Fluid Regimen Research Articles

This Month in Anesthesiology

This Month in Anesthesiology

Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)\u2014protocol for a multicenter, randomized, clinical, proof-of-concept trial

BackgroundIntravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care.MethodsThis is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care.The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions.Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022.DiscussionSepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis.Trial registrationEudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics – Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).

Does perioperative fluid management affect the development of postoperative complications in major gastrointestinal tract surgery? A retrospective cohort study

Background/Aim: In major abdominal surgeries, maintenance of electrolyte homeostasis and euvolemia is crucial. However there is still no consensus on the most effective intraoperative fluid regimen. Our primary aim in this study was to investigate the impact of colloid infusion given in addition to perioperative fluid replacement on the development of postoperative complications in patients undergoing major gastrointestinal tract surgery. Methods: Patients who underwent major abdominal surgery in our hospital due to gastrointestinal tract malignancy between January 2015 and January 2020 were enrolled in this retrospective cohort study. We recorded data regarding the volume of perioperative fluid replacement, the amount of crystalloid and colloid administered, postoperative complications, length of hospital stay, frequency of follow-up in the intensive care unit and length of stay. Results: A total of 326 patients, who underwent gastrointestinal tract surgery, were included in the study. Postoperative pulmonary complications (24.2%), wound infection (20.6%), and anastomotic leakage (3.1%) were the most-observed three complications in the study cohort. Among 163 patients who required postoperative ICU follow-up, 84 (25.7%) patients received colloid infusion, whereas 79 (24.2%) patients did not receive (P=0.181). However, the incidence of other complications in the group with a crystalloid intake of ≤2 L was found to be significantly higher compared to the group receiving >2 L of crystalloids (P=0.038). Conclusion: We found no association between the administration of colloids along with crystalloid infusion and the incidence of postoperative complications. Besides there was no relation with the adverse effects in terms of the length of hospital stay and the frequency of admission to the intensive care unit.

Restrictive versus Liberal Fluid Therapy in Patients Undergoing Pancreaticoduodenectomy

Introduction: Pancreaticoduodenectomy(PD) has significant morbidity (50%) and mortality (<5%) which may be influenced by perioperative fluid therapy. Traditional practice was the use of liberal fluid therapy. However, it is unclear what the ideal fluid therapy is for patients undergoing PD. This study was conducted to compare the postoperative complications between Restrictive fluid therapy (RES) and Liberal Fluid Therapy (LIB). Methods: Patients scheduled to undergo PD were consented for randomization to a perioperative Restrictive versus Liberal Fluid Therapy fluid regimen. Sample size was designed with 80% power to decrease Clavien Dindo Grade≥ IIIb complications from 60% to 30%. Sample size calculated was 40. Intraoperatively, RES patients received crystalloid 5ml/kg/hr and LIB patients received 10ml/kg/hr. Results: Between May 2020 and July 2021, 40 patients were included in the study. Patients were equally distributed for all demographic and intraoperative characteristics. Cumulative crystalloid given (median, IQR, ml) upto 24 hr of surgery was 3550 (1437.5) in RES group, 5325 (2525) in LIB group (p<0.001). Median operative time (median, IQR) for PD was 465(198) minutes for restrictive and 420(86) minutes for liberal fluid therapy (p=0.478). Grade ≥ IIIb complications occurred in 8 (40%) of RES and 3(15%) of LIB patients (p=0.08). Median length of hospital stay was 15.5 days and 16 days which was similar, in both study groups. The rate of complications like POPF, PPH and DGE were similar in both groups. Conclusion: The choice between restrictive or liberal fluid therapy did not affect overall major postoperative complications (Clavien Dindo Grade≥ IIIb) in pancreaticoduodenectomy.

Effect of Goal-Directed Intraoperative Fluid Therapy on Duration of Hospital Stay and Postoperative Complications in Patients Undergoing Excision of Large Supratentorial Tumors.

Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. CTRI/2016/10/007350.

Evaluation of Intraoperative Fluid Management

Objective:Especially in large surgical procedures, it is recommended that the fluid treatment be performed according to the needs of the patient in the presence of hemodynamic monitoring during the operation. We aimed to review intraoperative fluid treatments and to increase awareness of intraoperative fluid management. Methods:The patients (393) who underwent general anesthesia were included in the study. According to the information of intraoperative fluid applications, the demographic characteristics of the patients and the amount and type of fluid that should be given according to the type of operation performed were determined. Results:In our study, the mean amount of fluid given to patients was found to be 2677.61 ml. The mean intraoperative fluid volume was higher in patients who were treated with IV vasopressors than in untreated patients (3477.27 ml). When compared with patients with ASA 1-2 group, the amount of fluid given to the patients in the ASA-3 group was high (2795 ml). Comparing the type of surgery and the amount of fluid given intraoperatively, we observed that the amount of intraoperative fluid was significantly higher in the high-risk surgical group (3601.65 ml). We can say that we are close to liberal practices as a liquid strategy. The use of balanced crystalloid with the closest content to plasma is the most preferred liquid type in our clinical practice. Conclusion:Due to the variability of the concepts of liberal and restrictive fluid regimen and the lack of standardized targeted clinical and physiological parameters, no specific evidence-based guideline or procedure specific fluid treatment could be demonstrated. In our study, we see that fluid replacement is performed under standard fluid treatment, which still can be considered liberal. We think that it can be useful to use hemodynamic monitoring methods more frequently in patients who need them, also in selected patient groups. Key Words: Fluid, Liberal, Restrictive, Perioperative, Crystalloid, Colloid

Keto Rash: Ketoacidosis-Induced Prurigo Pigmentosa

A 37-year-old male patient has suffered from pruritic eruptions for 2 weeks and had a weight loss of 20 kg in 3 months. Associated symptoms included drowsiness, generalized weakness, nausea, nocturia, polydipsia, and polyphagia. On examination, pruritic erythematous papuloplaques mixed with brownish reticular hyperpigmentation were noted mainly on the back (Figure 1). Laboratory data revealed a serum glucose level of 805 mg/dL (44.68 mmol/L), high glycohemoglobin level (17.5%; reference range:<5.7 %), high serum level (7.2 mmol/L; reference range, <0.6 mmol/L), and high urinary ketone level (4+; reference range, negative). Histopathology revealed basket weave hyperkeratosis and perivascular lymphocytic infiltrate with many neutrophils in the dermis (Figure 2). On the basis of clinical and pathological findings, prurigo pigmentosa associated with diabetic ketoacidosis (keto rash) was diagnosed. Slit-lamp examination suggested no diabetic retinopathy. The patient received glucose-insulin-potassium and fluid regimen for diabetes ketoacidosis control. The skin eruption responded well with gradual resolution 2 weeks after the above-mentioned management and topical steroid treatment.Figure 2A, Histopathology revealed basket weave hyperkeratosis, parakeratosis, and superficial perivascular inflammatory cells infiltration in the upper dermis (hematoxylin and eosin stain, original magnification 40×). B, In higher magnification, sections revealed mild exocytosis, basal cell vacuolization, and superficial perivascular lymphocytic infiltration with neutrophils (hematoxylin and eosin stain, original magnification 200×).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Prurigo pigmentosa causes acquired diffuse reticulate pigmented eruptions on the trunk and commonly affects young patients.1Rotstein H. Mason G.H. A peculiar pruriginous dermatoses with gross reticular pigmentation.Australas J Dermatol. 1992; 33: 56-59Crossref PubMed Scopus (6) Google Scholar It is characterized by intensely pruritic symmetrical urticarial, erythematous papuloplaques coalescing into reticulated hyperpigmentation, which is usually distributed on the trunk and neck. The pathomechanisms are proposed to be neutrophil-mediated inflammation triggered by metabolic and environmental factors, and the role of ketoacidosis is increasingly reported.2Beutler B.D. Cohen P.R. Lee R.A. Prurigo pigmentosa: literature review.Am J Clin Dermatol. 2015; 16: 533-543Crossref PubMed Scopus (49) Google Scholar Patients with the underlying disease of anorexia nervosa and diabetes and on a ketogenic diet may be at a high risk of developing prurigo pigmentosa. With an increasing prevalence of ketogenic diets, the cases of prurigo pigmentosa are more commonly reported.3Michaels J.D. Hoss E. DiCaudo D.J. Price H. Prurigo pigmentosa after a strict ketogenic diet.Pediatr Dermatol. 2015; 32: 248-251Crossref PubMed Scopus (20) Google Scholar Management includes controlling blood sugar level and treatment with minocycline, doxycycline, or dapsone. Here, we present this case to raise awareness of distinct skin eruptions that can occur in the setting of diabetic ketoacidosis, or in patients on a ketogenic diet.

Should fluid management in thoracic surgery be goal directed?

To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed? 'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks. Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

Порівняльна характеристика лікувальних методів усунення гемоконцентрації у хворих із судинними захворюваннями головного мозку

Актуальність. Розведення крові (гемодилюцію) давно застосовують у практичній медицині у вигляді водного навантаження (посилене пиття) і парентерального введення водно-електролітних і плазмозамінних розчинів. Гемодилюція покращує реологічні властивості крові таким чином, що приплив кисню та поживних речовин до мозку покращується, і нейрони, яким загрожувала смерть, можуть вижити. Гемодилюція може бути досягнута кровопусканням (видалення крові), введенням розчинів у вигляді інфузій чи шляхом комбінації обох методів. Розчини, які використовуються при гемодилюції, можуть бути сольовими та колоїдними. Колоїдні розчини, які складаються з більшості нерозчинних молекул і призначення яких — збереження інтраваскулярної рідини, є більш ефективним засобом гемодилюції. В багатьох країнах гемодилюція використовується в клінічному лікуванні пацієнтів із 70-х років ХХ століття. Матеріали та методи. Проведено ретроспективний аналіз найбільш ефективного методу усунення гемоконцентрації у хворих на цереброваскулярні захворювання та іншу патологію, що лікувалися в ангіоневрологічному відділенні клініки нейрохірургії та неврології Військово-медичного клінічного центру Західного регіону з січня по червень 2018 року. Результати. Обстежено 212 хворих віком від 20 до 80 років. Середній вік пацієнтів становив 50 років. Чоловіків було 164 (73 %), жінок — 48 (23 %). Гемоконцентрація спостерігалася у 32 (15 %) пацієнтів. Порушення реологічних властивостей крові мало місце у 28 (17 %) чоловіків і 7 (14 %) жінок. При ішемічному інсульті (ІІ) порушення реологічних властивостей крові спостерігалось у 10 (24 %) пацієнтів, із наслідками перенесеного ІІ у 12 (24 %) пацієнтів, при дисциркуляторній енцефалопатії (ДЕ) у 8 (8 %) пацієнтів, аномалії Кімерлі — в 1 (20 %) пацієнта, вегетосудинній дистонії (ВСД) на фоні гострого періоду закритої черепно-мозкової травми (ЗЧМТ), струсу головного мозку — 1 (3 %) пацієнта. Питний режим був ефективний у 3 пацієнтів при ДЕ, ВСД на фоні гострого періоду ЗЧМТ, струсу головного мозку та аномалії Кімерлі. Позитивний ефект гіперволемічної гемодилюції (ГГ) спостерігався у 17 пацієнтів, ізоволемічної гемодилюції (ІГ) у 12 пацієнтів при гострому перебігу ІІ, наслідках перенесеного ІІ та ДЕ. При посиленому питному режимі, ГГ та ІГ рівень показників гемоглобіну та гематокриту нормалізовувався; показники протромбіну в середньому знижувалися на 10 одиниць. Рівень фібриногену, електролітного обміну, тромбоцитів при посиленому питному режимі суттєво не змінювався. Концентрація тромбоцитів при ГГ та ІГ незначно підвищувалася. Побічних реакцій не спостерігалося. Висновки. Порушення реологічних властивостей крові з тенденцією до гемоконцентрації найбільш характерне для пацієнтів віком 40–50 років чоловічої статі при ІІ та наслідках перенесеного ІІ. Найменш ефективний метод розрідження крові — питний режим, більш ефективний — ГГ. Питний режим недостатньо ефективний при ІІ та перенесених його наслідках. При даній патології показана ГГ чи ІГ. При неефективності ГГ доцільно застосовувати ІГ, для досягнення ефективності достатньо одного сеансу. Дані методи лікування є безпечними.

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery.

We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS). This is a retrospective case-control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI. A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1-11.2%, stage 2-2.0%, stage 3-0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0-17.0] days vs 6.0 [4.0-8.0] days; P < .001), more major complications (OR, 6.55; 95% CI, 3.00-14.35, P < .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48-4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10µmol/l; 95% CI, 1.03-1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06-0.39; P < 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22-1.55; P < 0.001), and major complications (OR, 5.55; 95% CI, 2.63-11.70; P < 0.001). Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.

Lung Ultrasound Assisted Comparison of Volume Effects of Fluid Replacement Regimens in Pediatric Patients Undergoing Penile Hypospadias Repair: A Randomized Controlled Trial.

BackgroundEffective perioperative fluid therapy is a great consideration.ObjectivesUsing lung ultrasound (LUS), this study evaluated the preference of the conventional and restrictive fluid replacement regimens for their volume impact in pediatric patients undergoing a relatively long procedure with limited volume loss (hypospadias repair).MethodsEighty pediatric patients scheduled for hypospadias repair surgery were enrolled for conventional (CG) or restrictive fluid management groups (RG). The CG obtained Ringer's lactate at the conventional calculated doses, while the RG obtained infusion of Ringer's lactate at a rate of 3 mL/kg/h. B-line numbers in the LUS, recovery score, urine output, blood pressure (BP), heart rate HR, and oxygen saturation (SpO2) were recorded.ResultsAs evidenced by the LUS, RG showed a higher incidence of normal lung morphology with a mean and SD of 1.3 ± 2.2 for B-line numbers, whereas, in CG, they were 3.1 ± 2.2 with a P-value < 0.001. Urine output was 3.2 ± 0.8 and 2.9 ± 0.7 for CG and RG, respectively, with a P-value equal to 0.07. HR, BP, and SpO2 differences between groups were statistically insignificant. The recovery score was higher in RG (5.8 ± 0.4) than in CG (5.1 ± 0.8) at the first postoperative 20 minutes, with a P-value < 0.001.ConclusionsIn lengthy procedures with limited volume loss, using a moderately restrictive regimen is preferred over the conventional intraoperative fluid regimen considering both respiratory dysfunctions and recovery score.

Does fluid balance affect neurodevelopmental outcomes in hypoxic-ischaemic encephalopathy?

Hypoxic-ischaemic encephalopathy (HIE) is a major cause of morbidity and mortality in neonates worldwide.1 Neonates with HIE are treated with therapeutic hypothermia (TH) and other supportive measures. Restrictive fluid regimen, with attention to fluid balance, is advocated in the treatment of HIE to prevent exacerbation of cerebral oedema.2, 3 However, there is no evidence to support this practice or to provide insight into the effect of fluid balance on outcomes of neonates with HIE.4, 5 This study by Ottolini et al. aimed to determine any association between positive fluid balance and death or moderate to severe brain injury on post-rewarming magnetic resonance imaging (MRI) in neonates with HIE treated with TH. All neonates were initially administered fluids at a standard rate of 60 ml/kg/day. Infusion rates were adjusted subsequently as per clinical discretion to maintain target sodium and glucose levels. Retrospective analysis of data showed positive fluid balance during the first 24 h of TH conferred 3.4 times higher odds of death or moderate to severe brain injury in neonates. The odds of this primary adverse outcome increased to 5.8 times in neonates with positive fluid balance at 48–72 h of TH. Ottolini et al. propose acute kidney injury and syndrome of inappropriate secretion of anti-diuretic hormone (SIADH), as mechanisms underlying the higher incidence of free water retention and lower plasma sodium levels observed in neonates who died or had moderate-to-severe brain injury in this study.6-8 Accordingly, whilst it could be hypothesised that positive fluid balance itself contributes to the adverse neurodevelopmental outcome, the degree of positive fluid balance may concurrently indicate the severity of hypoxic injury in neonates with HIE. Therefore positive fluid balance may be used as an early prognostic marker of severity of brain injury. Previous randomised controlled trials (RCT) found fluid restriction precipitated hypoglycaemia and hyponatremia, potentially confounding the observed adverse outcomes.4, 7 Anticipation and correction of these electrolyte disturbances gives this study's results with greater validity. However, the lack of further details of fluid management makes it difficult to determine exact fluid volumes administered throughout the study period. Consequently, it is unclear whether positive fluid balance, as a result of hypoxic injury, was exacerbated by the fluid strategy undertaken in the study. Apart from a median of 9 days of life, and an interquartile range of 6–10 days of life, definitive details of timing of the post-rewarming MRI assessment of brain injury have not been provided. Furthermore, twenty neonatal deaths were recorded prior to MRI, and deaths beyond this point were not reported. A multicentre RCT comparing a standard versus restrictive fluid regimen with long-term neurodevelopmental surveillance may address the controversy around the ideal fluid strategy in HIE. Comparing levels of biomarkers that indicate the severity of HIE and SIADH in both groups may also provide information on prognostication. Despite the limitations discussed, the study illustrates a significant association between positive fluid balance and adverse outcomes, and further research is warranted on fluid therapy in HIE. None declared. URL to the full review on the EBNEO website.

Preoperative fluid fasting : Establishment of a liberal fluid regimen using fasting cards

Preoperative fasting times for clear liquids surpass by far the recommendations of the specialist societies. The aim of this study was to introduce aliberal regimen for preoperative fasting of clear liquids using fasting cards as atraining tool and to evaluate the implementation. We developed aliberalized regimen of preoperative clear fluid fasting times, which allows patients to drink water, apple juice, tea and coffee until being called to the operating theatre. Each patient receives abed-side fasting card with written information specifying fasting times for solid food and liquids. Patients who are allowed to drink water, apple juice, tea and coffee until the call to the operating theatre receive ablue fasting card. Patients with coexisting diseases or conditions that can affect gastric emptying or who need longer fasting times because of the surgical procedure get ayellow fasting card on which fasting times for fluids and solids can be documented individually. Patients who need to be nil per os (for example patients with ileus or bowel obstruction, emergency care) receive ared fasting card. On the back of the card the information is written in English, Turkish, Russian and Arabic. After aperiod of 8 months all surgical ward managers were asked to complete aquestionnaire to assess the implementation of the new fasting regimen. The response rate of the questionnaire was 100%. Without exception all interviewees would recommend the use of our liberalized fasting regimen. Almost all would also support the implementation of fasting cards. Out of 11 wards 9 found that patients were more relaxed and asked for intravenous fluids less often while waiting for surgery. The multilingual nature of the cards makes it easier to deal with patients who do not speak German. All ward managers consistently approved the new regimen in the event they themselves would need an operation. In order to make the fasting cards also usable in the future for rescue centers and functional units, such as endoscopy, echo or cardiac catheters, the reasons for fasting on the blue and yellow cards have been extended to operation or examination and on the red card to illness, operation or upcoming examination. Patients should be allowed to drink water and hypotonic clear fluids until shortly before an operation to avoid complications of overly long fasting times. Fasting cards help to implement this by providing easy to understand information for patients and healthcare workers. This concept should be clearly structured, transparent for everyone, written down and brought to the attention of the patient without alanguage barrier.

MO349IMPACT OF EARLY FLUID ADMINISTRATION ON INPATIENT MORTALITY AND ACUTE KIDNEY INJURY IN PATIENTS WITH COVID-19 DISEASE

Background and AimsInitial WHO guidance advised cautious fluid administration for patients with COVID-19 due to concern about the development of acute respiratory distress syndrome (ARDS). However, as the pandemic unfolded it became apparent that patients who were admitted to hospital had high rates of AKI and this initiated a change in local clinical guidelines during early April 2020. We aimed to ascertain the impact of judicious intravenous fluid use on mortality, length of hospitalisation and AKI.MethodAn observational cohort study of 158 adults admitted with confirmed SARS-Cov-2 between 18th March and 9th May 2020 was conducted in a teaching hospital and designated centre for infectious diseases, London, UK. Key clinical and demographic data collected included clinical severity markers on admission, biochemical and haematological parameters as well as radiological findings. Primary outcomes were inpatient mortality, mortality at 6-weeks post discharge, length of hospitalisation and intensive care (ICU) admission. We also measured requirement for kidney replacement therapy (KRT) and AKI recovery rate at discharge. Using tests of difference, we compared key outcomes between patients treated with varying fluid regimens and then identified risk factors for AKI and mortality using multivariate logistic regression with results expressed as odds ratios (OR) with corresponding 95% confidence interval (CI).ResultsThe median age was 74.4 (IQR 59.90 - 84.35) years, 66% were male, 53% white with hypertension and diabetes being the commonest co-morbidities. The median duration of illness prior to admission was 7 days (IQR 2 – 10) with respiratory symptoms and fever most prevalent. The people who presented with AKI on admission were more likely to receive fluids (34% vs 15%, p=0.02).118 patients (75%) received fluids within 24-hours of admission with no difference in volume administered after local guidance change (p=0.78). Comparing patients receiving fluids with those who did not, we observed no difference in mortality (p=0.97), duration of hospital stays (p=0.26) or requirement for ICU admission (p=0.70). 18% died as an inpatient, and 52 patients were either admitted with or developed AKI.Of these 52 patients, 43 received fluids and 9 did not with no difference in KRT requirement (p=0.34), mortality (p=0.50) or AKI recovery (p=0.63). Peak AKI stage was greater among participants who received fluids though stage of AKI at presentation was also greater (p=0.04). Mortality rate in patients with an AKI is higher compared to overall inpatient mortality (31% vs 18%). Of the 36 patients with AKI who were discharged home, 25 patients (69.4%) had renal recovery by the time of discharge.Increasing age and clinical severity on admission were associated with higher mortality (see Figure 1). Older age was associated with 34 - 53 times higher risk of death compared with those aged ≤ 65 years (age 76 - 85 years: OR 34.26, 95% CI: 3.94 - 297.48, p=0.001; age > 85 years: OR 53.07, 95% CI: 5.23 - 539.03, p=0.001). Patients with NEWS2 >4 on admission has 5-fold increased risk of death than those with a score ≤4 (OR 5.26, 95% CI: 1.32 - 20.92). Black ethnicity was associated with a 16-fold increased risk of developing AKI (OR 15.86, 95% CI: 1.67 - 150.99).ConclusionTo our knowledge, this is the first study to examine the impact of fluid management on inpatient mortality as well as on renal-associated outcomes of COVID-19 admission. Fluid administration regimen did not have an impact on mortality, length of hospitalisation or ICU admission, nor did it affect renal outcomes. Given the high rates of AKI and KRT in COVID-19 disease, early fluid administration is likely to be an important cornerstone of future management. Further adequately powered prospective studies are required to identify whether early fluid administration can reduce renal injury.

Intravenous Fluid Selection for Unruptured Intracranial Aneurysm Clipping : Balanced Crystalloid versus Normal Saline.

ObjectiveWhile balanced crystalloid (BC) could be a relevant fluid regimen with buffer system compared with normal saline (NS), there have been no studies on the optimal fluid for surgery of an unruptured intracranial aneurysm (UIA). This study aimed to compare the effects of fluid regimens between NS and BC on the metabolic and clinical outcomes of patients who underwent surgery for UIA. MethodsThis study was designed as a propensity score matched retrospective comparative study and included adult patients who underwent UIA clipping. Patient groups were categorized as NS and BC groups based on the types of pre-operative fluid and the amount of fluid administered during surgery. The primary outcomes were defined as electrolyte imbalance and acidosis immediately after surgery. The secondary outcomes were the length of stay in the intensive care unit (ICU) and duration from the end of the operation to extubation. ResultsA total of 586 patients were enrolled in this study, with each of 293 patients assigned to the NS and BC groups, respectively. Immediately after surgery, serum chloride levels were significantly higher in the NS group. Compared to the NS group, the BC group had lower incidence rates of acidemia (6.5% vs. 11.6%, p=0.043) and metabolic acidosis (0.7% vs. 4.4%, p=0.007). As compared to NS group, BC group had significantly shorter duration from the end of the operation to extubation (250±824 vs. 122±372 minutes, p=0.016) and length of stay in ICU (1.37±1.11 vs. 1.12±0.61 days, p=0.001). Throughout multivariable analysis, use of BC was found to be significant factor for favorable post-operative results. ConclusionThis study showed that the patients who received BC during UIA clipping had lower incidence of metabolic acidosis, earlier extubation and shorter ICU stay compared to those who received NS. Therefore, using BC as a peri-operative fluid can be recommended for patients who undergo surgery for UIA.

Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline.

Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.

Outcomes and predictors of early emergency department discharge among children with acute gastroenteritis and moderate dehydration.

BackgroundGastroenteritis is one of the most common diseases that affects children and remains a leading cause of morbidity and mortality around the world. There is conflicting evidence regarding the effect of rapid intravenous fluid regimen on the clinical outcome of patients with acute gastroenteritis. This study aimed to assess the current practice of intravenous hydration on the clinical outcomes of pediatric patients with acute gastroenteritis and determine the predictive factors for early discharge and emergency department (ED) revisit.MethodsA cohort study was carried out among children aged from 1 month to 14 years who presented to the ED in a tertiary care hospital between September 2015 and September 2017. Children diagnosed with acute gastroenteritis and moderate dehydration who require intravenous hydration were included in the study. The patients were followed up until discharge from ED, admission to the hospital or revisit to the ED. Collected variables were demographics, presenting symptoms, biochemical marker, amount of intravenous fluid (IVF) received and prescription of anti-emetics. Descriptive statistics were summarized as mean, standard deviation for continuous variables and proportions for categorical variables. Logistic regression was used to identify risk factors.ResultsOut of 284 patients, 148 (52%) were males, 20 (7%) were infants, 80 (28%) were toddlers, 90 (32%) were in preschool, 88 (31%) were in school and 6 (2.1%) were adolescents. No significant difference was observed in the admission rate, discharge within 12 h or less and ED revisits for those who received IVF ≥40 ml/kg as compared to those who received <40 ml/kg. Patients with bicarbonate level closer to normal are more likely to be discharged after 4 h (odds ratio (OR) 1.2 and 95% CI 1.12–1.43). Patients presenting only with vomiting/diarrhoea were less likely to revisit ED (OR 0.33 (95% CI 0.143 - 0.776), while patients with an increase in CO2 level (OR 1.19 and 95% CI 1.0 -1.436) and anion gap (OR 1.29 and 95% CI 1.08–1.54) were more likely to revisit within 1 week post discharge.ConclusionThis study did not show any additional benefits of receiving IVF ≥ 40 ml/kg over 4 h neither in early discharge nor in reducing the ED revisit. CO2 closer to normal was a significant predictor for early discharge in 4 h where the closer level of CO2 and AGAP were associated with an increase in the chance of a revisit to the ED within 1 week after discharge.

Effect of fluid strategy on stroke volume, cardiac output, and fluid responsiveness in adult patients undergoing major abdominal surgery: a sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial

BackgroundWe designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes. MethodsStroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness. ResultsAnalysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6–48.8) vs liberal 44.0 (34.9–61.9) ml m−2; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32–4.05) vs 2.42 (1.94–3.26) L min−1 m−2; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant). ConclusionsThe liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups. Clinical trial registrationACTRN12615000125527.

Bioelectrical Impedance Analysis in Patients Undergoing Major Head and Neck Surgery: A Prospective Observational Pilot Study.

Background: Head and neck patients are prone to malnutrition. Perioperative fluids administration in this patient group may influence nutritional status. We aimed to investigate perioperative changes in patients undergoing major head and neck surgery and to examine the impact of perioperative fluid administration on body composition and metabolic changes using bioelectrical impedance. Furthermore, we sought to correlate these metabolic changes with postoperative complication rate. In this prospective observational pilot study, bioelectrical impedance analysis (BIA) was performed preoperatively and on postoperative days (POD) 2 and 10 on patients who underwent major head and neck surgeries. BIA was completed in 34/37 patients; mean total intraoperative and post-anesthesia fluid administration was 3682 ± 1910 mL and 1802 ± 1466 mL, respectively. Total perioperative fluid administration was associated with postoperative high extra-cellular water percentages (p = 0.038) and a low phase-angle score (p < 0.005), which indicates low nutritional status. Patients with phase angle below the 5th percentile at POD 2 had higher local complication rates (p = 0.035) and longer hospital length of stay (LOS) (p = 0.029). Multivariate analysis failed to demonstrate that high-volume fluid administration and phase angle are independent factors for postoperative complications. High-volume perioperative fluids administration impacts postoperative nutritional status with fluid shift toward the extra-cellular space and is associated with factors that increase the risk of postoperative complications and longer LOS. An adjusted, low-volume perioperative fluid regimen should be considered in patients with comorbidities in order to minimize postoperative morbidity.

Comparison of liberal and goal-directed fluid therapy after small intestinal surgery for strangulating lesions in horses.

There are few guidelines for the appropriate mode of fluid administration during and after colic surgery, and is challenging to reach the right balance while avoiding overhydration. This study aimed to compare goal-directed fluid therapy (GDFT) and 'liberal' fluid regimens (LFRs) in horses undergoing small intestinal surgery. Eighteen horses subjected to small intestinal surgery were matched according to the surgical lesion, type of anastomosis, length of resection, and duration of clinical signs. Horses in the LFR group were administered intravenous (IV) fluids for at least 24 h. In the GDFT group, IV fluids were administered only when considered necessary based on clinical parameters. Postoperative reflux (POR), packed cell volume, total protein, heart rate, venous lactate level, complications, and long-term survival rates were compared. Three horses in the LFR and one in the GDFT group developed POR. Horses in the GDFT group had a shorter time interval to first oral water intake and shorter hospitalisation time. Postoperative complication rates and survival were not different between groups. Further studies are necessary to set guidelines for the evaluation of hydration status and to plan postoperative fluid administration; however, GDFT may be a valid alternative to liberal fluid therapy after colic surgery.