological state by monitoring and regulating fluid input in real-time. To evaluate the efficacy of intraoperative GDFT in patients under anesthesia for gastrointestinal surgery. This study utilized a retrospective comparative study design and included 60 patients who underwent gastrointestinal surgery at a hospital. The experimental group (GDFT group) and the control group, each comprising 30 patients, received intraoperative GDFT and traditional fluid management strategies, respectively. The effect of GDFT was evaluated by comparing postoperative recovery, complication rates, hospitalization time, and other indicators between the two patient groups. Intraoperative blood loss in the experimental and control groups was 296.64 ± 46.71 mL and 470.05 ± 73.26 mL (P < 0.001), and urine volume was 415.13 ± 96.72 mL and 239.15 ± 94.69 mL (P < 0.001), respectively. The postoperative recovery time was 5.44 ± 1.1 days for the experimental group compared to 7.59 ± 1.45 days (P < 0.001) for the control group. Hospitalization time for the experimental group was 10.87 ± 2.36 days vs 13.65 ± 3 days for the control group (P < 0.001). The visual analogue scale scores of the experimental and control groups at 24 h and 48 h post-surgery were 3.38 ± 0.79 and 4.51 ± 0.86, and 2.05 ± 0.57 and 3.51 ± 0.97 (P < 0.001), respectively. The cardiac output of the experimental and control groups was 5.99 ± 1.04 L/min and 4.88 ± 1.17 L/min, respectively, while the pulse pressure variability for these two groups was 10.87 ± 2.36% and 17.5 ± 3.21%, respectively. The application of GDFT in gastrointestinal surgery can significantly improve postoperative recovery, reduce the incidence of complications, and shorten hospital stays.

Fluid Management in Critically Ill Children: Single-Center Retrospective Comparison of Trauma and Postoperative Patients, 2020-2022.

Injury and surgery both represent well-defined starting points of a predictable inflammatory response, but the consequent response to IV fluids has not been studied. We aimed to review and compare our single-center fluid management strategies in these two populations. Retrospective cohort study from January 2020 to July 2022. The primary outcome was total IV fluid volume administered. Net fluid balances and select clinical outcomes were also evaluated. Single tertiary academic center and level 1 pediatric trauma center in New York. A dataset of critically ill trauma and surgical patients aged 0-18 years who were admitted to the PICU, 2020-2022. Trauma patients had at least moderate traumatic injuries (Injury Severity Score ≥ 9) and surgical patients had at least a 1-hour operation time. None. We identified 25 trauma and 115 surgical patients. During the first 5 days of hospitalization, we did not identify an association between grouping and total IV fluids administered and fluid balance in the prehospital, emergency department, and operating room (p = 0.90 and p = 0.79), even when adjusted for weight (p = 0.96). Time trend graphs of net fluid balance and IV fluid administered illustrated analogous fluid requirement and response with the transition from net positive to net negative fluid balance between 48 and 72 hours. There was an association between total IV fluid and ventilator requirement (p = 0.003). Critically ill pediatric trauma and postoperative patients seem to have similar fluid management and balance after injury or surgery. In our opinion, these two critically ill populations could be combined in large prospective studies on optimal fluid therapy in critically ill children.

Intrarenal venous flow patterns - Guiding fluid management in sepsis with AKI: A case report.

Sepsis often leads to acute kidney injury (AKI), presenting significant challenges in fluid management. This study explores the potential of analyzing intrarenal venous flow (IRVF) patterns to guide tailored fluid therapy, aiming to improve patient outcomes. A patient was admitted to the intensive care unit with symptoms of septic shock, including fever, severe hypotension, and altered mental status, secondary to a perforated ascending colon adenocarcinoma. The patient was diagnosed with perforated ascending colon adenocarcinoma, septic shock, and AKI. Clinical findings included elevated inflammatory markers and impaired renal function. The primary therapeutic interventions included surgical resection of the perforated colon, administration of broad-spectrum antibiotics, and fluid resuscitation. Fluid management was guided by continuous monitoring of IRVF, which facilitated precise adjustments to optimize fluid balance and renal perfusion. By utilizing IRVF patterns to guide fluid therapy, the patient's circulatory status and renal function significantly improved. The individualized fluid management approach contributed to better stabilization of the patient's condition. This case underscores the potential utility of IRVF patterns in guiding fluid management strategies for patients with sepsis and AKI. The main is the benefit of IRVF-guided fluid therapy in improving patient outcomes. Further research is warranted to validate the efficacy and safety of this approach, with the aim of enhancing clinical outcomes in critically ill patients.

The effect of high-volume intraoperative fluid administration on outcomes among pediatric patients undergoing living donor liver transplantation

BackgroundPediatric patients undergoing liver transplantation are particularly susceptible to complications arising from intraoperative fluid management strategies. Conventional liberal fluid administration has been challenged due to its association with increased perioperative morbidity. This study aimed to assess the impact of intraoperative high-volume fluid therapy on pediatric patients who are undergoing living donor liver transplantation (LDLT).MethodsConducted at the Children’s Hospital of Chongqing Medical University from March 2018 to April 2021, this retrospective study involved 90 pediatric patients divided into high-volume and non-high-volume fluid administration groups based on the 80th percentile of fluid administered. We collected the perioperative parameters and postoperative information of two groups. Multivariable logistic regression was utilized to assess the association between estimated blood loss (EBL) and high-volume FA. Kaplan-Meier survival analysis was used to compare patient survival after pediatric LDLT.ResultsPatients in the high-volume FA group received a higher EBL and longer length of stay than that in the non-high-volume FA group. Multivariate logistic regression analysis indicated that hours of maintenance fluids and fresh frozen plasma were significantly associated risk factors for the occurrence of EBL during pediatric LDLT. In addition, survival analysis showed no significant differences in one-year mortality between the groups.ConclusionsHigh-volume fluid administration during LDLT is linked with poorer intraoperative and postoperative outcomes among pediatric patients. These findings underscore the need for more conservative fluid management strategies in pediatric liver transplantations to enhance recovery and reduce complications.

Venous Excess Ultrasound for Fluid Assessment in Complex Cardiac Patients With Acute Kidney Injury.

The introduction of point-of-care ultrasound (POCUS) into clinical practice has revolutionized bedside hemodynamic assessment in recent years. POCUS has expanded its utility to include evaluating and grading venous congestion through Doppler analysis of venous blood flow. This innovative technique, VExUS (venous excess ultrasound), comprehensively evaluates venous congestion across multiple sites, including the inferior vena cava (IVC), hepatic vein, portal vein, and intrarenal vasculature. The aim of the current study was to determine whether venous excess ultrasound can help guide fluid therapy in complex patients with acute kidney injury (AKI) in addition to the standard physical examination and imaging. Our current study shows instructive 18 clinical adult cases (enrolled between January 2024 and May 2024) to determine whether venous excess ultrasound can help guide fluid therapy in complex cardiac patients with acute kidney injury, in addition to the standard physical examination and imaging. VExUS was pivotal in guiding fluid therapy in all complex patients with AKI and suspected right ventricular dysfunction. By integrating VExUS findings with clinical data and cardiac ultrasound results, clinicians were able to make patient-favouring decisions regarding fluid management, diuresis, and vasopressor therapy, addressing critical aspects of conditions such as septic shock, heart failure, and acute kidney injury. In our study of VExUSin sick patients with AKI, we concluded that VExUS proved to be a valuable tool for fluid assessment and management. By providing real-time visualization of venous congestion, VExUS allowed for more precise and individualized fluid management strategies. This led to improved decision-making regarding fluid administration and removal, helping to prevent both fluid overload and hypovolemia. Consequently, the use of VExUS contributed to better clinical outcomes in patients with AKI, demonstrating its potential as a critical component in the management of fluid balance in this vulnerable patient population.

Advanced fluid management strategies in burn patients undergoing general surgery: a comprehensive review

Fluid management in burn patients undergoing general surgery poses unique challenges due to the complex pathophysiological changes associated with burn injuries. Effective resuscitation and perioperative fluid therapy are critical in optimizing outcomes and minimizing complications in this vulnerable patient population. This review explores the latest evidence-based approaches to fluid management in burn patients, emphasizing the importance of individualized strategies that consider burn size, depth, patient age, comorbidities, and surgical factors. We examine the role of advanced hemodynamic monitoring, crystalloid versus colloid solutions, and the integration of goal-directed therapy protocols. Additionally, we discuss the implications of burn-related complications such as systemic inflammatory response syndrome (SIRS), sepsis, and multi-organ dysfunction on fluid management strategies. By synthesizing current research and clinical guidelines, this review aims to provide a comprehensive framework for clinicians to enhance perioperative care in burn patients undergoing general surgery.

Use of colloids and crystalloids for perioperative clinical infusion management in cardiac surgery patients and postoperative outcomes: a meta-analysis

BackgroundThe optimal fluid management strategy for patients undergoing cardiac surgery was controversial regarding fluid volume and intraoperative fluid types. This study aimed to assess the correlation between colloids and crystalloids used for perioperative fluid therapy in cardiac surgery patients and postoperative prognosis.MethodsThe Ovid MEDLINE(R) ALL, Embase, and Cochrane Central Register of Controlled Trials databases were searched for eligible studies on fluid management strategies using colloids and crystalloids for cardiac surgery patients published before August 25th, 2023.ResultsTen randomized controlled trials met the eligibility criteria. Compared to the use of crystalloids, the use of colloids, including hydroxyethyl starch (HES), albumin, and gelatine, did not show any differences in mortality, transfusion, acute kidney injury, and atrial fibrillation rates, postoperative blood loss, the length of hospital stay, or the length of intensive care unit (ICU) stay. The results of this meta-analysis showed that the crystalloid group had significantly reduced postoperative chest tube output compared to the colloid group. In the subgroup analysis, the amount of fresh frozen plasma (FFP) infused was significantly lower when using fluid management in the ICU and when using isotonic crystalloids compared to the colloids. In addition, when using fluid management in the ICU, patients in the colloid group had a significant increase in urine volume 24 h after surgery. However, other related factors, including the type of crystalloid solution, type of colloidal solution, and timing of liquid management, did not affect most outcomes.ConclusionBoth colloids and crystalloids could be used as alternatives for perioperative fluid management after cardiac surgery. The use of crystalloids significantly reduced the postoperative chest tube output, and the need for FFP infusion decreased significantly with the use of isotonic crystalloids or fluid management during the ICU stay. ICU patients in the colloid group had higher urine output 24 h after surgery. In addition, although the infusion method was not related to most outcomes, the rates of red blood cell and FFP transfusion and postoperative blood loss in the crystalloid group seemed to be lower, which needed to be further studied in high-quality and large-sample RCTs.Trial registrationPROSPERO, CRD42023415234.

Biomarker-guided acute kidney injury risk assessment under liberal versus restrictive fluid therapy - the prospective-randomized MAYDAY-trial

Acute kidney injury (AKI) prevalence in surgical patients is high, emphasizing the need for preventative measures. This study addresses the insufficient evidence on nephroprotective intraoperative fluid resuscitation and highlights the drawbacks of relying solely on serum creatinine/urine output to monitor kidney function. This study assessed the impact of intraoperative fluid management on AKI in female breast cancer patients undergoing autologous breast reconstruction, utilizing novel urinary biomarkers (TIMP-2 and IGFBP-7). In a monocentric prospective randomized controlled trial involving 40 patients, liberal (LFA) and restrictive (FRV) fluid management strategies were compared. TIMP-2 and IGFBP-7 biomarker levels were assessed using the NephroCheck (bioMerieux, France) test kit at preoperative, immediate postoperative, and 24-h postoperative stages. FRV showed significantly higher immediate postoperative biomarker levels, indicating renal tubular stress. FRV patients had 21% (4/19) experiencing AKI compared to 13% (2/15) in the LFA group according to KDIGO criteria (p = 0.385). Restrictive fluid resuscitation increases the risk of AKI in surgical patients significantly, emphasizing the necessity for individualized hemodynamic management. The findings underscore the importance of urinary biomarkers in early AKI detection.

Perioperative Fluid Management in Paediatric Liver Transplantation: A Systematic Review.

Perioperative fluid management remains a challenging aspect of paediatric liver transplantation (LT) because of the risk of postoperative complications and haemodynamic instability. Limited research has specifically investigated the impact of fluid management and transfusion on mortality and morbidity in pediatric LT patients. This systematic review summarizes the evidence regarding perioperative fluid management and its clinical outcomes in paediatric LT patients. All primary studies published in English evaluating perioperative fluid management in paediatric LT patients were eligible. PubMed, EBSCOHost, Embase, Proquest, and Google Scholar databases were searched from inception to December 19, 2023. Risks of bias were assessed using the Joanna-Briggs Institute checklist. The results were synthesized narratively. Five retrospective cohort studies of good-excellent quality were included in this review. Two studies evaluated intraoperative fluid administration, one study compared postoperative fluid balance (FB) with outcomes, and two studies compared massive versus non-massive transfusion. A higher mortality rate was associated with intravenous lactated ringer's (LR) than with normal saline, but not with massive transfusion (MT). Longer hospital stays were correlated with MT, >20% positive FB in the first 72 hours, and greater total intraoperative blood product administration. Higher intraoperative fluid administration was associated with a greater thrombotic risk. Additionally, intraoperative MT and lR infusion were associated with an increased risk of 30-day graft loss and graft dysfunction, respectively. Fluid management may impact the outcomes of paediatric LT recipients. These findings underscore the need for more studies to explore the best fluid management and evaluation strategies for children undergoing LT.

Identifying novel clinical phenotypes of acute respiratory distress syndrome using trajectories of daily fluid balance: a secondary analysis of randomized controlled trials

BackgroundPreviously identified phenotypes of acute respiratory distress syndrome (ARDS) could not reveal the dynamic change of phenotypes over time. We aimed to identify novel clinical phenotypes in ARDS using trajectories of fluid balance, to test whether phenotypes respond differently to different treatment, and to develop a simplified model for phenotype identification.MethodsFACTT (conservative vs liberal fluid management) trial was classified as a development cohort, joint latent class mixed models (JLCMMs) were employed to identify trajectories of fluid balance. Heterogeneity of treatment effect (HTE) for fluid management strategy across phenotypes was investigated. We also constructed a parsimonious probabilistic model using baseline data to predict the fluid trajectories in the development cohort. The trajectory groups and the probabilistic model were externally validated in EDEN (initial trophic vs full enteral feeding) trial.ResultsUsing JLCMM, we identified two trajectory groups in the development cohort: Class 1 (n = 758, 76.4% of the cohort) had an early positive fluid balance, but achieved negative fluid balance rapidly, and Class 2 (n = 234, 24.6% of the cohort) was characterized by persistent positive fluid balance. Compared to Class 1 patients, patients in Class 2 had significantly higher 60-day mortality (53.5% vs. 17.8%, p < 0.001), and fewer ventilator-free days (0 vs. 20, p < 0.001). A significant HTE between phenotypes and fluid management strategies was observed in the FACTT. An 8-variables model was derived for phenotype assignment.ConclusionsWe identified and validated two novel clinical trajectories for ARDS patients, with both prognostic and predictive enrichment. The trajectories of ARDS can be identified with simple classifier models.

#1384 Obstructive sleep apnea and fluid management in the hemodialysis: are clinicians putting existing scientific evidence into practice?

Abstract Background and Aims Obstructive Sleep Apnea (OSA) prevalence was found to be higher in an intermittent hemodialysis (iHD) population of the French-speaking Switzerland than in the general population of the same geographical area. The high prevalence of OSA in iHD patients was linked to fluid overload. Interdialytic fluid management targeting a low dry weight showed to reduce OSA's severity, offering a novel therapeutic option in this population. The aims of this study were: 1) to assess the prevalence of confirmed OSA in an end-stage renal disease (ESRD) population undergoing iHD in the Italian-speaking area of Switzerland; 2) to assess the awareness of the treating nephrologists about the OSA's diagnosis of their patients; and 3) to evaluate whether nephrologists integrate the current knowledge in their fluid management strategy of iHD patients with OSA. Method We performed a multicenter, cross-sectional study between July 2022 and July 2023, screening all patients attending the four iHD units of the Ente Ospedaliero Cantonale (EOC), the public hospital network of Canton Ticino (Switzerland), and including those with confirmed OSA. For these patients, we collected anthropometric parameters, iHD protocol characteristics and fluid status from electronic patient dossiers. Fluid overload was measured by multifrequency bioelectrical impedance (Body Composition Monitor®, BCM®; Fresenius Medical Care). Nephrologists of the four iHD units were asked to identify patients with known OSA diagnosis, without consulting the medical dossiers, and were interviewed about their specific iHD strategy in patients with OSA. We compared the fluid management of patients identified as “OSA positive” and those with OSA diagnosis, but misclassified as “OSA negative” by the treating nephrologist. Results Out of 193 patients treated by iHD in the four HD units, 45 patients had a confirmed diagnosis of OSA and were included in this study. Mean age was 76.0 ± 7.5 y, 82.2% were men, mean BMI was 29.1 ± 4.5 kg/m2. They were treated 3 times per week, in mean for 3.76 ± 0.37 hours; 22 were treated by hemodialysis and 23 by hemodiafiltration. The 23% prevalence of diagnosed OSA observed in the study population was significantly lower than the 56% prevalence found in the French Switzerland iHD cohort (p &amp;lt; 0.001). Out of the 45 patients with diagnosed OSA, only 27 (60.0%) were correctly identified by the treating nephrologist. We found no difference in the dry weight target defined by the treating nephrologist between the patients correctly identified as “OSA positive” and those misclassified as “OSA negative”, both being close to the dry weight calculated with BCM® (mean difference 0.7 ± 2.3 vs 0.3 ± 1.4 kg; p = 0.564). The pre-dialysis fluid overload of the whole population was 2.4 ± 1.7 kg, being higher in the “OSA positive” group (2.9 ± 2.0 kg) than in the “OSA negative” group (1.8 ± 0.7 kg; p = 0.0172). However, we found no difference in post-dialysis achievement of dry weight between the groups (residual overweight 0.2 ± 1.0 and 0.1 ± 0.7 kg respectively; p = 0.672). In the interviews, only half of the nephrologists (4/8) were aware of the correlation between fluid overload and OSA, and two of them reported to integrate this knowledge in their fluid management strategy, even if not systematically. Conclusion Nephrologists' attention to sleep apnea in iHD patients seems to be low, despite its high prevalence in this population and scientific evidence supporting that targeting fluid overload is an effective option to improve OSA severity. However, nephrologists tried to achieve the dry weight very strictly in all patients, independently of OSA. More intensive training of nephrologists to the clinical and diagnostic peculiarities of OSA in patients with ESKD is required, in order to improve OSA diagnosis and targeted therapeutic care.

An observational prospective cross-sectional study on extravascular lung water by lung ultrasound as a guide to fluid resuscitation therapy in adult septic shock in tertiary care hospital in central India

Background Septic shock is a life-threatening condition characterized by systemic inflammation and organ dysfunction, with fluid resuscitation being a cornerstone of management. However, indiscriminate fluid administration can lead to fluid overload and worsen outcomes. Extravascular lung water (EVLW) estimation by lung ultrasound has emerged as a promising tool for guiding fluid therapy in septic shock, allowing clinicians to assess pulmonary edema and tailor resuscitation strategies accordingly. Methods This prospective observational study aims to evaluate the utility of EVLW estimation by lung ultrasound in guiding fluid resuscitation therapy in adult patients with septic shock admitted to a rural tertiary care teaching hospital. Eligible patients admitted to the intensive care unit (ICU) will undergo baseline demographic and clinical assessments, including lung ultrasound, to quantify EVLW using B-line analysis. Fluid resuscitation therapy will be initiated based on EVLW findings, with subsequent adjustments guided by repeat lung ultrasound examinations at 6, 12, 24, and 48 hours post-initiation. Outcome measures include changes in mean PaO2/FiO2 ratios, respiratory parameters, renal function, fluid balance, and mortality rates. Expected Outcome We anticipate that EVLW-guided fluid resuscitation therapy will lead to more precise and tailored management of septic shock, potentially reducing the incidence of fluid overload, ARDS, and renal dysfunction. By optimizing fluid management strategies based on individual patient characteristics and responses, we aim to improve clinical outcomes and enhance the delivery of care for patients with septic shock.

Renal implications of pneumoperitoneum in laparoscopic surgery: mechanisms, risk factors, and preventive strategies.

Pneumoperitoneum, which is established for laparoscopic surgery, has systemic implications on the renal system and may contribute to acute kidney injury or postoperative renal dysfunction. Specifically, when the pressure exceeds 10 mmHg, pneumoperitoneum decreases renal blood flow, leading to renal dysfunction and temporary oliguria. The renal effects of pneumoperitoneum stem from both the direct effects of increased intra-abdominal pressure and indirect factors such as carbon dioxide absorption, neuroendocrine influences, and tissue damage resulting from oxidative stress. While pneumoperitoneum can exacerbate renal dysfunction in patients with pre-existing kidney issues, preserving the function of the remaining kidney is crucial in certain procedures such as laparoscopic live donor nephrectomy. However, available evidence on the effects of pneumoperitoneum on renal function is limited and of moderate quality. This review focuses on exploring the pathophysiological hypotheses underlying kidney damage, mechanisms leading to oliguria and kidney damage, and fluid management strategies for surgical patients during pneumoperitoneum.

The effect of goal-directed crystalloid versus colloid administration on postoperative spirometry parameters: a substudy of a randomized controlled clinical trial

BackgroundPulmonary function is impaired after major abdominal surgery and might be less impaired by restrictive fluid administration. Under the assumption of a fluid-sparing effect of colloids, we tested the hypothesis that an intraoperative colloid-based goal-directed fluid management strategy impairs postoperative pulmonary function parameters less compared to goal-directed crystalloid administration.MethodsWe performed a preplanned, single-center substudy within a recently published trial evaluating the effect of goal-directed crystalloids versus colloids on a composite of major complications. Sixty patients undergoing major open abdominal surgery were randomized to Doppler-guided intraoperative fluid replacement therapy with lactated Ringer’s solution (n = 31) or unbalanced 6% hydroxyethyl starch 130/0.4 (n = 29). A blinded investigator performed bedside spirometry (Spirobank-G, Medical International Research, Rome, Italy) preoperatively as well as 6, 24, and 48 h postoperatively.ResultsMedian total intraoperative fluid requirements were significantly higher during crystalloid administration compared to patients receiving colloids (4567 ml vs. 3044 ml, p = 0.01). Six hours after surgery, pulmonary function parameters did not differ significantly between the crystalloid — and the colloid group: forced vital capacity (FVC): 1.6 l (1.2–2 l) vs. 1.9 l (1.5–2.4 l), p = 0.15; forced expiratory volume in 1 second (FEV1): 1.1 l (0.9–1.6 l) vs. 1.4 l (1.2–1.7 l), p = 0.18; and peak expiratory flow (PEF): 2 l.sec−1 (1.5 – 3.6 l.sec −1) vs. 2.3 l.sec −1 (1.8 – 3.4 l.sec −1), p = 0.23. Moreover, postoperative longitudinal time × group interactions of FVC, FEV1, and PEF between 6 and 48 postoperative hours did not differ significantly.ConclusionPostoperative pulmonary function parameters were similarly impaired in patients receiving goal-directed crystalloid administration as compared to goal-directed colloid administration during open abdominal surgery.Trial registrationClinicalTrials.gov (NCT00517127, registered on August 16, 2007) and EudraCT (2005-004602-86).

Management Changes After Echocardiography Are Associated With Improved Outcomes in Critically Ill Children.

To evaluate management changes and outcomes in critically ill children after formal echocardiography. Retrospective cohort study between January 1, 2011, and December 31, 2020. Tertiary care children's hospital. Patients from 1 to 18 years who had formal echocardiography within 72 hours of ICU admission and who were intubated and on vasoactive infusions at the time of the study. Patients were stratified into two cardiac function groups: 1) near-normal cardiac function and 2) depressed cardiac function. Clinical variables were abstracted from the electronic medical record and placed in time sequence relative to echocardiography. Vasoactive and fluid management strategies in place before echocardiography were associated with markers of tissue perfusion and volume overload. Management changes after echocardiography were characterized and associated with outcomes. None. Among patients eventually found to have depressed cardiac function, the use of vasoconstrictors was associated with worse lactate clearance and oxygen extraction ratio. Use of vasoconstrictors in this cohort was also associated with a more liberal fluid management strategy, evidence of increased lung water, and a worse Sp o2 /F io2 . An echocardiogram demonstrated depressed cardiac function was likely to be followed by management changes that favored inotropes and more conservative fluid administration. Patients with depressed cardiac function who were switched to inotropes were more likely to be extubated and to wean off vasoactive support compared with those patients who remained on vasoconstrictors. Among patients with depressed cardiac function, alterations in management strategy after echocardiography are associated with shortened duration of intensive care interventions.

Contemporary fluid management, humidity, and patent ductus arteriosus management strategy for premature infants among 336 hospitals in Asia.

The management of patent ductus arteriosus (PDA) is a critical concern in premature infants, and different hospitals may have varying treatment policies, fluid management strategies, and incubator humidity. The Asian Neonatal Network Collaboration (AsianNeo) collected data on prematurity care details from hospitals across Asian countries. The aim of this study was to provide a survey of the current practices in the management of PDA in premature infants in Asian countries. AsianNeo performed a cross-sectional international questionnaire survey in 2022 to assess the human and physical resources of hospitals and clinical management of very preterm infants. The survey covered various aspects of hospitals resources and clinical management, and data were collected from 337 hospitals across Asia. The data collected were used to compare hospitals resources and clinical management of preterm infants between areas and economic status. The policy of PDA management for preterm infants varied across Asian countries in AsianNeo. Hospitals in Northeast Asia were more likely to perform PDA ligation (p < 0.001) than hospitals in Southeast Asia. Hospitals in Northeast Asia had stricter fluid restrictions in the first 24 h after birth for infants born at <29 weeks gestation (p < 0.001) and on day 14 after birth for infants born at <29 weeks gestation (p < 0.001) compared to hospitals in Southeast Asia. Hospitals in Northeast Asia also had a more humidified environment for infants born between 24 weeks gestation and 25 weeks gestation in the first 72 h after birth (p < 0.001). A logistic regression model predicted that hospitals were more likely to perform PDA ligation for PDA when the hospitals had a stricter fluid planning on day 14 after birth [Odds ratio (OR) of 1.70, p = 0.048], more incubator humidity settings (<80% vs. 80%-89%, OR of 3.35, p = 0.012 and <80% vs. 90%-100%, OR of 5.31, p < 0.001). In advanced economies and Northeast Asia, neonatologists tend to adopt a more conservative approach towards fluid management, maintain higher incubator humidity settings and inclined to perform surgical ligation for PDA.

The impact of goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing thoracic surgery: a systematic review and meta-analysis.

Pulmonary complications after thoracic surgery are common and associated with significant morbidity and high cost of care. Goal-directed fluid therapy (GDFT) could reduce the incidence of postoperative pulmonary complications (PPCs) and facilitate recovery in patients undergoing major abdominal surgery. However, whether GDFT could reduce the incidence of PPCs in patients undergoing thoracic surgery was unclear. The present meta-analysis was designed to assess the impact of Goal-directed Fluid Therapy on PPCs in patients undergoing thoracic surgery. Randomized controlled trials (RCTs) comparing GDFT with other conventional fluid management strategies in adult patients undergoing thoracic surgery were identified. Databases searched included PubMed, Web of Science, Embase, and Cochrane Library databases. Review Manager 5.4 (The Cochrane Collaboration, Oxford, UK) software was used for statistical analysis. Heterogeneity was analyzed using I2 statistics, and a standardized mean difference with 95% CI and P value was used to calculate the treatment effect for outcome variables. The primary study outcomes were the incidence of PPCs. Secondary outcomes were the total volume infused, the length of hospitalization, the incidence of cardiac complications, and the incidence of renal dysfunction. Subgroup analysis was planned to verify the definite role of GDFT. A total of 6 RCTs consisting of 680 patients were included in this meta-analysis, which revealed that GDFT did not reduce the incidence of PPCs in patients undergoing thoracic surgery (RR, 0.57; 95% CI 0.29-1.14). However, GDFT decreased the total intra-operative fluid input (MD, - 244.40ml; 95% CI - 397.06 to - 91.74). There was no statistical difference in the duration of hospitalization (MD; - 1.31, 95% CI - 3.00 to 0.38), incidence of renal dysfunction (RR, 0.62; 95% CI 0.29-1.35), and incidence of cardiac complications (RR, 0.62; 95% CI 0.27-1.40). The results of this meta-analysis indicate that GDFT did not reduce the postoperative incidence of pulmonary complications in individuals undergoing thoracic surgery. However, considering the small number of contributing studies, these results should be interpreted with caution.

Initial Experience of Anesthetic Management in Combined Liver-Kidney Transplantation: A Case Report

In this case report, we present a successful combined liver-kidney transplantation (CLKT) performed on a 41-year-old female with end-stage liver and renal disease. The patient, previously undergoing liver transplantation and regular hemodialysis, underwent CLKT with a focus on specific anesthesia management strategies. Key aspects included the use of desflurane for anesthesia, balanced crystalloid solutions for fluid management, and careful monitoring of hemodynamics without intraoperative renal replacement therapy. Despite substantial intraoperative fluid and blood product administration, careful management ensured stable vital signs and acid-base balance. The patient's postoperative recovery was notable for significant improvements in liver and renal functions, demonstrated by decreased creatinine and bilirubin levels, and improved estimated glomerular filtration rate, without the need for postoperative dialysis. This case underscores the effectiveness of CLKT in patients with concurrent liver and renal dysfunction, highlighting the importance of tailored anesthesia and fluid management strategies. The report contributes to the limited literature on anesthesia in CLKT, providing insights for better outcomes in such complex surgical procedures.

Perspectives on fluid overload management among caregivers of end-stage renal disease patients undergoing hemodialysis

Background: Fluid overload is a significant problem often encountered in patients with end-stage renal disease. If not properly managed, it can have multiple adverse effects on a patient's health or may even be life-threatening. Objectives: This qualitative study explored the perspectives of caregivers concerning fluid overload management in end-stage renal disease (ESRD) patients undergoing hemodialysis. Methods: Eighteen caregivers, selected based on direct caregiving responsibilities and willingness to share their experiences were interviewed at Maharaj Nakorn Chiang Mai Hospital, Thailand, from January to April 2022. Data was collected through in-depth interviews. Thematic content analysis revealed varying degrees of knowledge and misconceptions among caregivers about fluid management strategies. Results: Some participants demonstrated a comprehensive understanding of dietary modifications, medication adherence, and lifestyle adjustments, recognizing their importance in maintaining fluid balance. However, gaps and misconceptions were identified with some caregivers lacking knowledge of specific strategies or believing that solely restricting fluid intake was sufficient. Participants underscored the pivotal role of healthcare professionals in guiding and supporting them emphasized the need for clear instructions, educational materials, and continuous communication. Conclusion: The findings highlighted the need to improve caregivers' knowledge and understand the significant role of healthcare providers in equipping caregivers with necessary information and skills. These insights can guide healthcare providers in tailoring education and support strategies to improve fluid overload management in ESRD patients. Further studies should explore the development and evaluation of targeted educational interventions for caregivers.