Fluid Management Strategy Research Articles

Non-specialist therapeutic strategies in acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. We undertook a meta-analysis of randomized controlled trials (RCTs) to determine the mortality benefit of non-specialist therapeutic interventions for ARDS available to general critical care units. A systematic search of MEDLINE, Embase, and the Cochrane Central Register for RCTs investigating therapeutic interventions in ARDS including corticosteroids, fluid management strategy, high PEEP, low tidal volume ventilation, neuromuscular blockade, prone position ventilation, or recruitment maneuvers. Data was collected on demographic information, treatment strategy, duration and dose of treatment, and primary (28 or 30-day mortality) and secondary (P<inf>a</inf>O<inf>2</inf>:FiO<inf>2</inf> ratio at 24-48 hours) outcomes. No improvement in 28-day mortality could be demonstrated in three RCTs investigating high PEEP (28.0% vs. 30.2% control; risk ratio [confidence interval] 0.93 [0.82-1.06]; eight assessing prone position ventilation (39.3% vs. 44.5%; RR 0.83 [0.68-1.01]; seven investigating neuromuscular blockade (37.8% vs. 42.0%; RR 0.91 [0.81-1.03]); ten investigating recruitment maneuvers (42.4% vs. 42.1%; RR 1.01 [0.91-1.12]); eight investigating steroids (34.8% vs. 41.1%; RR 0.81 [0.59-1.12]); and one investigating conservative fluid strategies (25.4% vs. 28.4%; RR 0.90 [0.73-1.10]). Three studies assessing low tidal volume ventilation (33.1% vs. 41.9%; RR 0.79 (0.68-0.91); P=0.001), and subgroup analyses within studies investigating prone position ventilation greater than 12 hours (33.1% vs. 44.4%; RR 0.75 [0.59-0.95), P=0.02) did reveal outcome benefit. Among non-specialist therapeutic strategies available to general critical care units, low tidal volumes and prone position ventilation for greater than 12 hours improve mortality in ARDS.

A Multicenter, Open-Label, Randomized Controlled Trial of a Conservative Fluid Management Strategy Compared With Usual Care in Participants After Cardiac Surgery: The Fluids After Bypass Study.

There is little evidence to guide fluid administration to patients admitted to the ICU following cardiac surgery. This study aimed to determine if a protocolized strategy known to reduce fluid administration when compared with usual care reduced ICU length of stay following cardiac surgery. Prospective, multicenter, parallel-group, randomized clinical trial. Five cardiac surgical centers in New Zealand conducted from November 2016 to December 2018 with final follow-up completed in July 2019. Seven-hundred fifteen patients undergoing cardiac surgery; 358 intervention and 357 usual care. Randomization to protocol-guided strategy utilizing stroke volume variation to guide administration of bolus fluid or usual care fluid administration until desedation or up to 24 hours. Primary outcome was length of stay in ICU. Organ dysfunction, mortality, process of care measures, patient-reported quality of life, and disability-free survival were collected up to day 180. Overall 666 of 715 (93.1%) received at least one fluid bolus. Patients in the intervention group received less bolus fluid (median [interquartile range], 1,000 mL [250-2,000 mL] vs 1,500 mL [500-2,500 mL]; p < 0.0001) and had a lower overall fluid balance (median [interquartile range], 319 mL [-284 to 1,274 mL] vs 673 mL [38-1,641 mL]; p < 0.0001) in the intervention period. There was no difference in ICU length of stay between the two groups (27.9 hr [21.8-53.5 hr] vs 25.6 hr [21.9-64.6 hr]; p = 0.95). There were no differences seen in development of organ dysfunction, quality of life, or disability-free survival at any time points. Hospital mortality was higher in the intervention group (4% vs 1.4%; p = 0.04). A protocol-guided strategy utilizing stroke volume variation to guide administration of bolus fluid when compared with usual care until desedation or up to 24 hours reduced the amount of fluid administered but did not reduce the length of stay in ICU.

Pragmatic Recommendations for the Prevention and Treatment of Acute Kidney Injury in Patients with COVID-19 in Low- and Middle-Income Countries.

.Current recommendations for the management of patients with COVID-19 and acute kidney injury (AKI) are largely based on evidence from resource-rich settings, mostly located in high-income countries. It is often unpractical to apply these recommendations to resource-restricted settings. We report on a set of pragmatic recommendations for the prevention, diagnosis, and management of patients with COVID-19 and AKI in low- and middle-income countries (LMICs). For the prevention of AKI among patients with COVID-19 in LMICs, we recommend using isotonic crystalloid solutions for expansion of intravascular volume, avoiding nephrotoxic medications, and using a conservative fluid management strategy in patients with respiratory failure. For the diagnosis of AKI, we suggest that any patient with COVID-19 presenting with an elevated serum creatinine level without available historical values be considered as having AKI. If serum creatinine testing is not available, we suggest that patients with proteinuria should be considered to have possible AKI. We suggest expansion of the use of point-of-care serum creatinine and salivary urea nitrogen testing in community health settings, as funding and availability allow. For the management of patients with AKI and COVID-19 in LMICS, we recommend judicious use of intravenous fluid resuscitation. For patients requiring dialysis who do not have acute respiratory distress syndrome (ARDS), we suggest using peritoneal dialysis (PD) as first choice, where available and feasible. For patients requiring dialysis who do have ARDS, we suggest using hemodialysis, where available and feasible, to optimize fluid removal. We suggest using locally produced PD solutions when commercially produced solutions are unavailable or unaffordable.

Excessive positive fluid balance has a negative effect on short-term renal outcomes after kidney transplantation

Background: Optimized postoperative fluid management is important in maintaining early allograft function after kidney trans plantation (KT). However, there is still no clear guidance on how to treat fluid after KT. In this study, we investigated the effect of fluid balance on postoperative allograft function. Methods: Recipients underwent KT between March 2012 and August 2018 were included and their medical records were re viewed retrospectively. We calculated fluid balance, which is the difference between total input and output during 3 days after KT, and analyzed the change of estimated glomerular filtration rate (eGFR) according to fluid balance. Results: A total of 178 patients were included, except those with delayed graft function or urine output less than 2,000 mL on the first day after KT. Among them, 116 received kidneys from living donors and 62 from deceased donors. The total fluid balance up to day 3 was 4,236.9±2,830.4 mL. Old age, high body mass index (BMI), excessive positive fluid balance of recipient and high final creatinine of donor were significantly associated with low eGFR at 1 week. In addition, age, BMI, and fluid balance predict ed 1-month eGFR. In multivariate analysis, an excessive positive fluid balance was an independent factor to predict low 1-week eGFR (P=0.031). In particular, this positive correlation was evident in the living donor KT recipients, suggesting that excessive positive fluid balance at early postoperative period can delay functional recovery of the transplanted kidney, regardless of donor kidney status. Conclusions: We have demonstrated that excessive positive fluid balance can negatively affect early graft function after KT. Therefore proper fluid management strategies based on volume conditions may provide new therapeutic opportunities to im prove early renal outcomes after KT.

Abstract 16766: Intraprocedural Ablation and Fluid Status Management in Heart Failure Patients Undergoing Catheter Ablation for Atrial Fibrillation

Background: Recent randomized clinical trial data has supported catheter ablation (CA) of atrial fibrillation (AF) in patients with heart failure (HF). Ablation and fluid management strategies could impact periprocedural outcomes especially in HF patients. Methods: We conducted a single-center retrospective analysis of 200 consecutive patients with and without HF undergoing CA at a tertiary care academic center from July 2017 through June 2018. HF was defined as any EF &lt; 40%, prior inpatient admission for HF exacerbation, or ambulatory management of HF confirmed by independent chart review. Diuretic regimens were reported as furosemide equivalent. Results: Among 200 patients, 65 (32.5%) had HF and 135 (67.5%) did not. HF patients had longer mean procedure times (299.8 ± 96 min vs 268.4 ± 96 min, p = 0.03) and were more likely to require mitral isthmus (p &lt; 0.001), posterior wall isolation (p = 0.002), and cavotriscupid isthmus (p = 0.004) ablations. There were no differences between the HF vs. non-HF groups’ intraprocedural volume intake, intraprocedural volume output, net fluid status, or intraprocedural diuretic dose (Table 1). HF patients received higher doses of IV (41.5 ± 43.0 mg vs 23.6 ± 11.8 mg, p = 0.007) and PO (43.2 ± 16.7 mg vs 26.7 ± 10.0 mg, p &lt; 0.001) postprocedural diuretic. There were no differences in the rates of major in-hospital complications (Table 1). In a multivariable regression analysis adjusted for procedural covariates, there were higher proportions of posterior wall isolation (p = 0.01) as well as postprocedural PO (p = 0.01) and IV diuretic (p = 0.002) administration in the HF cohort. Conclusion: Intraprocedural volume and diuretic management was similar between HF and non-HF patients undergoing CA of AF, though HF patients tended to receive more aggressive diuresis post procedurally with no difference in complications. Table 1. Intra- and post-procedural management and outcomes in HF vs non-HF patients undergoing CA for AF

The application progress of fluid de-escalation therapy in abdominal infection-induced septic shock

After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.

Individualized fluid administration for critically ill patients with sepsis with an interpretable dynamic treatment regimen model

Fluid strategy is the key to the successful management of patients with sepsis. However, previous studies failed to consider individualized treatment strategy, and clinical trials typically included patients with sepsis as a homogeneous study population. We aimed to develop sequential decision rules for managing fluid intake in patients with sepsis by using the dynamic treatment regimen (DTR) model. A retrospective analysis of the eICU Collaborative Research Database comprising highly granular data collected from 335 units at 208 hospitals was performed. The DTR model used a backward induction algorithm to estimate the sequence of optimal rules. 22,868 patients who had sepsis according to the Acute Physiology and Chronic Health Evaluation (APACHE) IV diagnosis group were included. Optimal fluid management (liberal [> 40 ml/kg/d] versus restricted [< 40 ml/kg/d]) strategy were developed on the Day 1, 3 and 5 after ICU admission according to current states and treatment history. Important determinants of optimal fluid strategy included mean blood pressure, heart rate, previous urine output, previous fluid strategy, ICU type and mechanical ventilation. Different functional forms such as quadratic function and interaction terms were used at different stages. The proportion of subjects being inappropriately treated with liberal fluid strategy (i.e. those actually received liberal fluid strategy, but could have longer survival time if they received restricted fluid strategy) increased from day 1 to 5 (19.3% to 29.5%). The survival time could be significantly prolonged had all patients been treated with optimal fluid strategy (5.7 [2.0, 5.9] vs. 4.1 [2.0, 5.0] days; p < 0.001). With a large volume of sepsis data, we successfully computed out a sequence of dynamic fluid management strategy for sepsis patients over the first 5 days after ICU admission. The decision rules generated by the DTR model predicted a longer survival time compared to the true observed strategy, which sheds light for improving patient outcome with the aim from computer-assisted algorithm.

A Higher Fluid Balance in the Days After Septic Shock Reversal Is Associated With Increased Mortality: An Observational Cohort Study.

Previous studies demonstrated that extensive fluid loading and consequently positive fluid balances during sepsis resuscitation are associated with adverse outcome. Yet, the association between fluid balance and mortality after reversal of shock, that is, during deresuscitation, is largely unappreciated. Our objective was to investigate the effects of fluid balance on mortality in the days after septic shock reversal. Retrospective observational cohort study. ICUs of two university-affiliated hospitals in The Netherlands. Adult patients admitted with septic shock followed by shock reversal. Reversal of septic shock was defined based on Sepsis-3 criteria as the first day that serum lactate was less than or equal to 2 mmol/L without vasopressor requirement. None. Reversal of septic shock occurred in 636 patients, of whom 20% died in the ICU. Mixed-effects logistic regression modeling, adjusted for possible confounders, showed that fluid balance in the days after reversal of septic shock (until discharge or death) was an independent predictor of ICU mortality: odds ratio 3.18 (1.90-5.32) per 10 mL/kg increase in daily fluid balance. Similar results were found for 30-day, 90-day, hospital, and 1-year mortality: odds ratios 2.09 (1.64-2.67); 1.79 (1.38-2.32); 1.70 (1.40-2.07); and 1.53 (1.17-2.01), respectively. Positive cumulative fluid balances vs. neutral or negative fluid balances on the final day in the ICU were associated with increased ICU, hospital, 30-day, and 90-day mortality: odds ratios 3.46 (2.29-5.23); 3.39 (2.35-4.9); 5.33 (3.51-8.08); and 3.57 (2.49-5.12), respectively. Using restricted cubic splines, we found a dose-response relationship between cumulative fluid balance after shock reversal and ICU mortality. A higher fluid balance in the days after septic shock reversal was associated with increased mortality. This stresses the importance of implementing restrictive and deresuscitative fluid management strategies after initial hemodynamic resuscitation. Prospective interventional studies are needed to confirm our results.

Fluid Management in Patients with Acute Respiratory Distress Syndrome and Diabetes Mellitus: A propensity score matched analysis of the fluid and catheter treatment trial.

Diabetes mellitus results in an attenuated inflammatory response, reduces pulmonary microvascular permeability, and may decrease the risk of developing acute respiratory distress syndrome (ARDS). Studies have shown that patients with ARDS are better managed by a conservative as compared to liberal fluid management strategy. However, it is not known if the same fluid management principles hold true for patients with comorbid diabetes mellitus and ARDS.As diabetes mellitus results in reduced pulmonary microvascular permeability and an attenuated inflammatory response, we hypothesize that in the setting of ARDS, diabetic patients will be able to tolerate a positive fluid balance better than patients without diabetes.The Fluid and Catheter Treatment Trial (FACTT) randomized patients with ARDS to conservative versus liberal fluid management strategies. In a secondary analysis of this trial, we calculated the interaction of diabetic status and differing fluid strategies on outcomes. Propensity score subclassification matching was used to control for the differing baseline characteristics between patients with and without diabetes.Nine hundred fifty-six patients were analyzed. In a propensity score matched analysis, the difference in the effect of a conservative as compared to liberal fluid management strategy on ventilator free days was 2.23 days (95% CI: -0.97 to 5.43 days) in diabetic patients, and 2.37 days (95% CI: -0.21 to 4.95 days) in non-diabetic patients. The difference in the effect of a conservative as compared to liberal fluid management on 60 day mortality was 2% (95% CI: -11.8% to 15.8%) in diabetic patients, and -7.9% (95% CI: -21.7% to 5.9%) in non-diabetic patients.When comparing a conservative fluid management strategy to a liberal fluid management strategy, diabetic patients with ARDS did not have a statistically significant difference in outcomes than non-diabetic patients.

Critically Ill Adults With Coronavirus Disease 2019 in New Orleans and Care With an Evidence-Based Protocol

BackgroundCharacteristics of critically ill adults with coronavirus disease 2019 (COVID-19) in an academic safety net hospital and the effect of evidence-based practices in these patients are unknown.Research QuestionWhat are the outcomes of critically ill adults with COVID-19 admitted to a network of hospitals in New Orleans, Louisiana, and what is an evidence-based protocol for care associated with improved outcomes?Study Design and MethodsIn this multi-center, retrospective, observational cohort study of ICUs in four hospitals in New Orleans, Louisiana, we collected data on adults admitted to an ICU and tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 9, 2020 and April 14, 2020. The exposure of interest was admission to an ICU that implemented an evidence-based protocol for COVID-19 care. The primary outcome was ventilator-free days.ResultsThe initial 147 patients admitted to any ICU and tested positive for SARS-CoV-2 constituted the cohort for this study. In the entire network, exposure to an evidence-based protocol was associated with more ventilator-free days (25 days; 0-28) compared with non-protocolized ICUs (0 days; 0-23, P = .005), including in adjusted analyses (P = .02). Twenty patients (37%) admitted to protocolized ICUs died compared with 51 (56%; P = .02) in non-protocolized ICUs. Among 82 patients admitted to the academic safety net hospital’s ICUs, the median number of ventilator-free days was 22 (interquartile range, 0-27) and mortality rate was 39%.InterpretationCare of critically ill COVID-19 patients with an evidence-based protocol is associated with increased time alive and free of invasive mechanical ventilation. In-hospital survival occurred in most critically ill adults with COVID-19 admitted to an academic safety net hospital’s ICUs despite a high rate of comorbidities.

EXCESSIVE POSITIVE FLUID BALANCE HAS A NEGATIVE EFFECT ON SHORT-TERM RENAL OUTCOMES AFTER KIDNEY TRANSPLANTATION

Background: Optimized postoperative fluid management is important in maintaining early allograft function after kidney trans plantation (KT). However, there is still no clear guidance on how to treat fluid after KT. In this study, we investigated the effect of fluid balance on postoperative allograft function. Methods: Recipients underwent KT between March 2012 and August 2018 were included and their medical records were re viewed retrospectively. We calculated fluid balance, which is the difference between total input and output during 3 days after KT, and analyzed the change of estimated glomerular filtration rate (eGFR) according to fluid balance. Results: A total of 178 patients were included, except those with delayed graft function or urine output less than 2,000 mL on the first day after KT. Among them, 116 received kidneys from living donors and 62 from deceased donors. The total fluid balance up to day 3 was 4,236.9±2,830.4 mL. Old age, high body mass index (BMI), excessive positive fluid balance of recipient and high final creatinine of donor were significantly associated with low eGFR at 1 week. In addition, age, BMI, and fluid balance predict ed 1-month eGFR. In multivariate analysis, an excessive positive fluid balance was an independent factor to predict low 1-week eGFR (P=0.031). In particular, this positive correlation was evident in the living donor KT recipients, suggesting that excessive positive fluid balance at early postoperative period can delay functional recovery of the transplanted kidney, regardless of donor kidney status. Conclusions: We have demonstrated that excessive positive fluid balance can negatively affect early graft function after KT. Therefore proper fluid management strategies based on volume conditions may provide new therapeutic opportunities to im prove early renal outcomes after KT.

Effects of intraoperative hemodynamic management on postoperative acute kidney injury in liver transplantation: An observational cohort study.

Intraoperative restrictive fluid management strategies might improve postoperative outcomes in liver transplantation. Effects of vasopressors within any hemodynamic management strategy are unclear. We conducted an observational cohort study on adult liver transplant recipients between July 2008 and December 2017. We measured the effect of vasopressors infused at admission in the intensive care unit (ICU) and total intraoperative fluid balance. Our primary outcome was 48-hour acute kidney injury (AKI) and our secondary outcomes were 7-day AKI, need for postoperative renal replacement therapy (RRT), time to extubation in the ICU, time to ICU discharge and survival up to 1 year. We fitted models adjusted for confounders using generalized estimating equations or survival models using robust standard errors. We reported results with 95% confidence intervals. We included 532 patients. Vasopressors use was not associated with 48-hour or 7-day AKI but modified the effects of fluid balance on RRT and mortality. A higher fluid balance was associated with a higher need for RRT (OR = 1.52 [1.15, 2.01], p<0.001 for interaction) and lower survival (HR = 1.71 [1.26, 2.34], p<0.01 for interaction) only among patients without vasopressors. In patients with vasopressors, higher doses of vasopressors were associated with a higher mortality (HR = 1.29 [1.13, 1.49] per 10 μg/min of norepinephrine). The presence of any vasopressor at the end of surgery was not associated with AKI or RRT. The use of vasopressors might modify the harmful association between fluid balance and other postoperative outcomes. The liberal use of vasopressors to implement a restrictive fluid management strategy deserves further investigation.

Changes in transfusion and fluid therapy practices in severely injured children: an analysis of 5118 children from the TraumaRegister DGU\xae

PurposeTrauma is the leading cause of death in children. In adults, blood transfusion and fluid resuscitation protocols changed resulting in a decrease of morbidity and mortality over the past 2 decades. Here, transfusion and fluid resuscitation practices were analysed in severe injured children in Germany.MethodsSeverely injured children (maximum Abbreviated Injury Scale (AIS) ≥ 3) admitted to a certified trauma-centre (TraumaZentrum DGU®) between 2002 and 2017 and registered at the TraumaRegister DGU® were included and assessed regarding blood transfusion rates and fluid therapy.Results5,118 children (aged 1–15 years) with a mean ISS 22 were analysed. Blood transfusion rates administered until ICU admission decreased from 18% (2002–2005) to 7% (2014–2017). Children who are transfused are increasingly seriously injured. ISS has increased for transfused children aged 1–15 years (2002–2005: mean 27.7–34.4 in 2014–2017). ISS in non-transfused children has decreased in children aged 1–15 years (2002–2005: mean 19.6 to mean 17.6 in 2014–2017). Mean prehospital fluid administration decreased from 980 to 549 ml without affecting hemodynamic instability.ConclusionBlood transfusion rates and amount of fluid resuscitation decreased in severe injured children over a 16-year period in Germany. Restrictive blood transfusion and fluid management has become common practice in severe injured children. A prehospital restrictive fluid management strategy in severely injured children is not associated with a worsened hemodynamic state, abnormal coagulation or base excess but leads to higher hemoglobin levels.

Reposição de volume orientada pela variação da pressão de pulso durante transplante renal: estudo randomizado controlado

PurposeKidney transplantation is the gold‐standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV‐guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the PPV Group received fluids whenever PPV was higher than 12%, patients in the Free Fluid Group received fluids following our institutional standard care protocol for kidney transplantations (10mL.kg‐1.h‐1). ResultsUrinary output was similar at every time‐point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. ConclusionPPV‐guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial

PurposeKidney transplantation is the gold-standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the “PPV” group received fluids whenever PPV was higher than 12%, patients in the “free fluid” group received fluids following our institutional standard care protocol for kidney transplantations (10 mL.kg-1. h-1). ResultsUrinary output was similar at every time-point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. ConclusionPPV guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Recognition, Treatment, and Monitoring of Canine Hypovolemic Shock in First Opinion Practice in the United Kingdom

The aim of this study was to gain a greater understanding of the detection, treatment, and monitoring of hypovolemic shock (HVS) in dogs by general practitioners in the United Kingdom (UK). An online survey was devised and distributed by email to first opinion practices in the UK. All veterinarians working in first opinion practice treating small animals were eligible to complete the survey. Most respondents (n = 164, 93%) were confident with HVS diagnosis. Isotonic crystalloid fluids were the most common fluid type for first-line treatment and administered as a 10-30 mL/kg bolus over 10-30 minutes by 57% respondents. Initial intravenous isotonic crystalloid fluid rates for HVS management ranged from maintenance fluid requirements to 90 mL/kg/hr for an undefined time period. A synthetic colloid was the most popular second-line fluid choice, typically considered after a total administered volume of 60-90 mL/kg of isotonic crystalloid fluids. Only 72 respondents (40.7%) were able to measure blood lactate in-house, which was used routinely by 36 respondents (20.3%) for initial treatment decision making. Respondents treating HVS most frequently were more likely to use lactate for initial decision making (P = .008). This study highlighted variabilities in the initial approach, fluid management strategies and monitoring instituted by UK general practitioners when faced with canine patients in HVS. This suggests that there is a discrepancy in what is determined to be the most optimal diagnostic and treatment plan for canine HVS patients.

701 Outcome Evaluation of High Dose Ascorbic Acid Infusion in Adult Burn Patients

Abstract Introduction High dose ascorbic acid (HDAA) infusion has been associated with lower resuscitation volumes following severe burn injuries. Recent data has linked the use of HDAA to an increased risk of renal failure. HDAA infusion causes an osmotic diuresis which confounds fluid titration. For these two reasons, HDAA has become controversial. The objective of this study is to examine the outcomes of adult burn patients who received HDAA infusion during acute burn resuscitation. Methods This study is an IRB approved retrospective chart review of all adult burn patients admitted from January 2016 through December 2018 who received HDAA for resuscitation. Patients were excluded if age &amp;lt; 18 years, had pre-existing hemodialysis-dependent chronic kidney disease, received &amp;lt; 16 hours of HDAA, or expired/withdrew from care within 48 hours of admission. The primary outcome was the incidence of patients receiving HDAA infusion who required renal replacement therapy (RRT) within 7 days of admission. Secondary outcomes included the incidence of abdominal compartment syndrome (ACS), duration of mechanical ventilation, actual crystalloid volume administered in the first 24 hours compared to estimated volume, ICU length of stay (LOS), and mortality. Results Twenty-four patients were included with a mean age of 48 (+/-16) and a mean TBSA of 49.1% (+/-17.8). The estimated fluid requirements in the 1st 24 hours were calculated using 4mL/kg/TBSA. Four patients required RRT (16.7%) and 12 patients were diagnosed with ACS (50%). The mean volume of crystalloid administered in the 1st 24 hours was 4.7 mL/kg/TBSA (+/-1.9), and the ratio of actual to estimated crystalloid in the 1st 24 hours was 1.2 (+/-0.5). Seventeen patients received albumin therapy in the 1st 24 hours. The mean urine output in 1st 24 hours was 1.7 mL/kg/hr. Mean duration of mechanical ventilation and ICU LOS was 15 and 16 days respectively. Thirteen patients died (54.2%). Conclusions The incidence of patients requiring RRT, along with the crystalloid volume administered and the observed to expected ratio of crystalloids in the 1st 24 hours were comparable to recent literature. The known effect of osmotic diuresis from HDAA potentially impacted fluid titration practice, increasing the risk of complications from over-resuscitation such as ACS, and mortality. Additionally, the estimation of 24-hour fluid requirements using 4mL/kg/TBSA may have contributed to the rates of ACS. Further studies comparing fluid management strategies are necessary. Applicability of Research to Practice This study describes the outcomes associated with HDAA during acute burn resuscitation at an adult burn center. Given the current controversy surrounding HDAA infusion, this study provides further data to help burn centers make a decision regarding their opinion of HDAA during acute burn resuscitation.

Management of Acute Kidney Injury in the Setting of Acute Respiratory Distress Syndrome: Review Focusing on Ventilation and Fluid Management Strategies.

Acute respiratory distress syndrome (ARDS) is a major cause of mortality in adults with acute hypoxic respiratory failure and can predispose those afflicted to develop acute kidney injury (AKI). In the setting where AKI and ARDS overlap, incidence of mortality, length of intensive care unit stay, and complexity of management increases drastically. Lung protective ventilation strategy and conservative fluid management are the main focus of therapy in patients with ARDS, but have major implications on renal function. This review aims to provide concise discussion of pathophysiology, ventilation, and fluid management strategies as it relates to AKI in the setting of ARDS.

Less Is More?—A Feasibility Study of Fluid Strategy in Critically Ill Children With Acute Respiratory Tract Infection

Background: Fluid overload is common in critically ill children and is associated with adverse outcome. Therefore, restricting fluid intake may be beneficial. This study aims to study the feasibility of a randomized controlled trial (RCT) comparing a conservative to a standard, more liberal, strategy of fluid management in mechanically ventilated pediatric patients with acute respiratory tract infection (ARTI).Methods: This is a feasibility study in a single, tertiary referral pediatric intensive care unit (PICU). Twenty-three children receiving mechanical ventilation for ARTI, without ongoing hemodynamic support, admitted to the PICU of the Emma Children's Hospital/Amsterdam UMC between 2016 and 2018 were included. Patients were randomized to a conservative (<70% of normal intake) or standard (>85% of normal intake) fluid strategy, which was kept throughout the period of mechanical ventilation.Results: Primary endpoints were adherence to fluid strategy and safety parameters such as calorie and protein intake. Secondary outcomes were cumulative fluid intake (CFI) and cumulative fluid balance (CFB) on day 3. In the conservative group, in 75% of the mechanical ventilation days patients achieved their target fluid intake. Median [25th−75th percentiles] calorie intake over all mechanical ventilation days was 67.9 [51.5–74.0] kcal/kg/day in the conservative vs. 67.2 [58.0–75.2] kcal/kg/day in the standard group (p = 0.878). Protein intake was 1.6 [1.3–1.8] gr protein/kg in the conservative and 1.5 [1.2–1.7] gr protein/kg in the standard group (p = 0.598). No adverse effects on hemodynamics or electrolyte imbalances were noted. Mean (±SD) CFI on day 3 was 262.3 (±58.9) ml/kg in the conservative group vs. 360.5 (±52.6) ml/kg in the standard fluid group (p < 0.001), which did not result in a lower CFB.Conclusions: A conservative fluid strategy in mechanically ventilated children with ARTI seems feasible, without limiting metabolic needs. However, in our study a conservative fluid strategy surprisingly did not reduce the degree of fluid overload. This study aids the design and sample size calculation of a future larger multicenter RCT, in which we need to redefine the target fluid strategy, possibly by even further fluid restriction and early initiation of active diuresis.Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT02989051.

Effects of Intraoperative Fluid Balance During Liver Transplantation on Postoperative Acute Kidney Injury: An Observational Cohort Study.

Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.