Volume Of Fluid Resuscitation Research Articles

Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients With Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis

Initial fluid resuscitation volume for sepsis is controversial, particularly in patients at high baseline risk for complications. This study was designed to assess the association between 30mL/kg crystalloids and intubation in patients with sepsis or septic shock and heart failure, end-stage renal disease, or cirrhosis. This propensity score-matched retrospective cohort study included patients with sepsis or septic shock admitted to a large medical ICU. Primary exposure was IV fluid volume in the first 6h following sepsis diagnosis, divided into two cohorts:≥ 30mL/kg (standard group) and< 30mL/kg (restricted group). The primary outcome was need for mechanical ventilation within 72h following initiation of fluid resuscitation. Secondary outcomes were length of stay, ventilator days, and time to intubation. A total of 208 patients were included, with 104 (50%) in the restricted group (<30mL/kg) and 104 in the standard group (≥ 30mL/kg). No difference in intubation incidence was detected between the two groups, with 36 patients (35%) in the restricted group and 33 (32%) in the standard group (adjusted OR, 0.75; 95%CI, 0.41-1.36; P= .34) intubated. There was no difference between standard and restricted groups in alive ICU-free days (17 ± 11days vs17 ± 10days; P= .64), duration of mechanical ventilation (10 ± 12days vs11 ± 16days; P= .96), or hours to intubation (16 ± 19h vs14 ± 15; P= .55). No differences were detected in the incidence of intubation in patients with sepsis and cirrhosis, end-stage renal disease, or heart failure who received guideline-recommended fluid resuscitation with 30mL/kg compared with patients initially resuscitated with a lower fluid volume.

Quantifying the Volume of Fluid Resuscitation Required to Normalize Lactate in Septic Patients

Wang, Andrew MD; Dhillon, Navpreet K. MD; Ko, Ara MD; Rottler, Nicholas P. MD; Barmparas, Galinos MD, FACS; Ley, Eric J. MD, FACS Author Information

An Interdisciplinary Code Sepsis Team to Improve Sepsis-Bundle Compliance: A Quality Improvement Project

ProblemSepsis is one of the leading causes of mortality, with more than 700,000 hospitalizations and 200,000 deaths annually. Various tools exist to aid in the early identification and treatment of sepsis, including electronic alert systems, standardized order sets, nurse-initiated protocols (NIPs) and specially trained teams. Despite available guidelines, mortality rates for severe sepsis and septic shock are near 50%. MethodsThe aims of this rapid cycle quality improvement project were to develop and implement an interdisciplinary team to address early implementation of sepsis bundles in the emergency department and to compare sepsis bundle compliance 3 months pre- and 3 months postintervention implementation. The population included all patients above 18 years of age presenting to the emergency department with clinical indications of sepsis, severe sepsis, or septic shock. Data were collected via electronic health records (EHRs), switchboard-paging records, and a billing database. ResultsThe pre-post intervention analysis shows an improvement in time to each bundle element except antibiotics and completion of blood cultures. There were noteworthy changes in meeting bundle compliance in fluid resuscitation volume (χ2 = 16.3, P ≤ 0.001): initial lactate collected within 180 min (χ2 = 11.3, P ≤ 0.01) and time to second lactate within 360 min (χ2 = 27.7, P ≤ 0.001). Mortality rates showed a steady decline from over 12% to 5%. No differences were found in mortality rates related to age or gender. DiscussionInterprofessional teams can use existing knowledge, skills, and tools to improve sepsis-bundle compliance and mortality outcomes in patients with sepsis presenting to the emergency department.

THE ROLE OF INFERIOR VENA CAVA DIAMETER VARIATION RATIO MEASURED BY ULTRASONOGRAPHY VERSUS CENTRAL VENOUS PRESSURE IN ASSESSMENT OF VOLUME RESPONSIVENESS OF SHOCKED HEPATIC PATIENTS

Background: Liver cirrhosis is a major cause of morbidity and mortality in chronic liver disease patients which is multifactorial in nature, leading to several complications including ascites, variceal bleeding, hepatic encephalopathy and hepatorenal syndrome. Aim of the study: to evaluate the relationship between inferior vena cava (IVC) diameter variation ratio measured by ultrasonography (USG) versus central venous pressure as measured via central venous catheter, and whether it is reliable for use in evaluating intravascular volume status during the management of shock in hepatic patients. Patients and Methods: This study included one hundred cirrhotic liver patients with Child-Pugh classification B and C with acute circulatory failure of either sex, aging ≥18 years old, admitted in the ICU at Ain Shams University hospitals. A standard resuscitation strategy was applied. The patients were monitored using mean arterial blood pressure (MAP), heart rate (HR), central venous pressure (CVP) and ultrasound guided IVC collapsibility index (IVCCI) simultaneously at baseline and along the subsequent stages of standard shock management protocol at intervals 1, 4 and 8 hours. Results: The current study showed that 77 patients (77%) responded to volume resuscitation with improvement as regard elevated MAP with maximal mean value of 67.34 (±4.01) mmHg., decreased HR with minimal mean value of 103 (±4.89) b/min., elevated central venous pressure with maximal mean value of 9.05(±2.07) cmH2O and decreased IVC- CI with minimal mean value of 0.64 (±0.05) after 8 hours of volume management, these patientswere considered volume responders., while 23 patients (23%) didn’t respond to volume resuscitation with no response or even deterioration as regard low MAP with maximal mean value of 49.61 (±3.56) mmHg., high HR with minimal mean value of 133 (±4.86) b/min., low central venous pressure with maximal mean value of 2.17 (±0.78) cmH2O and low fixed IVC- CI with minimal mean value of 0.39 (±0.06) after 8 hours of volume management, despite maximal possible volume of fluid resuscitation necessitating use of vasopressor agents, these patients were considered volume non responders.Conclusion: Measurements of CVP and IVC-CI throughout the study in volume responder patients were found to have a solid negative correlation denoting that Inferior Vena Cava collapsibility index assessment is a safe option being non invasive technique and sensitive at least when compared to measuring CVP and to avoid complications of central venous line (CVL) insertion with its complications especially in hepatic patients with coagulopathy.

Hyperchloremia in Intensive Care Unit Mortality: An Underestimated Fact.

ObjectiveThe goal of the study was to determine the percentage of hyperchloremia in patients who died in medical intensive care unit (ICU) and thus emphasizing the need of avoiding chloride-rich solutions due to their deleterious effects.Study designWe conducted a retrospective study of data from 206 patients who expired in medical ICU in one year from January 2017 to December 2017 in the department of critical care medicine at Shifa International Hospital, Islamabad.Material and methodsThe study included 206 patients: 93 (43.1%) men and 123 (56.9%) women, over the age of 18 years who expired in medical ICU in one year from January 2017 to December 2017. Patients included for the study were all those who expired with any diagnosis but those who remained admitted in ICU for at least 72 hours and received intravenous fluids. The serum chloride levels of the patients at the time of admission and at 72 hours of stay in ICU were collected. The patients who were having serum chloride levels of 107 milliequivalent per deciliter (meq/dl) or more were labeled as having hyperchloremia. The data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Crop., Armonk, NY, USA). The mean and standard deviations were calculated for continuous variables while frequency and percentages were calculated for qualitative variables.ResultsAmong 206 patients who expired in our ICU, 109 (50.5%) patients had hyperchloremia at 72 hours of admission in ICU while 107 (49.5%) patients did not had hyperchloremia. Hyperchloremia was more frequent in patients with sepsis or septic shock.ConclusionHigher percentage (50.5%) of hyperchloremia at 72 hours of admission among patients (who expired in our medical ICU) indicates excessive use of chloride-rich intravenous fluids. This finding may have significant impact on mortality along with other contributing factors that lead to death of the patients. Keeping in view the findings of the study, chloride-rich solutions should be used carefully to counter the effects of hyperchloremia in patients requiring large volume fluid resuscitation in ICU. Fluids with lower content of chloride such as lactated ringer may be equally good in large volume fluid resuscitation with advantage of avoiding hyperchloremia.

Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study.

Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.

The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy.

To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. Therapeutic study, level IV.

Intraabdominal hypertension/abdominal compartment syndrome after pelvic fractures: How they occur and what can be done?

BackgroundLimited data exist regarding intraabdominal hypertension/abdominal compartment syndrome (IAH/ACS) after pelvic fractures. We aimed to explore risk factors for IAH/ACS in pelvic fracture patients, assess the physiological effects of decompressive laparotomy (DL) on IAH/ACS, and generate an algorithm to manage IAH/ACS after pelvic fracture. Materials and methodsPelvic fracture patients were included based on the presence of IAH/ACS. Intraabdominal pressure (IAP) was measured through a Foley catheter. DL was performed in patients with refractory IAH or ACS. Multivariable linear regression was applied to assess associations between IAP levels (≥12 mmHg) and age, sex, injury severity score (ISS), pelvic fracture, volume of resuscitation fluids over 24 h and hemoglobin values. The Wilcoxon signed-rank test for paired samples was used to compare variables before and after DL. ResultsAmong 455 pelvic fracture patients, 44 (9.7%) and 5 (1.1%) were diagnosed with IAH and ACS, respectively. The volume of resuscitation fluids over 24 h exhibited a significant positive correlation with IAP levels (≥12 mmHg) (p = 0.002). The main findings during DL were edematous bowel (11/20) and retroperitoneal hematoma (7/20). DL caused a significant decrease in the mean IAP from 24.4 ± 8.5 mmHg to 13.4 ± 4.0 mmHg (p < 0.0001). Physiological parameters (APP, PaO2/FIO2 ratio, PIP, arterial lactate and UOP) were significantly improved after DL. The mortality rate was 15% in patients who underwent DL and 40% in ACS patients. ConclusionsIAH/ACS is common in pelvic fracture patients. The most effective method to decrease IAP in pelvic fracture patients is DL. Prophylactic DL is important for decreasing mortality as it prevents IAH from progressing to ACS. Massive fluid resuscitation is a significant risk factor for IAH/ACS. A pathway incorporating prophylactic/therapeutic DL and optimized fluid resuscitation to prevent and manage IAH/ACS after pelvic fractures may reduce morbidity and mortality.

Effectiveness of Parkland formula in the estimation of resuscitation fluid volume in adult thermal burns

PurposeAcute burn resuscitation in initial 24 h remains a challenge to plastic surgeons. Though various formulae for fluid infusion are available but consensus is still lacking, resulting in under resuscitation or over resuscitation. Parkland formula is widely used but recently its adequacy is questioned in studies. This study was conducted to see how closely the actual volume of fluid given in our center matches with that of calculated volume by Parkland formula. MethodsAll patients admitted with more than 20% flame burn injury and within 8 h of incident were included in this study. Crystalloid solution for infusion was calculated as per Parkland formula; however, it was titrated according to the urine output. Data on fluid infusion were collected from patient's inpatient records and analyzed. ResultsThe study included a total of 90 patients, about 86.7% (n = 78) of the patients received fluid less than the calculated Parkland formula. Rate of fluid administered over 24 h in our study was 3.149 mL/kg/h. Mean hourly urine output was found to be 0.993 mL/kg/h. The mean difference between fluid administered and fluid calculated by Parkland formula was 3431.825 mL which was significant (p < 0.001). ConclusionThe study showed a significant difference in the fluid infused based on urine output and the fluid calculated by Parkland formula. This probably is because fluid infused based on end point of resuscitation was more physiological than fluid calculated based on formulae.

The value of volume substitution in patients with septic and haemorrhagic shock with respect to the microcirculation.

After decades of ordinary scientific interest, fluid resuscitation of patients with septic and haemorrhagic shock took centre stage in intensive care research at the turn of the millennium. By that time, resuscitation fluids were the mainstay of haemodynamic stabilisation, avoidance of vasopressors and treatment of hypovolaemia in patients in shock, but were accompanied by adverse events such as excessive tissue oedema. With the spread of early goal-directed therapy research intensified and it was realised that type, volume and timing of resuscitation fluids might affect the course and outcome of critically ill patients. At the same time, the importance of microvascular blood flow as target of resuscitation was accepted. Today, once-forbidden albumin is the recommended colloid in severe sepsis and septic shock, and the European Medical Agency is considering the removal of starch solutions from the European market because of an increased incidence of acute kidney injury and mortality. This is unprecedented, especially because the administration of low-molecular-weight starches seems to have advantages in indications other than sepsis, and because practices in fluid resuscitation have changed fundamentally since the negative starch studies. Crystalloids are still the mainstay of hypovolaemia treatment in critically ill patients, but awareness is increasing that electrolyte composition, strong ion gap, tonicity and the bicarbonate-substituting anion may have an effect on adverse effects and outcome. In haemorrhagic shock, the utilisation of crystalloids and colloids is retreating, and plasma and erythrocyte concentrates are gaining more importance in the resuscitation of the patient with acute bleeding. However, there are still influential voices warning against the liberal usage of plasma concentrates and erythrocytes in trauma and haemorrhagic shock. This review describes the evidence relating to fluid resuscitation in sepsis, septic shock and massive haemorrhage. Beside the scientific evidence based on clinical trials, possible effects on the microcirculation and, therefore, organ function will be illustrated and areas of future research highlighted. The critical appraisal of the existing evidence should enable the reader to choose the optimal volume substitution for an individual patient.

Acute Phase Response in Critically Ill Elderly Burn Patients.

Survival of elderly burn patients remains unacceptably poor. The acute phase, defined as the first 96 hours after burn, includes the resuscitation period and influences subsequent outcomes and survival. The aim of this study was to determine if the acute phase response post burn injury is significantly different in elderly patients compared with adult patients and to identify elements contributing to adverse outcomes. Cohort study. Tertiary burn center. Adult (< 65 yr old) and elderly (≥ 65 yr old) patients with an acute burn injury. None. We included all patients with an acute burn injury greater than or equal to 20% total body surface area to our burn center from 2011 to 2016. Clinical and laboratory measures during the acute phase were compared between adult and elderly patients. Outcomes included clinical hemodynamic measurements, organ biomarkers, volume of fluid resuscitation, cardiac agents, and the inflammatory cytokine response in plasma. Data were analyzed using the Student t test, Mann-Whitney U test, and Fisher exact test. A total of 149 patients were included, with 126 adults and 23 elderly. Injury severity was not significantly different among adult and elderly patients. Elderly had significantly lower heart rates (p < 0.05), cardiac index (p < 0.05), mean arterial pressure (p < 0.05), PaO2/FIO2 (p < 0.05), and pH (p < 0.05), along with higher lactate (p < 0.05). Organ biomarkers, particularly creatinine and blood urea nitrogen, showed distinct differences between adults and elderly (p < 0.05). Elderly had significantly lower levels of interleukin-6, monocyte chemotactic protein-1, monocyte chemotactic protein-3, and granulocyte-colony stimulating factor during the acute phase (p < 0.05). Overall mortality was significantly higher in elderly patients (5% vs 52%; p < 0.0001). Response to the burn injury during the acute phase response after burn is substantially different between elderly and adult burn patients and is characterized by cardiac depression and hypoinflammation.

Serial blood volume estimation in rabbits using trivalent chromium – An exploratory study

Though often used in cardiac intensive monitoring set up, simultaneous evaluation of several variables like CVP, PCWP, SVV and hTEE for fluid volume resuscitation (especially when capillary permeability is major problem than cardiac performance) is a major challenge in many ICU setups. Therefore, repetitive determination of blood volume by trivalent chromium [51Cr (III)] as a direct single variable method may be a near ideal method during fluid volume resuscitation in cases where capillary permeability is a major problem (e.g. Burns). Hence, in the present article the repeatability and reliability of 51Cr (III) method in New Zealand white rabbits was explored. Mean blood volume values of initial measurement were 195.66 ± 47.30 ml or 89.81 ± 17.88 ml/kg body weight. Repeated mean blood volume values, measured after 1 h, was 181.98 ± 53.16 ml or 83.68 ± 22.09 ml/kg body weight. The average difference between the initial and repeated measurements was 10.93 ml (95% CI −3.33, 25.19 ml), which is not statistically significant (P = 0.128). The method using 51Cr (III) for repeat blood volume measurements after sixty minutes in rabbits is a reliable method.•Rapid•Repeatable•Reliable

The effect of scenario based teaching for critical care nurses and physicians on their knowledge of fluid creep

Introduction: Fluid resuscitation is a major component of the acute management of critically ill patients. The phenomenon of providing excessive fluid resuscitation volumes has been termed “fluid creep”. Today, the science of nursing becomes more complex. Accurate fluid balance assessment and recording is important component of nursing care that assures patient’s safety especially in critically ill patients. The aim of the work is to examine the effect of scenario based teaching for critical care nurses and physicians on their knowledge of fluid balance &amp; fluid creep.Methods: The study design: pre &amp; posttest research design. Setting: This study was implemented in general, trauma, obstetric and burn intensive care units (ICUs) at Assiut university Hospital-Assiut-Egypt. Subjects: 35 critical care nurses and 29 intensive care physicians were drawn from the previously mentioned ICUs. Methodology: A pre &amp; posttest questionnaire of nurses’ and physicians’ knowledge, perception and satisfaction regarding fluid creep and fluid balance was adapted from the articles and was used in data collection before and after the application of scenario based teaching. This questionnaire was implemented on two phases (pre and after the teaching program). The data was collected from January 2018 to July 2018.Results: There is a considerable improvement in participants’ knowledge and perception concerning fluid balance and fluid creep after applying the scenario based teaching (p value &lt; .001).Conclusions: Nowadays, nurses and physicians need advanced level of knowledge to be able to deal with the physiological changes that occur in critically ill.

Use of Vasopressor Increases the Risk of Mortality in Traumatic Hemorrhagic Shock: A Nationwide Cohort Study in Japan.

To evaluate the possible association of vasopressor use with mortality in traumatic hemorrhagic shock patients. Retrospective cohort study. Traumatic hemorrhagic shock patients at 260 emergency hospitals in Japan between 2004 and 2015. Three-thousand five-hundred fifty-one traumatic hemorrhagic shock patients who had systolic hypotension (< 90 mm Hg) on arrival at the emergency department and a blood transfusion received within the first 24 hours. The use of vasopressor for traumatic hemorrhagic shock within the first 24 hours. Among 236,698 trauma patients, 3,551 were included in the study. Overall, 198 of 459 patients (43%) in the vasopressor+ group expired compared with 481 of 3,092 patients (16%) in the vasopressor- group. Use of vasopressor had an odds ratio of 2.172 (95% CI, 1.666-2.833) for in-hospital mortality adjusted for age, gender, year of onset, cause of injury, mechanism of injury, vital signs at the emergency department, Injury Severity Score, use of prehospital IV fluid, and volume of blood transfusion within the first 24 hours. In the propensity score-matched cohort and two subgroup analyses (massive transfusion and survivable injury models), use of vasopressor was associated with higher mortality (odds ratio, 2.168; 95% C, 1.442-3.320), (odds ratio, 2.029; 95% CI, 1.414-2.911; massive transfusion model), and (odds ratio, 1.959; 95% CI, 1.364-2.814; survivable injury model). Use of vasopressor for traumatic hemorrhagic shock was associated with mortality after controlling for biases (trauma severity; volume of fluid resuscitation).

Perioperative Fluid Accumulation Impairs Intestinal Contractility to a Similar Extent as Peritonitis and Endotoxemia.

Perioperative resuscitation with large amounts of fluid may cause tissue edema, especially in the gut, and thereby impairing its functions. This is especially relevant in sepsis where capillaries become leaky and fluid rapidly escapes to the pericapillary tissue. We assessed the effects of endotoxemia and peritonitis, and the use of high and moderate volume fluid resuscitation on jejunal contractility. We hypothesized that both endotoxemia and peritonitis impair jejunum contractility and relaxation, and that this effect is aggravated in peritonitis and with high fluid administration. Pigs were randomized to endotoxin (n = 16), peritonitis (n = 16), or sham operation (n = 16), and either high (20 mL/kg/h) or moderate volume (10 mL/kg/h) fluid resuscitation for 24 h or until death. At the end of the experiment, jejunal contractility and relaxation were measured in vitro using acetylcholine and sodium nitroprusside reactivity, and the effect of nitric oxide synthase inhibition (NOS-I) was assessed. Mortality in the respective groups was 88% (peritonitis high), 75% (endotoxemia high), 50% (peritonitis moderate), 13% (endotoxemia moderate and sham operation high), and 0% (sham operation moderate volume resuscitation). Although gut perfusion was preserved in all groups, jejunal contractility was impaired in the two peritonitis and two endotoxemia groups, and similarly also in the sham operation group treated with high but not with moderate volume fluid resuscitation (model-fluid-contraction-interaction, P = 0.036; maximal contractility 136 ± 28% [average of both peritonitis, both endotoxemia and sham operation high-volume groups) vs. 170 ± 74% of baseline [sham operation moderate-volume group]). NOS-I reduced contractility (contraction-inhibition-interaction, P = 0.011) without significant differences between groups and relaxation was affected neither by peritonitis and endotoxemia nor by the fluid regimen. Intestinal contractility is similarly impaired during peritonitis and during endotoxemia. Moreover, perioperative high-volume fluid resuscitation in sham-operated animals also decreases intestinal contractility. This may have consequences for postoperative recovery.

An algorithm for responsive fluid resuscitation at the Western Cape Provincial Tertiary Adult Burn Centre

Fluid resuscitation and its role in the management of burns patients has an important link to the outcome of these patients and their injuries. The algorithm designed in this research utilises the modified Parklands formula, and includes instances where albumin can limit fluid overload in severe cases that may require large volumes of fluid resuscitation. It is also a schematic intended to be understandable and easy to execute by various staff members, as part of the resuscitation team. As such, it is not all-inclusive, but covers the important areas of fluid balance, and additional measurements to complete the resuscitation process in qualifying patients with burn injuries.

Burn injury and multiple sclerosis: A retrospective case-control study

ObjectivesThe purpose of this study was to determine whether having a previous diagnosis of multiple sclerosis (MS) changed acute care needs in burn-injured patients. MethodsThis was a retrospective case-control study that included adult (aged ≥18years) patients with an acute burn injury. Control patients were matched with eleven patients with a history of MS at a 4:1 ratio. Outcomes included fluid resuscitation volumes, temperature, heart rate, mean arterial pressure, in-hospital complications, and hospital length of stay (LOS). ResultsThere were fifty-five patients included and of those, eleven had a documented history of MS. Fluid resuscitation volumes, temperature, heart rate, and mean arterial pressure were similar between groups during the resuscitation period (p>0.05). LOS was similar between both groups (12, IQR: 2–17 vs. median 16, IQR: 12–21; p=0.090). However, when normalized to % TBSA burn, patients with MS had a significantly higher median LOS/% TBSA burned (1.2, IQR: 0.7–2.0 vs. 2.1, IQR: 1.1–7.1; p=0.031). ConclusionsPatients with concurrent burn injuries and MS have a significantly longer LOS/% TBSA burn suggesting that more time is required to heal their wounds. Surprisingly, there were no other significant differences in the after the burn acute phase between these two cohorts.

Emergency Care of the Burn Patient Before the Burn Center: A Systematic Review and Meta-analysis.

Good burn care starts with correct management of the burn patient before transfer to a burn center. The purpose of this study was to perform a systematic review of the medical literature describing preburn center care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review. Studies were included if they were published from a burn center and they measured or evaluated any aspect of preburn center care of adult or pediatric acute burn patients referred to that burn center. A comprehensive search of MEDLINE, EMBASE, and Cochrane databases was performed from their inception to May 28, 2018. Outcomes of interest included errors in burn size estimation, airway management, fluid resuscitation, dressings and wound care, use of systemic antibiotics, core temperature monitoring and preservation, and analgesia provision. Meta-analysis of the discrepancy between preburn center and burn center burn size estimation was conducted. From 3768 initially identified titles, 37 studies were included in this systematic review. Burn size estimation was frequently inaccurate. The ratio of overestimation to underestimation in burn size ranged between 2.2:1 and 19:1. The pooled mean absolute error in % total body surface area burn was 6.28 (95% CI: 4.72, 7.85). The average relative percent error in burn size estimation by referring providers ranged between 75% and 3500%. Unnecessary endotracheal intubation was performed in 28% to 53% of transfers. Over-estimation and over-delivery of fluid resuscitation volumes was prevalent, but other problems pertaining to resuscitation included administration of the wrong fluid and failure to titrate fluids. Wounds were not consistently covered with simple dry dressings or sheets. Core temperature was not consistently monitored or preserved. Analgesics were often not given or were of insufficient dose. Many elements of preburn center care need improvement. These findings should be used to form the foundation of future initiatives between burn professionals and emergency providers to improve care of the burn patient before transfer to a burn center.

Small volume resuscitation with 20% albumin in intensive care: physiological effects : The SWIPE randomised clinical trial.

We set out to assess the resuscitation fluid requirements and physiological and clinical responses of intensive care unit (ICU) patients resuscitated with 20% albumin versus 4-5% albumin. We performed a randomised controlled trial in 321 adult patients requiring fluid resuscitation within 48h of admission to three ICUs in Australia and the UK. The cumulative volume of resuscitation fluid at 48h (primary outcome) was lower in the 20% albumin group than in the 4-5% albumin group [median difference - 600ml, 95% confidence interval (CI) - 800 to - 400; P < 0.001]. The 20% albumin group had lower cumulative fluid balance at 48h (mean difference - 576ml, 95% CI - 1033 to - 119; P = 0.01). Peak albumin levels were higher but sodium and chloride levels lower in the 20% albumin group. Median (interquartile range) duration of mechanical ventilation was 12.0h (7.6, 33.1) in the 20% albumin group and 15.3h (7.7, 58.1) in the 4-5% albumin group (P = 0.13); the proportion of patients commenced on renal replacement therapy after randomization was 3.3% and 4.2% (P = 0.67), respectively, and the proportion discharged alive from ICU was 97.4% and 91.1% (P = 0.02). Resuscitation with 20% albumin decreased resuscitation fluid requirements, minimized positive early fluid balance and was not associated with any evidence of harm compared with 4-5% albumin. These findings support the safety of further exploration of resuscitation with 20% albumin in larger randomised trials. http://www.anzctr.org.au . Identifier ACTRN12615000349549.

COLLOIDS VS CRYSTALLOIDS FOR POSTOPERATIVE RESUSCITATION IN PATIENTS UNDERGOING OFF-PUMP CORONARY ARTERY BYPASS SURGERY

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Coronary Artery Bypass Grafting (CABG) may be associated with a postoperative systemic inflammatory response syndrome, increased vascular capacitance, third-space fluid shifts, and high preload requirements, thus mandating zealous fluid resuscitation. These effects may be somewhat mitigated by avoiding the use of extra-corporeal circulation during the procedure, completing the operation off-pump. Indeed, over-aggressive fluid management in patients undergoing off-pump coronary artery bypass (OPCAB) can have adverse impacts upon ventilation requirements, gas-exchange, transfusion needs, and also effect length of stay and overall morbidity. There is a paucity of data regarding the optimal type of fluids to utilize postoperatively specifically in patients who have OPCAB surgery. We sought to analyze perioperative outcomes in patients who had primary OPCAB surgery, comparing those individuals who received colloids vs. those who were given crystalloid fluids for postoperative resuscitation. METHODS: A comprehensive retrospective review was undertaken of all patients who underwent first-time OPCAB surgery at our institution between 2012 and 2016. Of these, 50 cases were selected at random, 25 of whom received albumin (colloid) as their fluid resuscitation postoperatively, as compared with the remaining 25 patients, all of whom were given crystalloid. The type of fluid that was administered at the time to any given patient was at the discretion of the treating physician. Perioperative outcomes were analyzed using linear & logistic regression, where appropriate. RESULTS: Both patient groups were well-matched for all demographic factors. The albumin cohort had significantly longer ICU and overall lengths of stay (p = 0.007, p = 0.01, respectively). The albumin group demonstrated a greater degree of (temporary) worsening of renal function than did those patients who received crystalloid (p = 0.0036). The crystalloid group required greater total volume of fluid resuscitation than did the colloid group (p < 0.0001). There was no difference between patient groups with respect to vasopressor requirements, ventilation times, perioperative bleeding, or need for transfusion. CONCLUSIONS: Crystalloids after OPCAB surgery are at least as effective as colloids for postoperative resuscitation, and may be associated with better preservation of renal function, and with shorter lengths of stay, concomitantly reducing overall cost and resource utilization. CLINICAL IMPLICATIONS: Crystalloids after OPCAB surgery are at least as effective as colloids for postoperative resuscitation, and may be associated with better preservation of renal function, and with shorter lengths of stay, concomitantly reducing overall cost and resource utilization. DISCLOSURES: No relevant relationships by Jessica Nino, source=Web Response No relevant relationships by Kush Dholakia, source=Web Response No relevant relationships by Jonathan Hemli, source=Web Response No relevant relationships by Crystal Kyaw, source=Web Response No relevant relationships by Efstathia Mihelis, source=Web Response Owner/Founder relationship with Hearth Repair Technology Please note: $1-$1000 Added 02/13/2018 by Nirav Patel, source=Web Response, value=Ownership interest No relevant relationships by Samuel Scheinerman, source=Web Response