Fluid Resuscitation Strategies Research Articles

Trends in pre-hospital volume resuscitation of blunt trauma patients: a 15-year analysis of the British (TARN) and German (TraumaRegister DGU®) National Registries

IntroductionFluid resuscitation has long been a cornerstone of pre-hospital trauma care, yet its optimal approach remains undetermined. Although a liberal approach to fluid resuscitation has been linked with increased complications, the potential survival benefits of a restrictive approach in blunt trauma patients have not been definitively established. Consequently, equipoise persists regarding the optimal fluid resuscitation strategy in this population.MethodsWe analysed data from the two largest European trauma registries, the UK Trauma Audit and Research Network (TARN) and the German TraumaRegister DGU® (TR-DGU), between 2004 and 2018. All adult blunt trauma patients with an Injury Severity Score > 15 were included. We examined annual trends in pre-hospital fluid resuscitation, admission coagulation function, and mortality rates.ResultsOver the 15-year study period, data from 68,510 patients in the TARN cohort and 82,551 patients in the TR-DGU cohort were analysed. In the TARN cohort, 3.4% patients received pre-hospital crystalloid fluids, with a median volume of 25 ml (20–36 ml) administered. Conversely, in the TR-DGU cohort, 91.1% patients received pre-hospital crystalloid fluids, with a median volume of 756 ml (750–912 ml) administered. Notably, both cohorts demonstrated a consistent year-on-year decrease in the volume of pre-hospital fluid administered, accompanied by improvements in admission coagulation function and reduced mortality rates.ConclusionConsiderable variability exists in pre-hospital fluid resuscitation strategies for blunt trauma patients. Our data suggest a trend towards reduced pre-hospital fluid administration over time. This trend appears to be associated with improved coagulation function and decreased mortality rates. However, we acknowledge that these outcomes are influenced by multiple factors, including other improvements in pre-hospital care over time. Future research should aim to identify which trauma populations may benefit, be harmed, or remain unaffected by different pre-hospital fluid resuscitation strategies.

Isotonic hydroxyethyl starch is ineffective in restoring blood pressure during experimental septic shock: Implications for fluid resuscitation strategies

Objectives: The objectives of the study were to evaluate the effect of isotonic or hypertonic hydroxyethyl starch (HES) solutions on blood pressure and to assess the influence of the neurohypophyseal system on this response during experimental septic shock. Male Wistar rats were randomly allocated to undergo either cecal and ligation puncture (CLP) or a simulated surgical procedure (sham). Materials and Methods: Of 6 h post-surgery, either isotonic saline (0.9% sodium chloride, 4 mL/kg), isotonic (HES; at doses of 4, 8 or 16 mL/kg), or hypertonic saline-HES (HS-HES; 4 mL/kg) was administered through the endovenous route, followed by the recording of blood pressure and heart rate. In addition, the levels of sodium, vasopressin, and oxytocin were evaluated after the fluid infusion. Results: The administration of HES did not have a significant effect on blood pressure in our study. However, the HS-HES solution increased plasma osmolality, sodium, vasopressin, and oxytocin levels. Furthermore, the HS-HES induced a transient elevation in blood pressure immediately after infusion, which could be completely blunted by the pre-administration of a V1-vasopressin antagonist. Conclusion: Our results demonstrate that the infusion of an isotonic blood volume expander during experimental septic shock is ineffective in restoring blood pressure due to blood vessel compliance. In contrast, the infusion of a hypertonic solution stimulates vasopressin secretion and can transiently restore blood pressure.

Therapeutic assessment of crystalloid fluid resuscitation in experimental military injury.

A significant part of blast injury is accompanied by hemorrhagic shock (BS), while research on its fluid resuscitation strategies have not been reported. Although blood products are usually recommended in most resuscitation cases, they are less available in certain conditions. To this end, here, we focused on a widely used and more accessible fluid type- crystalloid fluid, in BS treatment. We conducted studies in rats comparing the therapeutic effects of 3 different crystalloid solutions at different time points after BS, and explored the underlying mechanisms. Generally, the survival rates gradually dropped along with the time when fluid resuscitation was given. Among different types of solution, the hypertonic saline (HS) group showed the highest survival rates. The lactated Ringer's solution (LR) only displayed lifesaving effect at 0.5h resuscitation time point. Moreover, it is worth noting that the survival rates of the normal saline (NS) group at all the time points were lower than the non-treatment control. Mechanism study in rats indicated that the therapeutic differences may be caused by varied degrees of pulmonary edema and inflammatory responses under different crystalloid fluid resuscitation. In conclusion, we assessed the effects and investigated the mechanisms of different crystalloid fluid resuscitation strategies for BS for the first time, which potentially contributes to the establishment of guidance for crystalloid fluid resuscitation of BS patients.

Practice and effect evaluation of early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department: a retrospective cohort study.

To explore the practice and effect evaluation of the early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department. A total of 239 sepsis patients, who were treated in the emergency department of our hospital from January to September 2020, were selected as the participants of this study, and a retrospective analysis was performed. According to different fluid resuscitation, they were divided into an improved group and a control group. One hundred and twelve patients who received restrictive fluid resuscitation were in the improved group; another 127 patients who received adequate fluid resuscitation were in the control group. The ICU stay time, ventilator use time and 28-day mortality rate of the two groups were observed. The hemodynamic indexes, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score and complications of the two groups before and after treatment were compared. After treatment, in the improved group, the APACHE II and SOFA scores were lower than in the control group, fluid replacement decreased, lactate clearance increased, ICU admission time shortened and the proportion of ventilator time to ICU admission time decreased. The incidence of acute respiratory distress syndrome (ARDS), cTn I and brain natriuretic peptic in the improved group were significantly lower than those in the control group. From the dimension within the group, the APACHE II score, SOFA score, heart rate and shock index were lower after treatment than before treatment in the improved and control groups. Restricted fluid resuscitation can effectively alleviate the condition of emergency sepsis patients, improve haemodynamics, reduce the incidence of ARDS and prevent patient deaths. It is worthy of clinical application.

New Insights into the Fluid Management in Patients with Septic Shock.

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.

709 Augmented Renal Clearance (ARC) is Highly Prevalent in Critically Ill Burn Patients

Abstract Introduction Augmented renal clearance (ARC) has been reported to occur across many critical illnesses but has not been evaluated in critically ill burn patients. The impact of ARC on clinical outcomes within this population remains unknown. We hypothesize that ARC is prevalent in critically ill burn patients and is associated with improved survival. Methods We retrospectively reviewed a prospectively-maintained registry of Burn ICU patients from July 2021 – September 2022 at an academic burn center. We included patients in whom 24-hour urine creatinine collection was performed on admission and excluded patients in whom accurate collection was not performed within 48 hours of admission. Creatinine clearance was calculated for all patients who met inclusion criteria. ARC was determined to occur when creatine clearance exceeded 130 mL/min/1.73m2. Clinical outcomes were compared between patients with and without ARC. Results The analysis included 24 patients (67% male, median age 42 [31-55] years). The median percentage of total body surface area (TBSA) burned was 25 [10-38]. ARC was present in 17 patients (71%). Mean creatinine clearance was 162 ml/min/1.73m2 (range 37-313), and 7 patients (29%) had creatinine clearance greater than 200. Complication rates were low and were similar between patients with and without ARC (all p >0.05). Conclusions ARC appears to be a common phenomenon among critically injured burn patients. While the presence of ARC could be particularly meaningful in this population of patients that often receives massive volumes of resuscitative fluids, the sample size of our study did not permit the detection of statistically significant differences in outcomes between burn patients with and without ARC. Further work must be undertaken to assess the impact of ARC on fluid resuscitation strategies and medication dosing including that of antibiotics and thromboprophylaxis agents. Applicability of Research to Practice Augmented renal clearance (ARC) has never before been characterized in the population of critically injured burn patients. This topic merits further research, as it could have far-reaching clinical impact relating to fluid resuscitation practices and dosing of renally-cleared medications (antibiotics, thromboprophylaxis, etc.).

708 Clinical Impact of a Revised Burn Resuscitation Guideline at an Adult Burn Center

Abstract Introduction The American Burn Association recommends volume resuscitation at 2-4ml/kg/TBSA; however, in practice, fluid resuscitation often exceeds these goals. Additional strategies used for burn resuscitation include the use of colloid rescue and high dose ascorbic acid (HDAA). In 2018, our institution moved from a fluid resuscitation strategy which included calculating fluid requirements using 4ml/kg/TBSA and HDAA infusion for burns > 30% TBSA to a strategy that calculated fluids using a 2ml/kg/TBSA with the removal of HDAA. Additionally, the guidance for colloid rescue was updated to provide specific time points for evaluation of the need for initiation of this intervention. The primary objective of this study was to compare outcomes of the new institutional resuscitation strategy to the previous one. Methods This was a retrospective cohort study evaluating outcomes for acute burn resuscitation between the previous institutional resuscitation guideline with the updated guideline. This study included adult patients admitted for burn injury with >20% TBSA between August 1, 2016, to September 30, 2021. The primary outcome was a composite safety endpoint which included incidence of acute kidney injury and intra-abdominal hypertension requiring intervention. Acute kidney injury was defined as a serum creatinine increase 1.5 times baseline. Statistical analyses utilized the Mann-Whitney U test for non-normally distributed continuous data and the chi-squared and Fischer’s exact test for categorical data. A p-value of < 0.05 was considered statistically significant. Results The final analysis included 43 in the pre-group and 52 in the post-group update. Baseline characteristics between the groups were similar. The primary composite safety outcome was non-statistically significantly lower in the post-guideline update group (39.5% vs. 28.8%, p= 0.273). Total fluid volume administered (3.74 ml/kg/TBSA vs. 2.97 mL/kg/TBSA, p=0.007) and hourly urine output within the first 24 hours (1.26 mL/kg/hour vs. 0.75 mL/kg/hour, p=0.007) were significantly lower in the post-group. No differences were observed in vasopressor use (32.6% vs 36.5%, p=0.63), vasopressor duration (70.3 hours vs. 50.4 hours p=0.24), or duration of mechanical ventilation (5.1 days vs 10.4 days, p=0.113). Conclusions The burn resuscitation guideline update resulted in significantly lower 24 hour- fluid volumes, without negative hemodynamic consequences. Applicability of Research to Practice The comparison of two resuscitation protocols provides evidence for other institutions to help optimize their resuscitation practice

Ultrasound-guided fluid resuscitation versus usual care guided fluid resuscitation in patients with septic shock: a systematic review and meta-analysis

Abstract Background Ultrasound is widely used in critical care for fluid resuscitation in critically ill patients. We conducted a systematic review to assess the relationship between ultrasound-guided fluid resuscitation strategies and usual care in septic shock. Methods We searched PubMed, Embase, Cochrane Library, Web of Science, and registers for randomized controlled trials to evaluate the prognosis of ultrasound-guided fluid resuscitation in patients with septic shock. Results Twelve randomized controlled studies with 947 participants were included. Ultrasound-guided fluid resuscitation in patients with septic shock was associated with reduced mortality (risk ratio: 0.78; 95% confidence interval [CI]: 0.65 to 0.94; P = 0.007) and 24-hour fluid volume (mean differences [MD]: −1.02; 95% CI: −1.28 to −0.75; P < 0.001), low heterogeneity (I 2 = 29%, I 2 = 0%), and increased dose of norepinephrine (MD: 0.07; 95% CI: 0.02–0.11; P = 0.002) and dobutamine dose (MD: 2.2; 95% CI: 0.35–4.04; P = 0.02), with low heterogeneity (I 2 = 45%, I 2 = 0%). There was no reduction in the risk of dobutamine use (risk ratio: 1.67; 95% CI: 0.52 to 5.36; P = 0.39; I 2 = 0%). Inferior vena cava–related measures reduced the length of hospital stay (MD: −2.91; 95% CI: −5.2 to −0.62; P = 0.01; low heterogeneity, I 2 = 8%) and length of intensive care unit stay (MD: −2.77; 95% CI: −4.51 to −1.02; P = 0.002; low heterogeneity, I 2 = 0%). The use of the passive leg-raising test combined with echocardiography to assess fluid reactivity was superior. Ultrasound-guided fluid resuscitation did not significantly change the length of the free intensive care unit stay (MD: 1.5; 95% CI: −3.81 to 6.81; P = 0.58; I 2 = 0%). Conclusion Ultrasound-guided fluid resuscitation in patients with septic shock is beneficial, especially when using inferior vena cava–related measures and the passive leg-raising test combined with echocardiography.

Effect of early fluid balance on the prognosis in severe acute pancreatitis

To observe the correlation between early fluid resuscitation and prognosis in patients with severe acute pancreatitis (SAP). SAP patients admitted to the department of critical care medicine of the People's Hospital of Chuxiong Yi Autonomous Prefecture of Yunnan Province from June 2018 to December 2020 were enrolled and analyzed retrospectively. All patients were given the routine treatment according to their condition and relevant diagnostic According to their different prognosis, enrolled patients were divided into death group and survival group. The differences in gender, age, acute physiology and chronic health evaluation II (APACHE II) and Ranson score on admission between the two groups were analyzed. Taking 24 hours as an observation day, the fluid inflow, outflow, and net balance at the first, second, and third 24 hours after admission were recorded, and the ratio of the fluid inflow at the first 24 hours to the total fluid inflow in 72 hours (FV24 h-1 st) was calculated as a study index. Using 33% as the standard, compare the proportion of patients in the two groups who achieved FV24 h-1 st < 33%. The differences of various indicators between the two groups were compared, and the effect of early fluid balance on the prognosis of SAP patients was analyzed. Eighty-nine patients were included in the study (41 in the death group, 48 in the survival group). There were no statistically significant differences on age (years old: 57.6±15.2 vs. 49.5±15.2), gender (male: 61.0% vs. 54.2%), APACHE II score (18.0±2.4 vs. 17.3±2.3), and Ranson score (6.3±1.4 vs. 5.9±1.2) between the death group and the survival group at the time of admission on the intensive care unit (ICU) (all P > 0.05). The fluid intake of the death group in the first 24 hours, the second 24 hours and the third 24 hours after admission to ICU was significantly higher than that of the survival group, and the difference was statistically significant (mL: 4 138±832 vs. 3 535±1 058, 3 883±729 vs. 3 324±516, 3 786±490 vs. 3 212±609, all P < 0.05), and the fluid inflow in the death group at the first 24 hours was greater than 4 100 mL. After treatment, the fluid outflow of the death group at the three 24-hour periods after admission on the ICU was an increasing trend, but it was still significantly less than that of the survival group at the three 24-hour periods (mL: 1 242±465 vs. 1 795±819, 1 536±579 vs. 2 080±524, 1 610±585 vs. 2 932±752, all P < 0.01). Due to the fact that the total fluid inflow and total fluid outflow in the three 24-hour periods in the death group were more than those in the survival group, the net fluid balances in the three 24-hour periods in the death group were still significantly more than those in the survival group finally (mL: 2 896±782 vs. 1 740±725, 2 347±459 vs. 1 243±795, 2 176±807 vs. 338±289, all P < 0.01). There was no difference in FV24 h-1 st between the death group and survival group [FV24 h-1 st > 33%: 56.1% (23/41) vs. 54.2% (26/48), P > 0.05]. Fluid resuscitation is an important method for early treatment of SAP, but it also has many adverse reactions. Fluid resuscitation indexes such as fluid inflow, outflow, net balance, and FV24 h-1 st within 24 to 72 hours after admission are related to the prognosis of patients with SAP, and can be used as indicators to evaluate the prognosis of SAP. The optimized fluid resuscitation strategy can improve the prognosis of patients with SAP.

Association between the volume of fluid resuscitation and mortality modified by disease severity in patients with sepsis in ICU: a retrospective cohort study

ObjectiveThe important effect modifiers of high disease severity on the relationship between the different volumes of early fluid resuscitation and prognosis in septic patients are unknown. Thus, this study was...

63: RESTRICTIVE FLUIDS IN SEPSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: While large-volume fluid resuscitation as a part of early-goal directed therapy (EGDT) for sepsis has been widely adopted and endorsed by the SCCM Surviving Sepsis Guidelines, the risks of volume overload in the critically ill challenge this approach. The objective of this study is to assess the effects of a restrictive fluid resuscitation approach in sepsis given divergent results from randomized studies. Methods: A systematic review using a random effects meta-analysis with trial sequential analysis (TSA) of randomized controlled trials published from 2001 were evaluated. Studies were included if they evaluated adult patients with sepsis or septic shock involving a comparator group with an effective restrictive resuscitation approach. Two blinded reviewers independently assessed studies for inclusion and risk of bias and extracted data using Cochrane Collaborative methodology. The primary outcome was the incidence of mortality at the latest reported study period. Secondary outcomes included rates of acute kidney injury (AKI), ventilator days, intensive care unit (ICU) and hospital length of stay (LOS), duration of vasopressor therapy, and limb ischemia. Results: A total of 2,375 patients were included among the 8 trials analyzed. The risk of bias was high in 6 studies and low in 2 studies. All studies implemented fluid restriction after an initial 30 mL/kg volume. Use of a restrictive resuscitation approach did not significantly reduce mortality in all studies compared to usual care (37% vs 40% with usual care; risk ratio [RR] 0.94, 95% confidence interval [CI] 0.85–1.04, P=0.25, I2 = 24%) and was confirmed by TSA findings. There were no significant differences in rates of AKI (5 studies), LOS in ICU (4 studies) or hospital (2 studies), duration of vasopressor therapy (6 studies), or incidence of limb ischemia (3 studies). However, a restrictive resuscitation strategy significantly reduced ventilator days evaluated in 7 studies (mean difference -1.25 days, 95% CI -0.59 to -1.93 days, P=0.0003, I2 = 90%). Conclusions: This meta-analysis demonstrated that a restrictive fluid resuscitation strategy in sepsis resulted in no difference in mortality but may reduce ventilator days. Larger randomized trials are required to determine the optimal management of fluids in patients with sepsis.

Moderate Fluid Resuscitation Is Preferable in Acute Pancreatitis

de-Madaria J, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med 2022;387:989–1000. Almost 1 in 3 patients presenting with acute pancreatitis progress to a moderate or severe form. Aggressive fluid resuscitation has been thought to improve perfusion, and thus outcomes, but the current literature is conflicting regarding the optimal fluid resuscitation strategy. The WATERFALL (Aggressive Versus Non-aggressive Goal-Directed Fluid Resuscitation in Acute Pancreatitis; NCT04381169) study originally planned to recruit 744 patients with mild acute pancreatitis whose symptoms had started less than 24 hours before and were diagnosed less than 8 hours before and randomize them to either aggressive or moderate fluid resuscitation (AFR or MFR) with lactated Ringer’s solution, an intravenous crystalloid with antiinflammatory properties. Those allocated to AFR received a 20-mL/kg fluid bolus followed by a 3-mL·kg−1·h−1 infusion, whereas those in the MFR group received a 10-ml/kg bolus (only if hypovolemic) followed by a 1.5-mL·kg−1·h−1 infusion. Fluid resuscitation was changed to goal-directed therapy after 12 hours, with patients with ongoing hypovolemia continuing with the strategies outlined above, while normovolemic patients received 1.5 mL·kg−1·h−1. Safety checkpoints were regularly undertaken, with fluids decreased or stopped in the event of fluid overload. The study was halted at the first planned interim safety analysis time point of 249 patients, having found no difference in the primary outcome—the development of moderately severe or severe pancreatitis—between AFR and MFR (22% vs 17%, adjuste relative risk [RR] 1.30, 95% confidence interval [CI] 0.78–2.18), but AFR was associated with higher rates of fluid overload (21% vs 6%, aRR 2.85, 95% CI 1.36–5.94). On average, patients in the AFR group received 7.8 L compared with 5.5 L in the MFR group. There were no differences in secondary outcomes such as organ failure, local complications, respiratory failure, necrotizing pancreatitis, intensive care unit admission, or length of hospitalization. The results were similar in prespecified subgroup analyses for patients with baseline hypovolemia or systemic inflammatory response syndrome. A study limitation was the exclusion of a large number of subjects who did not meet the relatively strict timelines for symptom duration or diagnosis (276 out of 676 screened patients, 41%). Thus, the results might not be applicable to the almost one-half of patients with acute pancreatitis who present late. In addition, the inability to meet the sample size as a result of the early termination could have affected the detection of differences in the measured outcomes. Nonetheless, the results of this trial support the use of MFR rather than AFR in patients with acute pancreatitis. Some questions regarding the optimal fluid resuscitation strategy in acute pancreatitis remain. For example, is Ringer’s the best solution? Should the fluid resuscitation be even more restrictive, especially if oral feeding is commenced early? Or would early aggressive fluid resuscitation for a short period be beneficial?

Penalized Spline-Involved Tree-based (PenSIT) Learning for estimating an optimal dynamic treatment regime using observational data.

Dynamic treatment regimes are a set of time-adaptive decision rules that can be used to personalize treatment across multiple stages of care. Grounded in causal inference methods, dynamic treatment regimes identify variables that differentiate the treatment effect and may be used to tailor treatments across individuals based on the patient's own characteristics - thereby representing an important step toward personalized medicine. In this manuscript we introduce Penalized Spline-Involved Tree-based Learning, which seeks to improve upon existing tree-based approaches to estimating an optimal dynamic treatment regime. Instead of using weights determined from the estimated propensity scores, which may result in unstable estimates when weights are highly variable, we predict missing counterfactual outcomes using regression models that incorporate a penalized spline of the propensity score and other covariates predictive of the outcome. We further develop a novel purity measure applied within a decision tree framework to produce a flexible yet interpretable method for estimating an optimal multi-stage multi-treatment dynamic treatment regime. In simulation experiments we demonstrate good performance of Penalized Spline-Involved Tree-based Learning relative to competing methods and, in particular, we show that Penalized Spline-Involved Tree-based Learning may be advantageous when the sample size is small and/or when the level of confounding of the outcome is high. We apply Penalized Spline-Involved Tree-based Learning to the retrospectively-collected Medical Information Mart for Intensive Care dataset to identify variables that may be used to tailor early fluid resuscitation strategies in septic patients.

Fluid Resuscitation Aggravates the Cellular Injury in a Hemorrhagic Shock Model

Background: Resuscitation is the initial step for hemorrhagic shock. However, there is still controversy as to which fluid achieves the best results clinically and experimentally. Aim: It was aimed to investigate the effects of 0.9% NaCl (sodium chloride) and 6% HES (hydroxyethyl starch) on the kidney and blood environment. Methods: Twenty-four male Wistar rats were assigned as control, shock, and resuscitated (colloid: 6% HES and crystalloid: 0.9% NaCl) groups. Besides hemodynamics (mean arterial pressure and shock index) monitoring and kidney function evaluation, hemolysis, oxidative stress, inflammation, and glycocalyx degradation were evaluated in the plasma and kidney. Results: (1) Macrohemodynamics were successfully restored by both fluids. (2) Although 3 times more crystalloid volume was applied compared to the colloid resuscitation, similar hematocrit levels were found in both resuscitation strategies (32.8 ± 2.3 vs. 33.3 ± 1.0). (3) NaCl resuscitation led to increases in the hemolytic index, catalytic iron, and sialic acid compared to control, while HES administration increased the levels of malondialdehyde, ischemia-modified albumin, and sialic acid. (4) However, both fluid resuscitation strategies could inhibit inflammation and oxidative stress in the kidney and restore kidney function parameters. Conclusion: Although both NaCl and HES resuscitation showed protection of the kidney function against oxidative stress and inflammation, these fluids initiated the injury process.

A Protective Fluid Resuscitation Strategy In HF Patients With Sepsis Does Not Significantly Influence Mortality

<h3>Objective</h3> : Administration of at least 30mL/kg of IV crystalloids within the first 3 hours of recognition of sepsis is the current fluid resuscitation goal per the 2018 Surviving Sepsis Campaign update. However, sepsis and concomitant heart failure create a challenging clinical scenario due to fear of volume overload. Our meta-analysis sought to determine if this strategy vs. lower infusion rates influences in-hospital mortality for heart failure patients with sepsis. <h3>Methods</h3> : The terms "heart failure" and "sepsis" or "septic shock" and "fluid bolus" or "fluid administration" were used in Embase and Pubmed. Studies were included if they had: sepsis patients with heart failure, or a subgroup of patients with heart failure, and mortality data on these patients that did or did not meet the 30mL/kg-by-3 hour (30 × 3) goal. Five eligible studies were found. The odds ratio and 95% confidence interval for mortality among HF patients with sepsis who received <30 × 3 vs. at least 30 × 3 were calculated for the five studies using their mortality data. The mortality data from the five studies were totaled to calculate a total odds ratio and 95% CI. <h3>Results</h3> : One study demonstrated a statistically significant increase in the odds ratio for in-hospital mortality when comparing the <30 × 3 vs. the 30 × 3 group (OR 2.96; 95% CI 1.18-7.41) (Table 1 and Figure 1). All other studies demonstrated a non-significant increase in odds of in-hospital mortality. Totaling the data from these studies resulted in 616 patients with HF and sepsis. 78 of the 281 in the <30 × 3 group died and 84 of the 335 in the 30 × 3 group died (OR=1.14; 95% CI 0.84-1.64). <b>Conclusions</b>: Our meta-analysis shows a non-significant increase in odds of in-hospital mortality among hospitalized HF patients with sepsis/septic shock who received a restrictive resuscitation strategy compared to those who met the 30 × 3 goal. This study highlights the need for larger prospective trials to study this interaction further. Limitations include the retrospective nature of the studies. Additional work is needed to account for the influence of systolic vs. diastolic heart failure history, sepsis severity, pressor requirement, ICU vs. non-ICU level of care, and use of invasive hemodynamic monitoring to guide resuscitation.

Fluid resuscitation strategy and efficacy evaluation in shock stage in severely burned children with different burn areas in different age groups

Fluid resuscitation strategy and efficacy evaluation in shock stage in severely burned children with different burn areas in different age groups

Restricted sub-tree learning to estimate an optimal dynamic treatment regime using observational data.

Dynamic treatment regimes (DTRs), consisting of a sequence of tailored treatment decision rules that span multiple stages of care, present a unique opportunity in our drive toward personalized medicine. Given that estimation of optimal DTRs is often exploratory and communication with clinicians is vital, robust and flexible methods that yield interpretable results are needed. Tree-based methods utilizing a purity measure defined on the full set of covariates have enjoyed much success in meeting this goal. Often, however, it is necessary for clinical, practical, or ethical reasons to restrict certain covariates that should be used when making treatment decisions. Herein we present restricted sub-tree learning (ReST-L), a flexible and robust, sub-tree-based method to estimate an optimal multi-stage multi-treatment DTR that enables restrictions to the set of prespecified candidate tailoring variables. ReST-L employs a purity measure derived from an augmented inverse probability weighted estimator for the counterfactual mean outcome, using observational data to build multi-stage decision trees that are restricted in sub-tree spaces defined by the corresponding prescriptive covariates. We show that ReST-L is able to correctly estimate the optimal DTR searching over a large number of variables with relatively small sample sizes and improves upon competing estimation methods. We demonstrate the utility of ReST-L to estimate a two-stage fluid resuscitation strategy for patients admitted to an intensive care unit with acute emergent sepsis.

What's New in Shock, July 2021?

What's New in Shock, July 2021?

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial

BackgroundFluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.MethodsA pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan–Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built.ResultsA total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications.ConclusionAmong postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

Crossing the rubicon: Exploring different peri – Operative fluid resuscitation strategies in traumatic extremity free tissue transfer- a retrospective case control study

Free tissue transfer has added to the plastic surgeon's armamentarium and has afforded patients more chances towards limb salvage in recent decades following severe trauma. Venous congestion is a common occurrence, can be the result of several reasons and has devastating results in patients' outcomes. Recent studies have highlighted the importance of restrictive fluid administration. We hypothesized that a restrictive fluid administration in the intra – operative period would be associated with a lower incidence of venous congestion in patients undergoing free flap reconstruction of traumatic defects of the extremities. All patients undergoing a perforator free flap soft tissue reconstruction of traumatic defects of the extremities, from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities and technical aspects of the operation were extracted. The study population was divided in two groups based on the amount of fluids administered (restrictive: < 6 ml/kg/hr; liberal: ≥ 6 ml/kg/hr). Multivariate analyses were performed to identify the impact of fluid strategy on the development of clinically significant venous congestion. A total of 75 patients were identified. Out of these, 24 patients had clinically significant venous congestion. Fluid administration strategy [AOR (95% CI): 1.53 (1.22, 1.92)], use of the superficial venous system [0.03 (0.01, 0.26)], operative time [1.98 (1.97, 1.99)] and age>50 [5.60 (1.10, 28.52)]. A cut – off analysis identified 6 ml/kg/hr as the cut off point for fluid administration. Liberal fluid administration (≥6 ml/kg/hr) was independently associated with a higher incidence of venous congestion and return to the OR for flap debridement, both overall and after exclusion of anastomotic revisions. Venous congestion in free flap reconstruction following traumatic defects of the extremities remains high. Several factors are associated with congestion. Liberal fluid administration ≥6 ml/kg/hr is independently associated with this complications and should be avoided when possible. • Free Fasciocutaneous tissue transfer in lower extremity trauma is challenging. • Venous congestion can result in complete or partial flap loss. • Peri – operative fluid administration has been shown to increase the complication rate infree flaps. • Fluid administration intra – operative of more than 6 ml/kg/hr resulted in a higher incidence of venous congestion. • Judicious fluid administration may be warranted.