Fluid Therapy Protocol Research Articles

New fluid therapy protocol in acute burn from a tertiary burn care centre

BackgroundRinger lactate is the main fluid for resuscitation of acute burns. However it is not a complete fluid alone, as it does not take care of sugar and electrolyte balance adequately. This study has been carried out to compare the use of Ringer lactate (RL) alone and combination of RL with Dextrose Normal Saline (DNS) as fluid replacement therapy in acute burn. ObjectiveTo assess the biochemical parameters with the use of DNS as maintenance fluid in combination with Ringer lactate as resuscitation fluid in acute burns resuscitation. MethodA prospective randomized control study has been carried out by enrolling 200 patients into 2 groups, treated in ICU and resuscitated by using Modification of Brooke’s formula (2mL/kg/% TBSA for resuscitation plus 2500mL maintenance). Group A received RL for resuscitation and DNS as maintenance in 1st 72h of burns. Group B received RL only for 1st 72h. The effects of this on various blood parameters were studied. ResultsMean value of sodium at 24h was 137.79±3.89 in group A and was 133.2±4.57 (p<.0001) in group B. The sodium levels remained in range of 137–138 (p<.0001) in group A with only 22% patients showing lower range of sodium levels, whereas, there was a falling trend (p<.0001) of sodium levels in group B on subsequent days with 54.00% (p<.0001) showing hyponatremia on 1st day which increased to 76% on 3rd day. Mean values of early morning random blood sugar (RBS) levels in group A remained between 165.5±65.51mg/dL–115.82±32.52mg/dL on all 3days but in group B there was a falling trend from 127.49±46.11mg/dL to 102.84±22.92mg/dL by 3rd day. Thus, there was significant difference in levels of sodium and RBS in patients receiving DNS as maintenance fluid in addition to RL in acute phase. ConclusionRL is not an ideal fluid for maintenance as it is low in sodium (130mEq/L) as well as potassium (4mEq/L) in view of daily electrolyte requirement. There is no glucose content in it to provide calories. Therefore, DNS should be added as daily maintenance fluid with RL as replacement for evaporative losses following burns.

Fluid therapy protocols in people with acute pancreatitis

Fluid therapy protocols in people with acute pancreatitis

Effects of different fluid therapy protocols on postoperative nausea and vomiting in pediatric patients undergoing ambulatory surgery

Objective To evaluate the effects of different fluid therapy protocols on postoperative nausea and vomiting (PONV) in pediatric patients undergoing ambulatory surgery. Methods A total of 160 pediatric patients, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, aged 3-7 yr, weighing 14-24 kg, with body mass index <30 kg/m2, undergoing elective lower abdominal ambulatory surgery, were randomized into Ⅰ and Ⅱ groups (n=80 each) using a random number table method.Lactated Ringer′s solution 10 ml·kg-1·h-1 and 30 ml·kg-1·h-1 were intravenously infused in group Ⅰand group Ⅱ, respectively.Ibuprofen 20 mg/kg was given orally after operation to maintain Face Legs Activity Cry Consolability score ≤4.The development of PONV and thirst and requirement for antiemetics was recorded within 24 h postoperatively.The time of first PONV, time of first thirst and score for satisfaction of family members were also recorded. Results Compared with group Ⅰ, the incidence of PONV and thirst was significantly decreased, the time of first requirement for antiemetics and time of first thirst were prolonged, and the score for satisfaction of family members was increased (P 0.05). Conclusion Intravenously infusing fluid 30 ml·kg-1·h-1 can decrease the occurrence of PONV when compared with intravenously infusing fluid 10 ml·kg-1·h-1 in pediatric patients undergoing ambulatory surgery. Key words: Children; Fluid therapy; Postoperative nausea and vomiting; Day care

Effect of Implementing Fluid Therapy Protocol on Pregnant and Postpartum Women Outcomes Who At Risk For Developing Acute Kidney Injury

Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many people. Aim of the study was to evaluate the effect of implementing fluid therapy protocol for pregnant and postpartum women outcomes who at risk for developing acute kidney injury. Patients and Methods: Quasi experimental research design was used to conduct this study; the study was carried out in Obstetric ICU at Assiut University Hospital. The study sample consisted of intervention group (15 patients) who received fluid therapy protocol and control group (15 patients) who received only the routine hospital care, the study was conducted in 6 months. Tools: first tool Renal impairment assessment sheet, second tool Protocol of fluid flow chart , third tool Patients' outcomes evaluation sheet. Results: No patients in the intervention group developed acute kidney injury but 60% of control group developed AKI with a statistical significant difference between intervention and control groups in relation to developing AKI (P=0.001). Conclusion: Implementing fluid therapy protocol was significantly effective in preventing developing AKI among at risk pregnant and postpartum women. Recommendations: Emphasize on the importance of accurate monitoring of urine output and CVP in obstetric patients who at risk for developing AKI in detection and preventing any problem or deterioration.

Risk factors associated with case fatality in 225 diarrhoeic calves: A retrospective study

The aim of this retrospective study was to identify the major risk factors associated with case fatality in diarrhoeic calves undergoing a standard therapeutic protocol. Clinical and laboratory findings were reviewed in 225 Holstein Friesian diarrhoeic calves over a 2 year period. Calves were treated according to a fluid therapy protocol using an oral electrolyte solution or an IV infusion. After therapy, 159 calves were discharged in a healthy state, whereas 66 calves died. Logistic regression analysis showed that serum total protein (STP) concentration (odds ratio, OR, 0.51; 95% confidence interval, CI 0.31–0.84; P<0.01) and the strength of suckle reflex (OR 4.83; CI 1.17–19.88; P<0.05) were the major risk factors associated with case fatality in diarrhoeic calves. These results could help to distinguish between diarrhoeic calves with a good prognosis and those with a major risk of treatment failure.

The impact of using an intraoperative goal directed fluid therapy protocol on clinical outcomes in patients undergoing total pancreatectomy and islet cell autotransplantation

BackgroundPatients undergoing total pancreatectomy and islet cell autotransplant (TPIAT) for treatment of pancreatitis are at risk for complications of over and under resuscitation. We hypothesized that using a goal directed fluid therapy (GDFT) protocol might impact clinical outcomes. Materials and methodsA consecutive series of adult patients undergoing TPIAT were managed intraoperatively using either standard fluid therapy (SFT, n = 44) or GDFT (n = 23) as part of a pilot study between January 2013 and May 2015. Patient characteristics, intraoperative, and postoperative data were recorded prospectively, then retrospectively analyzed for differences between the groups. ResultsThe GDFT group had lower total fluid resuscitation (3,240 cc vs 5,173 cc, p < 0.0001) and transfusion requirements (1.0 cc/kg vs 3.3 cc/kg, p = 0.050) compared to the SFT group. The pre to postop nadir hemoglobin change was significantly less for GDFT (4.2 vs 5.1 gm/dl, p = 0.021) despite less transfusion. ConclusionsCompared to SFT, using an intraoperative GDFT protocol in TPIAT patients was associated with significantly decreased intraoperative fluid resuscitation, blood transfusion and less postoperative dilutional anemia, without any difference in complications of underresuscitation. This pilot study suggests that GDFT is likely safe and further investigation is warranted.

The impact of perioperative fluid therapy on short-term outcomes and 5-year survival among patients undergoing colorectal cancer surgery – A prospective cohort study within an ERAS protocol

BackgroundRestricted perioperative fluid therapy is one of several interventions in the enhanced recovery after surgery (ERAS) protocol, designed to reduce morbidity and hospital stay after surgery. The impact of this single intervention on short and long term outcome after colorectal surgery is unknown. Patients and methodsThis cohort study includes all consecutive patients operated with abdominal resection of colorectal cancer 2002–2007 at Ersta Hospital, Stockholm, Sweden. All patients were treated within an ERAS protocol and registered in the ERAS-database. Compliance to interventions in the ERAS protocol was analysed. The impact of a restrictive perioperative fluid therapy (≤3000 ml on the day of surgery) protocol on short-term outcomes as well as 5-year survival was assessed with multivariable analysis adjusted for confounding factors. ResultsNine hundred and eleven patients were included. Patients receiving ≤3000 ml of intravenous fluids on the day of surgery had a lower risk of complications OR 0.44 (95% C I 0.28–0.71), symptoms delaying discharge OR 0.47(95% C I 0.32–0.70) and shorter length of stay compared with patients receiving >3000 ml. In cox regression analysis, the risk of cancer specific death was reduced with 55% HR 0.45(95% C I 0.25–0.81) for patients receiving ≤ 3000 ml compared with patients receiving >3000 ml. ConclusionA restrictive compared with a non-restrictive perioperative fluid therapy on the day of surgery may be associated with lower short-term complication rates, faster recovery, shorter length of stay and improved 5-year survival.

The Bariatric Patient in the Intensive Care Unit: Pitfalls and Management.

The increasing number of bariatric/metabolic operations as important alternatives for the treatment of obesity and type 2 diabetes brought several concerns about the intensive care of patients undergoing those procedures. Intensive Care Unit admission criteria are needed in order to better allocate resources and avoid unnecessary interventions. Furthermore, well-established protocols, helpful in many clinical situations, are not directly applicable to obese patients. Indeed, difficult airway management, mechanical ventilation, fluid therapy protocols, prophylaxis, and treatment of venous thromboembolic events have unique aspects that should be taken into consideration. Finally, new data related to planning nutrition therapy of the critically obese have been highlighted and deserve consideration. In this review, we provide an outline of recent studies related to those important aspects of the care of the bariatric/metabolic patients in critical conditions.

Goal-Directed Fluid Therapy Based on Stroke Volume Variation in Patients Undergoing Major Spine Surgery in the Prone Position: A Cohort Study.

A retrospective observational study. The aim of this study was to test whether a goal-directed fluid therapy (GDFT) protocol, based on stroke volume variation (SVV), applied in major spine surgery performed in the prone position, would be effective in reducing peri-operative red blood cells transfusions. Recent literature shows that optimizing perioperative fluid therapy is associated with lower complication rates and faster recovery. Data from 23 patients who underwent posterior spine arthrodesis surgery and whose intraoperative fluid administration were managed with the GDFT protocol were retrospectively collected and compared with data from 23 matched controls who underwent the same surgical procedure in the same timeframe, and who received a liberal intraoperative fluid therapy. Patients in the GDFT group received less units of transfused red blood cells (primary endpoint) in the intra (0 vs. 2.0, P = 0.0 4) and postoperative period (2.0 vs. 4.0, P = 0.003). They also received a lower amount of intraoperative crystalloids, had fewer blood losses, and lower intraoperative peak lactate. In the postoperative period, patients in the GDFT group had fewer pulmonary complications and blood losses from surgical drains, needed less blood product transfusions, had a shorter intensive care unit stay, and a faster return of bowel function. We found no difference in the total length of stay among the two groups. Our study shows that application of a GDFT based on SVV in major spine surgery is feasible and can lead to reduced blood losses and transfusions, better postoperative respiratory performance, shorter ICU stay, and faster return of bowel function. 3.

A Randomized Trial of Goal Directed vs Standard Fluid Therapy in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

The use of adequate fluid therapy during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. The aim of the study was to assess whether the use of fluid therapy protocol combined with goal-directed therapy (GDT) is associated with a significant change in morbidity, length of hospital stay, and mortality compared to standard fluid therapy. Patients American Society of Anesthesiologists (ASA) II–III undergoing CRS and HIPEC were randomized into two groups. The GDT group (N = 38) received fluid therapy according to a protocol guided by monitored hemodynamic parameters. The control group (N = 42) received standard fluid therapy. We evaluated incidence of major complications, total length of hospital stay, total amount of fluids administered, and mortality rate. The incidence of major abdominal complications was 10.5 % in GDT group and 38.1 % in the control group (P = 0.005). The median duration of hospitalization was 19 days in GDT group and 29 days in the control group (P < 0.0001). The mortality rate was zero in GDT group vs 9.5 % in the control group (P = 0.12). GDT group received a significantly (P < 0.0001) lower amount of fluid (5812 ± 1244 ml) than the control group (8269 ± 1452 ml), with a significantly (P < 0.0001) lower volume of crystalloids (3884 ± 1003 vs 68,528 ± 1413 ml). In CRS and HIPEC, the use of a GDT improves outcome in terms of incidence of major abdominal and systemic postoperative complications and length of hospital stay, compared to standard fluid therapy protocol.

Intraabdominal pressure in critical burn patients

The aim was to study the evolution and incidence of intraabdominal hypertension in critical burn patients using a slightly restrictive fluid therapy protocol based on monitoring transpulmonary thermodilution and lactic acid.

Fluid therapy and perfusional considerations during resuscitation in critically ill patients with intra-abdominal hypertension.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are consistently associated with morbidity and mortality among the critically ill or injured. Thus, avoiding or potentially treating these conditions may improve patient outcomes. With the aim of improving the outcomes for patients with IAH/ACS, the World Society of the Abdominal Compartment Syndrome recently updated its clinical practice guidelines. In this article, we review the association between a positive fluid balance and outcomes among patients with IAH/ACS and how optimisation of fluid administration and systemic/regional perfusion may potentially lead to improved outcomes among this patient population.Evidence consistently associates secondary IAH with a positive fluid balance. However, despite increased research in the area of non-surgical management of patients with IAH and ACS, evidence supporting this approach is limited. Some evidence exists to support implementing goal-directed resuscitation protocols and restrictive fluid therapy protocols in shocked and recovering critically ill patients with IAH. Data from animal experiments and clinical trials has shown that the early use of vasopressors and inotropic agents is likely to be safe and may help reduce excessive fluid administration, especially in patients with IAH. Studies using furosemide and/or renal replacement therapy to achieve a negative fluid balance in patients with IAH are encouraging. The type of fluid to be administered in patients with IAH remains far from resolved. There is currently insufficient evidence to recommend the use of abdominal perfusion pressure as a resuscitation endpoint in patients with IAH. However, it is important to recognise that IAH either abolishes or increases threshold values for pulse pressure variation and stroke volume variation to predict fluid responsiveness, while the presence of IAH may also result in a false negative passive leg raising test.Correct fluid therapy and perfusional support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension. Controlled studies determining whether the above medical interventions may improve outcomes among those with IAH/ACS are urgently required.

Restrictive parenteral fluid therapy in infants and children presenting with acute severe viral pneumonia in the PICU: a single-center experience

Acute viral (RSV and non-RSV) pneumonia is one of the most common causes of lower respiratory tract infection in infants and children. Although only 2 to 3% of infants with bronchiolitis require hospitalized management based on published literature, in recent years we see more children requiring hospitalization in high-dependency units. Most of these children require intravenous fluid therapy and some form of oxygen supplementation. As there is no standardized evidence-based parenteral fluid therapy protocol specific for acute severe viral pneumonia available, we decided to retrospectively analyze the result of our restrictive fluid therapy protocol.

Comparison of arterial and venous whole blood clot initiation, formation, and strength by thromboelastography in anesthetized swine

Thromboelastography (TEG) analysis was used to determine if differences exist between venous and arterial samples in anesthetized swine, using identical sampling techniques for each of the samples. We hypothesized that TEG parameters would not differ between native whole blood venous and arterial samples. Thirty male Landrace swines were included in the study. Both the femoral artery and vein were catheterized using standard cut-down techniques and with identically sized catheters to rule out any catheter size effects on the results. Standard TEG parameters for native whole venous and arterial blood samples (r, K, α, MA, G, and coagulation index) were measured or calculated, and t-test or Mann-Whitney rank-sum test used for comparison when appropriate. Significant differences were detected for r (venous < arterial), K (venous < arterial), α (venous > arterial), and coagulation index (venous > arterial) TEG parameters. No significant differences were measured for MA or G. These differences are important, especially when temporal changes in TEG are utilized to monitor patient stability and fluid therapy protocols using trends in coagulation properties. Taken together, these results suggest that clots are more likely to form at a faster rate in venous samples compared to arterial samples, but the overall clot strength does not differ. Therefore, if TEG analysis is being used to monitor coagulation profiles in a patient, care should be taken to use the same site and technique if results are to be used for comparative purposes.

Diabetic ketoacidosis: an overlooked child killer in sub‐Saharan Africa?

The true incidence of diabetic ketoacidosis (DKA) in sub-Saharan Africa is unknown but unlike in the Western countries, DKA is also uniquely frequent among type 2 diabetes patients of African origin. Increased hyperglycaemia and hepatic ketogenesis lead to osmotic diuresis, dehydration and tissue hypoxia. Acute complications of DKA include cerebral oedema, which may be compounded by malnutrition, parasitic and microbial infections with rampant tuberculosis and HIV. Overlapping symptoms of these conditions and misdiagnosis of DKA contribute to increased morbidity and mortality. Inability of the patients to afford insulin treatment leads to poor glycemic control as some patients seek alternative treatment from traditional healers or use herbal remedies further complicating the disease process. Standard treatment guidelines for DKA currently used may not be ideal as they are adapted from those of the developed world. Children presenting with suspected DKA should be screened for comorbidities which may complicate fluid and electrolyte replacement therapy protocol. Patient rehabilitation should take into account concurrent treatment for infectious conditions to avoid possible life-threatening drug interactions. We recommend that health systems in sub-Saharan Africa leverage the Expanded Immunization Programme or TB/HIV/AIDS programmes, which are fairly well entrenched to support diabetes services.

Goal-directed fluid and hemodynamic therapy in major colon surgery with the pressure recording analytical method cardiac output monitor (MostCare®-PRAM®): prospective analysis of 58 patients

Optimal fluid therapy in colon surgery is controversial. The aim of this study is to assess the impact on postoperatory complications, fluid administration, and length of hospital stay, of GD fluid and hemodynamic therapy protocol based on PRAM®-MostCare® hemodynamic variables.

Complexity of blood volume control system and its implications in perioperative fluid management

The use of fluid therapy attempts to optimize blood circulation by manipulating the circulating blood volume (BV). BV may be a key intermediate parameter between fluid therapy and the blood circulation, and it has been assumed that BV can be controlled by fluid therapy. In order to construct a fluid therapy protocol, firstly, we have to confirm whether BV can actually be controlled by fluid therapy. Volume kinetics studies and dilution techniques for BV measurements have enabled the actual effects of fluid management on BV to be analyzed in the presence of various pathological conditions. Various studies have shown that the effect of fluid, especially crystalloid, on BV varies considerably among individuals, and even BV values measured at a single time point vary from 40 ml kg(-1) to 110 ml kg(-1). It has become apparent that such wide variations in interindividual BV preclude the establishment of universal optimal fluid management protocols. Thus, secondly, it should be clarified how BV is controlled, and whether or not we can control it. Perioperative BV reportedly changes in a manner that is independent of the in-out fluid balance, but is related to hormonal factors. Because inflammation and some hormones control vascular permeability and the renal adjustment of solutes and fluids, such factors may readjust the BV even after interventional fluid therapy. Perioperative BV may be predominantly controlled by an internal regulatory system, regardless of whether "restrictive" or "liberal" fluid management strategies are employed. Recognizing this physiological control of BV may help us to develop individualized fluid management strategies.

Solução concentrada de albumina eqüina na fluidoterapia em eqüinos com desidratação leve a moderada

Avaliou-se o efeito da solução concentrada de albumina eqüina diluída a 5% em solução fisiológica (SF) durante fluidoterapia em eqüinos, após indução de desidratação leve a moderada, utilizando-se cinco eqüinos adultos, sem alterações clínicas. Cada animal passou por dois protocolos de fluidoterapia: apenas com SF (metade sob pressão e metade em fluxo contínuo - grupo-controle); com solução de albumina eqüina e SF (apenas em fluxo contínuo - grupo experimental). Avaliaram-se peso, exame físico geral, hematócrito, osmolalidade plasmática, gasometria, proteína total, albumina, uréia, creatinina, Na, K, débito cardíaco e pressão arterial, e calcularam-se pressão oncótica e volume plasmático. Após a aplicação de metade da SF sob pressão nos animais do grupo-controle, as alterações no hematócrito, na proteína total, na albumina, na pressão arterial e na pressão oncótica foram semelhantes às encontradas nos do grupo experimental após aplicação apenas da solução de albumina. Conclui-se que a solução de albumina eqüina é de fácil preparação e aplicação, não demonstra efeitos deletérios na dose e velocidade utilizadas e é passível de ser utilizada como colóide na fluidoterapia na espécie eqüina.

Successful treatment of severe salt intoxication in a dog

AbstractObjective: To report successful treatment of severe salt intoxication and hypernatremia in a dog.Case summary: A 5‐year‐old intact female Doberman Pinscher was admitted to the intensive care unit with a history of seizures and coma. The owner had administered approximately 100 g of cooking salt to induce vomiting following ingestion of a nontoxic dose (10 g) of chocolate. Upon admission, the dog was comatose with intermittent seizures and vomiting. Diagnostic tests confirmed salt intoxication (Na: 200 mEq/L, Cl: 180 mEq/L) and metabolic acidosis (pH: 7.18; pCO2: 39 mmHg; HCO3: 14.3 mmol/L). Immediate treatment included intravenous fluid therapy, an anticonvulsant, antiemetic, diuretic, low molecular weight heparin, and supplemental oxygen. A fluid therapy protocol was initiated to decrease serum sodium concentration by approximately 2 mEq/L/hr. After 24 hours of intensive care, the patient regained consciousness and volume and acid‐base abnormalities improved. The patient developed a variety of abnormal clinical signs as a result of the severe hypernatremia. After 5 days of treatment, the serum sodium concentration returned to the established reference range. The patient recovered completely in 10 days.New information provided: Severe hypernatremia due to salt ingestion is a rare condition in dogs. All dogs in previous case reports of salt intoxication have died. This case report is the first to report survival of a dog with severe salt intoxication.

Acute hospital-induced hyponatremia in children: A physiologic approach

Physicians giving children fluid therapy today seldom encounter overt dehydration or signs of shock that call for rapid and aggressive extracellular fluid (ECF) expansion. Physicians in the era when severe diarrheal dehydration was common first restored ECF' with isotonic saline, a then planned maintenance and replacement therapies, using hypotonic saline. Today, physicians plan fluid therapy mostly for children with pneumonia, meningitis, other acute disorders, or for children scheduled for surgery. These children are seldom overtly dehydrated or in shock. Common practice in this setting is to initiate fluid therapy with hypotonic saline as maintenance therapy. However, hyponatremia has been a worrisome complication with this practice. 1,2,3 In extreme cases, convulsions, brain injury, or death have resulted.4 Two recent articles 5,6 have recommended giving maintenance therapy as isotonic saline to avoid this risk. While authors of these articles have done a service in calling attention to the problem of hyponatremia, we believe their remedy has risks of its own. Our analysis of the cases we reviewed suggests a more physiologic approach, using tested principles of fluid therapy. In this report, we review maintenance therapy, cite clinical findings in the cases we surveyed that support subtle hypovolemia as the common cause of hyponatremia, describe the role of rapidly giving isotonic saline to correct hypovolemia, cite risks of using isotonic saline as maintenance therapy, and define a physiologically based fluid therapy protocol that avoids hyponatremia.