Intravenous (IV) fluid therapy is one of the basic procedures applied for the infusion of fluid, medicine and nutrients to patients. Continuous measurement of IV fluid level is necessary for avoiding risks like dehydration, blood reflux, air embolism and discontinuation of therapy. The current practice for measurement mainly involves manual observation of healthcare staff at regular intervals, which might delay the response in case of emergency due to workload in clinical settings. Hence, in order to resolve this problem, this paper proposes an Internet of Things (IoT) based Intra Venous (IV) Fluid Monitoring System with Real Time Alert and remote supervision of IV fluid therapy. The proposed design involves 5 kg load cell, HX711 amplifier, ESP32 microcontroller, LCD screen, buzzer and Blynk platform to monitor IV bag weight, measure the remaining amount of fluid in the bag and communicate the information wirelessly to the healthcare personnel. Alerts are set based on threshold values and generated both locally and remotely if the level reaches the critical value. The experimental testing proved that the system has an accuracy rate of 98.7%. The system exhibited reliable synchronization in the cloud, quick notifications, and consistent real-time operation, thus proving to be a cost-efficient, scalable, and effective approach towards enhancing patient safety.

The optimal mean arterial pressure (MAP) target in high-risk hypertensive patients undergoing major abdominal surgery remains unclear. The HISTAP trial evaluated whether targeting an intraoperative MAP ≥ 80 compared with ≥ 65mmHg reduces postoperative organ dysfunction and 30-day mortality, in this population. HISTAP was a multicenter, randomized trial conducted at 18 Italian centers between March 2023 and April 2025. The study included patients aged ≥ 60years with chronic hypertension requiring home therapy, undergoing elective major abdominal surgery and having at least one additional high-risk criterion. The intraoperative MAP was targeted to ≥ 80mmHg (Treatment group) or ≥ 65mmHg (Control group). The primary outcome was a composite endpoint including postoperative mortality and at least one major organ dysfunction. Of 636 randomized patients, 6 were excluded since surgery was canceled after randomization, 630 completed the trial and were included in the intention-to-treat analysis (median age, 74years [IQR, 69-79]). Mean intraoperative MAP was 77 ± 7mmHg in the Control group and 88 ± 9mmHg in the Treatment group. The primary composite outcome occurred in 48.9% of patients inthe Control group versus 38.1% ofpatients in the Treatment group (relative risk, 0.78; 95% CI 0.65-0.93; P = 0.006). Acute kidney injury was significantly less frequent in the Treatment group (23.5 vs. 33.7%; P = 0.005). Among hypertensive patients receiving continuous hemodynamic monitoring and protocolized fluid therapy at increased postoperative risk undergoing major abdominal surgery, targeting an intraoperative MAP ≥ 80mmHg, compared with ≥ 65mmHg, reduced major organ dysfunction, primarily due to fewer mild-to-moderate acute kidney injuries. The HISTAP trial has been registered at ClinicalTrials.gov, NCT05637606 (Date of registration: 24 November 2022).

Information regarding mortality associated with standing procedures in horses is sparse. To report data from >12,000 standing sedations. Confidential, observational, prospective, multicentre, cohort study. We collected records of horses/ponies undergoing standing sedation for surgery or advanced diagnostic imaging using at least one top-up or controlled rate infusion (CRI). Procedures were either NON-COLIC or COLIC. Outcome at seven days was recorded as (i) ALIVE, (ii) EUTHANASIA or (iii) DEAD. Data were collected with a portable document format (PDF)questionnaire, which evolved into a webpage, and processed with the statistical software R. Data were collected from 12,307 standing sedations in 61 centres in 23 countries. Death rates were 0.15% overall (19/12,307), 0.13% for NON-COLICs (16/12,237) and 4.29% for COLICs (3/70). The causes of death in the 16 NON-COLICs were abdominal complications in 10 (62.50%), fracture/repeat fracture in three (18.75%), two were 'found dead' (12.50%) and one (6.25%) for 'other reasons'. In most cases premedication consisted of combinations of alpha-2 agonists/opioids with or without acepromazine. Sedation was maintained using top-ups (9668/12,307), CRIs (3795/12,307) or CRI + top-up (1156/12,307). Detomidine was the alpha-2 agonist most frequently used for top-ups (8258/12,307) and butorphanol the most common opioid (2754/12,307). Detomidine was the most frequently used alpha-2 agonist for CRI (3231/12,307); 364 and 305/12,307 received butorphanol and morphine as CRIs, respectively. Only 24.2% received fluid therapy. Loco-regional anaesthesia was performed in 37.6% of the cases. Monitoring was minimal, with temperature (5.8%), electrocardiogram (3.8%), non-invasive arterial pressure (2.1%), end-tidal carbon dioxide (1.1%) and pulse-oximetry (0.9%). Sample size, selection bias, questionnaire initially designed for general anaesthesia, potential human errors for data entry and potential missing cases. Standing sedation in horses is not risk free. Horses die unexpectedly within seven days of sedation. Efforts should be made to reduce these mortality rates further.

Perioperative intravenous fluid and chronic kidney disease: long-term follow-up of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) randomised trial.

Navigating Modern Intravenous Fluid Therapy in Critical Care.

Prolonged length of stay (LOS) and postoperative nausea and vomiting (PONV) are frequent after metabolic bariatric surgery (MBS) and negatively affect recovery. This study aimed to identify predictors of prolonged LOS and PONV in patients undergoing MBS. A retrospective cohort of 476 patients undergoing MBS, including laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB), between January 2022 and September 2023 was analyzed. Patient characteristics and perioperative variables were reviewed. Prolonged hospitalization was defined as LOS > 3 days. Multivariable logistic regression modeling was used to identify independent predictors of prolonged LOS. Among 476 patients, the median LOS was 3 days, and 23.1% required hospitalization > 3 days. Multivariable analysis identified longer anesthesia duration (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.70-5.50, p < 0.001), greater intraoperative fluid rate (OR: 1.41, 95% CI: 1.11-1.78, p = 0.005), asthma (OR: 2.99, 95% CI: 1.09-8.18, p = 0.033), and PONV (OR: 2.09, 95% CI: 1.29-3.40, p = 0.003) as independent predictors of prolonged hospitalization. These associations remained significant after adjustment for baseline covariates. The type of surgery (LRYGB vs. LAGB) was not an independent predictor of prolonged LOS in the multivariable model (OR: 1.65, 95% CI 0.94-2.87, p = 0.079). PONV occurred in 45.6% of patients and was more common in females and younger patients (p < 0.001). Prolonged anesthesia duration, greater intraoperative fluid rate, asthma, and PONV independently predicted extended hospital stay after MBS. Optimizing anesthesia time, fluid therapy, procedure-specific management, and respiratory management may enhance recovery and shorten hospitalization.

Familial chylomicronemia syndrome (FCS) is a rare disorder characterized by the accumulation of chylomicrons in the circulation due to genetic defects or autoantibodies affecting lipoprotein lipase (LPL), the key enzyme responsible for the metabolism of chylomicrons and very-low-density lipoproteins (VLDL), or its associated proteins, including apolipoprotein (apo) C-II, apoA-V, glycosylphosphatidylinositol-anchored high-density lipoprotein-binding protein 1 (GPIHBP1), and lipase maturation factor 1 (LMF1). This condition is associated with markedly elevated serum triglyceride (TG) levels and, in severe cases, recurrent episodes of pancreatitis and eruptive xanthomas. Among these etiologies, genetic deficiency of GPIHBP1 is exceedingly rare. We aimed to clarify the clinical and genetic basis and treatment strategies of a patient with GPIHBP1 deficiency. A 47-year-old woman with a childhood diagnosis of FCS presented with severe epigastric pain and was admitted to Rinku General Medical Center for emergency management of acute pancreatitis secondary to severe chylomicronemia. She had a history of severe hypertriglyceridemia complicated by pancreatitis during her first pregnancy and extreme hypertriglyceridemia exceeding 6,000 mg/dL during her second pregnancy without the development of pancreatitis. DNA sequence analysis was performed as a clinical diagnostic test and outsourced to KUBIX Inc. (Hakusan, Ishikawa, Japan). Laboratory evaluation revealed marked hypertriglyceridemia (1,262 mg/dL) with a type V hyperlipoproteinemia pattern. Serum preheparin LPL mass was markedly reduced, and circulating GPIHBP1 was undetectable. Genetic analysis identified a novel homozygous frameshift mutation in the GPIHBP1 gene (NM_178172.4:c.20del [p.Val7AlafsTer73]), which has not been previously reported in public databases. No pathogenic variants were detected in other LPL-related genes. Acute pancreatitis improved rapidly with fasting and intravenous fluid therapy. Strict dietary fat restriction, followed by the addition of the selective PPARα modulator pemafibrate, successfully maintained TG levels below 500 mg/dL during follow-up. We report an extremely rare case of FCS caused by a novel homozygous mutation in the GPIHBP1 gene, in which pregnancy served as a major trigger for severe hypertriglyceridemia. Early diagnosis and strict lipid control are essential to prevent recurrent pancreatitis in patients with GPIHBP1 deficiency.

IntroductionPHPT in pregnancy is a rare condition that may be difficult to recognize due to nonspecific symptoms and physiologic changes that can mask hypercalcemia. Delayed diagnosis is associated with significant maternal and fetal morbidity.Case PresentationA 36‐year‐old Spanish‐speaking gravida 5 para 3 woman at 30 weeks gestation presented with decreased fetal movement in the setting of absent prenatal care. Evaluation revealed severe polyhydramnios, fetal growth restriction, and nonimmune fetal hydrops. Laboratory studies demonstrated hypercalcemia with elevated parathyroid hormone levels, consistent with PHPT, with preserved renal function and concurrent vitamin D insufficiency. Ultrasound identified a parathyroid adenoma. Initial management with intravenous hydration and calcitonin resulted in only partial improvement in calcium levels. Ongoing management was complicated by competing priorities between treatment of maternal hypercalcemia and obstetric concerns, as escalation of fluid therapy was limited by the risk of fluid overload in the setting of severe polyhydramnios. Despite medical management, worsening fetal status, including abnormal umbilical artery Doppler findings, necessitated preterm cesarean delivery. The neonate required intubation and admission to the neonatal intensive care unit for management of hydrops fetalis. Following delivery, the patient underwent definitive surgical management with parathyroidectomy, resulting in normalization of calcium and parathyroid hormone levels and confirming biochemical cure.ConclusionThis case highlights the diagnostic challenges of PHPT in pregnancy and the complexity of management when standard treatment pathways are limited. It also demonstrates how delayed access to prenatal care and language discordance may contribute to more advanced disease at presentation. Early recognition and coordinated multidisciplinary care may improve maternal and fetal outcomes. This case supports consideration of PHPT in pregnant patients with hypercalcemia and informs clinical approaches to management in complex presentations.

Situs inversus totalis (SIT) is a rare congenital anatomical anomaly characterized by mirror-image reversal of thoracic and abdominal organs. Perioperative management becomes particularly challenging when SIT coexists with inferior vena cava (IVC) malformation (e.g., agenesis of the hepatic segment), decompensated cirrhosis, and respiratory insufficiency-a complex scenario for which relevant anesthesia experience is exceedingly limited. A 66-year-old female patient with SIT complicated by polysplenia syndrome and agenesis of the hepatic segment of the IVC presented for surgical management of intrahepatic bile duct stones, cholangitis, and obstructive jaundice. Preoperatively, she had Child-Pugh C cirrhosis and respiratory insufficiency. The patient underwent laparoscopic cholecystectomy, choledochoscopic-assisted intrahepatic bile duct stone extraction, and T-tube drainage. The anesthesia strategy comprised mirror-image ECG lead placement, transthoracic echocardiography (TTE) -guided preload assessment utilizing left ventricular end-diastolic area with subsequent optimization of fluid therapy, preferential selection of hepatically non-metabolized drugs, and employing lung-protective ventilation with permissive hypercapnia targeting PaCO₂ ≤ 65 mmHg. The procedure lasted 320min with stable hemodynamics. The patient was transferred to the intensive care unit (ICU) with the endotracheal tube in situ and was successfully extubated 1h after admission. She was discharged from the ICU on postoperative day 6, showing improvement in liver function and overall clinical status compared with her preoperative baseline. To our knowledge, this is the first description of anesthesia management for a patient with SIT complicated by Child-Pugh C cirrhosis and respiratory insufficiency, highlighting TTE as an alternative for preload monitoring in the presence of IVC anomalies. Anticipation of anatomical variations and implementation of an individualized anesthesia strategy are critical to ensuring perioperative safety.

Personalized perioperative fluid therapy is important for reducing postoperative complications and adverse outcomes. Although large language models (LLMs) show promise in healthcare, their application in fluid therapy remains challenged by hallucinations, limited domain-specific knowledge, and insufficient personalization. To address these limitations, Retrieval-Augmented Generation (RAG) is an effective method, while Knowledge Graphs (KGs) provide more accurate and reliable information. In this paper, we constructed a Personalized Fluid Therapy Knowledge Graph (PFTKG) comprising 6,490 entities and 15,687 relationships, and adapted GraphRAG, a graph-based RAG strategy that employs community detection and recursive summarization to support finding-level retrieval of clinically relevant information. We compared GraphRAG with document-based retrieval-augmented generation (DocRAG) and mainstream prompting strategies, including Vanilla, Chain-of-Thought (CoT), and Reflection-of-Thoughts (RoT), across three LLMs: GPT-4o, Claude Opus 4, and Gemini 2.5 Pro. Performance was evaluated using a 300-question knowledge-based question set and a 262-question retrospective case-based question set derived from 206 abdominal surgery patients. Evaluation included accuracy, honesty, error composition, response length, and response time. On the knowledge-based question set, GraphRAG achieved the highest average accuracy: 96.89% for multiple-choice questions and 66.44% for open-ended questions. On the retrospective case-based question set, GraphRAG also showed the strongest overall performance, with an average accuracy of 71.12%, compared with 62.47% for DocRAG, 54.20% for CoT, 52.67% for Vanilla, and 52.54% for RoT. Adding a “Don’t know” option increased explicit acknowledgment of uncertainty, and GraphRAG reduced context-irrelevant errors compared with DocRAG. These results support GraphRAG as a domain-adapted retrieval strategy for personalized perioperative fluid therapy question answering. By integrating a clinical knowledge graph with hierarchical summarization and finding-level retrieval, it improved answer accuracy and promoted more conservative responses under uncertainty in both knowledge-based and retrospective case-based evaluations, supporting its use in future clinically integrated studies.

The optimal approach to early resuscitation in septic shock is unknown. Equipoise exists between the use of larger volumes of intravenous fluids to restore perfusion and the use of early vasopressor therapy along with smaller volumes of fluids to minimize potential harm from excess fluid. We randomly assigned adult patients who presented to the emergency department with septic shock to receive either fluids at restricted volumes and early vasopressor therapy (vasopressor group) or higher volumes of fluids and later vasopressor therapy (fluids group) for at least 6 hours and up to 24 hours. The primary outcome was days alive and out of the hospital from randomization to day 90. A total of 1000 patients underwent randomization, with 499 assigned to the vasopressor group and 501 to the fluids group. Informed consent was not obtained for 37 patients, which left 963 patients in the intention-to-treat population (481 in the vasopressor group and 482 in the fluids group). Three patients in the fluids group were lost to follow-up for the primary outcome. In the first 24 hours after randomization, patients in the vasopressor group received less intravenous fluid than those in the fluids group (median difference, -1108 ml; 95% confidence interval [CI], -1395 to -850). The percentage of patients who received vasopressors was higher by 18.9 percentage points (95% CI, 13.3 to 24.5) in the vasopressor group. The median number of days alive and out of the hospital at day 90 was 76 (interquartile range, 55 to 83) in the vasopressor group and 76 (interquartile range, 55 to 82) in the fluids group (difference, 0.0 days; 95% CI, -2.7 to 2.7; P = 1.00). Adverse events occurred in similar percentages of patients in the two groups, except for pulmonary edema (0.6% in the vasopressor group vs. 5.0% in the fluids group; P<0.001). Among adult patients who presented to the emergency department with septic shock, an approach that involved restricted fluid volume and early vasopressors did not result in a greater number of days alive and out of the hospital at day 90 than an approach involving greater fluid volume and later administration of vasopressors. (Funded by the Australian National Health and Medical Council Medical Research Future Fund and the New Zealand Health Research Council; ARISE FLUIDS ClinicalTrials.gov number, NCT04569942.).

During one-lung ventilation (OLV) with low tidal volumes, asymmetric intrathoracic pressures may blunt the cardiopulmonary interactions on which conventional dynamic indices rely, limiting their usefulness for guiding fluid therapy. The positive end-expiratory pressure (PEEP) test, a reduction in PEEP to augment venous return, has been proposed as a fluid-free assessment of preload responsiveness in mechanically ventilated patients. However, whether its diagnostic performance is retained during OLV is unknown. We therefore hypothesized that the stroke-volume change (ΔSVPEEP test) induced by the PEEP test would predict fluid responsiveness during OLV. We conducted a single-center prospective interventional study (June to September 2024) in adults undergoing elective lung resection requiring OLV. The primary objective was to evaluate the diagnostic accuracy of the ΔSVPEEP test for predicting fluid responsiveness. Secondary objectives were to assess the diagnostic performance of the PEEP test-induced change in mean arterial pressure (ΔMAPPEEP test) and baseline stroke volume variation (SVV), and to compare their predictive abilities. After stabilization using OLV (PEEP 10 cm H2O) but before skin incision (closed-chest conditions), baseline hemodynamics were recorded; stroke volume (SV) was measured by arterial pulse-contour analysis. PEEP was then reduced from 10 to 0 cm H2O, and variables were re-measured. Subsequently, a 15° head-down tilt (Trendelenburg) served as an autotransfusion challenge; patients with ≥10% SV increase were classified as responders. Receiver operating characteristic (ROC) analysis was used to assess the predictive ability of each index. A gray-zone analysis was performed for the ΔSVPEEP test to delineate the range of diagnostic uncertainty. Of 43 patients screened, 38 were analyzed; 18 (47%) were responders. ΔSVPEEP test was larger in responders than in nonresponders (16.7% ± 8.9 vs 4.6% ± 4.3; P < .0001). ΔSVPEEP test predicted fluid responsiveness with an area under the ROC curve (AUC) of 0.95 (95% confidence interval [CI], 0.82-0.99; P < .0001), and the optimal cutoff of 8.6% yielded 94.4% sensitivity (95% CI, 72.7-99.9) and 80.0% specificity (95% CI, 56.3-94.3). ΔMAPPEEP test showed an AUC of 0.84 (95% CI, 0.68-0.94; P < .0001), whereas SVV was not predictive (AUC 0.64, 95% CI, 0.47-0.79; P = .12). The gray zone for the ΔSVPEEP test was 3.6% to 12.5%, comprising 14 of 38 (36.8%) of patients. During OLV, the relative increase in SV elicited by the PEEP test predicted fluid responsiveness as defined by the Trendelenburg maneuver. This simple, fluid-free maneuver may assist intraoperative fluid management during thoracic anesthesia.

The aim of this study was to identify the main causes of neonatal mortality in dairy calves (0-30 days of age) in Poland and to assess how infectious factors and management practices influenced the pattern of mortality. A retrospective analysis was performed on 498 calves from 312 herds between 2018 and 2024. The protocol included necropsy, enteropathogen diagnostics (PCR and ELISA), and analysis of herd management questionnaires. The leading causes of death were chronic diarrhea (42.4%), acute diarrhea (25.3%), and septicemia (10.8%). Calves that died from septicemia were the youngest (mean age 7.7 days), whereas those that died from chronic diarrhea were the oldest (20.3 days; p < 0.001). Lack of dam vaccination was associated with a higher occurrence of acute diarrhea (RR = 2.04) and septicemia (RR = 2.01) within the necropsied calf population. Inappropriate colostrum management was also associated with a higher occurrence of septicemia (RR = 1.99). Despite widespread antimicrobial use (>80%), intensive fluid therapy was used rarely (<7% in diarrheal cases). ETEC, rotavirus, and coronavirus were detected significantly more frequently in acute diarrhea, whereas Cryptosporidium parvum (C. parvum) was significantly more frequent in chronic diarrhea. Antimicrobials were used extensively, while intensive fluid therapy for diarrhea was implemented infrequently and inadequately relative to disease severity. This study makes an important contribution to the understanding of calf mortality in dairy herds by combining comprehensive postmortem diagnostics with pathogen detection (PCR and ELISA) and the assessment of management practices, thereby providing a holistic perspective on the problem. The analysis of 498 calves from 312 farms over a 7-year period offers an unprecedented and representative picture of the situation in Poland, one of Europe's major milk producers. These results emphasize the crucial importance of proper colostrum management and vaccination, while also indicating a clear and urgent need to expand the use of fluid therapy in calves requiring treatment. The results identify not only the dominant pathogens and differences in disease course, but also management factors with direct implications for animal welfare and preventive strategies in dairy production.

ABSTRACTVolume status of a patient is difficult to assess clinically. Methods to measure plasma volume as well as changes in plasma volume in connection with fluid therapy are therefore valuable for research purposes and could potentially be used bedside to guide fluid therapy in individual patients. The objective of the present study was to evaluate hematocrit as a marker of changes in plasma volume and an anthropometric formula to estimate absolute plasma volume against the reference method, plasma volume measurements using radiolabeled albumin. A total of 64 postoperative patients received 10 mL/kg of albumin. The plasma volumes were measured with the reference method (radiolabeled albumin) at baseline, after 30 and 180 min. Plasma volumes were compared with plasma volumes derived from either the baseline measurements and subsequent changes in hematocrit (calibrated method) or from an anthropometric formula and subsequent hematocrit changes (anthropometric method). Bland–Altman plots were used to test agreements between methods. The mean difference in plasma volume between the anthropometric and the reference method at baseline was −0.1 mL/kg (95% CI –2.1 to 1.8) with lower and upper LOA of −18.0 and 17.0 mL/kg. The agreement remained essentially unchanged after fluid therapy (mean difference −0.1 mL/kg (95% CI –1.8 to 1.5) with LOAs of −18.0 and 17.0 mL/kg). The mean difference between the calibrated and reference methods was −0.1 mL/kg (95% CI –0.9 to 0.7) with LOAs of −9.4 and 9.2 mL/kg. The anthropometric formula yields low precision in predicting plasma volumes in postsurgical patients. Changes in hematocrit during fluid therapy cannot replace the reference method to assess changes in plasma volume in the individual patient because of the imprecision.Editorial CommentClinical appreciation of plasma volume is relevant for assessing treatment where intravenous fluid resuscitation is involved. This analysis, using a reference method for plasma volume assessment, and comparing to simpler methods to estimate the same, demonstrates that there are important limitations with some simpler and readily acceptable methods to perform this estimation.

BackgroundBirth asphyxia is a major cause of neonatal morbidity and mortality, particularly in low-resource settings. Hypoxia and metabolic derangements that occur during asphyxia predispose neonates to electrolyte abnormalities, which may worsen the clinical course and contribute to poor outcomes. Early recognition and management of such imbalances can improve survival and prevent long-term neurological damage. This study aimed to determine the incidence, predictors, and early outcomes of electrolyte imbalance among term neonates admitted with birth asphyxia in Lira Regional Referral Hospital, Uganda.MethodsA hospital-based prospective cohort study was conducted among term neonates admitted with birth asphyxia, defined as a 5-minute Apgar score <7. Serum sodium, potassium, and calcium levels were measured at admission, and repeated on days 3, 7, and 14 for those still admitted. Clinical information including maternal and perinatal characteristics was recorded. Modified Poisson regression (using SPSS) was performed to identify independent predictors of electrolyte imbalance. Early outcomes, including mortality and length of hospital stay, were documented within the first 14 days.ResultsA total of 152 neonates were enrolled; 52.6% were male. During follow-up, 42 (29.0%) developed hyponatremia, 29 (19.5%) hyperkalemia, and 31 (21.2%) hypocalcemia. Independent predictors of hyponatremia included low Apgar score (0–3), severe hypoxic ischemic encephalopathy (HIE), prolonged intravenous fluid administration (>48 hours), resuscitation at birth, and dehydration. Convulsions, prolonged intravenous fluids, and resuscitation were significantly associated with hypocalcemia, while hyperkalemia was linked to low birth weight and prolonged intravenous fluids (p < 0.05 for all). Mortality was highest among neonates with hyperkalemia, whereas hypocalcemia was significantly associated with prolonged hospital stay (p < 0.05).ConclusionElectrolyte imbalances are common among term neonates with birth asphyxia and hypoxic-ischemic encephalopathy, with hyponatremia, hypocalcemia, and hyperkalemia occurring in nearly one-fifth to one-third of cases. These imbalances are predicted by HIE severity, convulsions, prolonged intravenous fluid therapy, and are associated with increased early neonatal mortality, highlighting the need for routine electrolyte monitoring, standardized intravenous fluid protocols, and timely correction of derangements to improve outcomes.

Intestinal transplantation remains the definitive treatment for irreversible intestinal failure, yet its perioperative anesthetic management presents substantial challenges. Recent innovations in organ preservation, monitoring, and enhanced recovery concepts have driven progress. However, a dedicated synthesis focused on anesthetic management is lacking, and the available evidence is largely observational and derived from small cohorts. A structured literature search was conducted in PubMed, Web of Science, CNKI, and Wanfang databases for articles published between January 2020 and December 2025. Studies addressing perioperative anesthetic management in intestinal transplantation were included. The search was structured and transparent but not exhaustive to the standard of a registered systematic review; a narrative synthesis was employed to integrate the heterogeneous literature. A PRISMA flow diagram (Fig.1), study characteristics table (Table1), and quality assessments (using AMSTAR-2 and ROBINS-I) are provided. Twenty-six studies met inclusion criteria. Because the included studies are predominantly small, single-center, and observational, all findings should be regarded as hypothesis-generating. Preoperative evaluation suggests that intestinal failure-associated liver disease and a history of thrombosis influence anesthetic planning. Intraoperative hemodynamic management may benefit from stage-specific approaches with dynamic parameters guiding fluid therapy. Regional anesthesia, particularly transversus abdominis plane block, has been associated in preliminary single-center reports with opioid reductions of 30-50% and has facilitated early extubation. Viscoelastic coagulation testing has been linked, mainly in liver transplantation and general surgery cohorts, to targeted blood component therapy with estimated reductions in unnecessary exposure of 20-30%. Normothermic machine perfusion represents a promising technology that, based on indirect evidence from liver transplantation, may reduce post-reperfusion syndrome and improve graft outcomes. Multimodal analgesia integrated with enhanced recovery principles has been associated with improved postoperative recovery. Several developments hold promise in intestinal transplantation anesthesia, although high-quality evidence remains scarce. Regional anesthesia is increasingly incorporated into enhanced recovery protocols, normothermic machine perfusion has the potential to reshape perioperative strategies, and multimodal monitoring could contribute to optimizing patient outcomes. However, the findings remain exploratory, and there is an urgent need for multicenter collaborative research.

Background: Microvascular free flap reconstruction is an established method for the management of complex head and neck defects in pediatric patients. However, the influence of perioperative anesthetic management on flap outcome in this population remains insufficiently defined. The aim of this study was to evaluate the association between selected perioperative anesthetic factors and flap outcome in pediatric patients. Methods: This retrospective observational study included pediatric patients undergoing microvascular free flap reconstruction between August 2011 and July 2020. Of 80 screened patients, 56 met the inclusion criteria based on complete medical records. Demographic, surgical, and perioperative anesthetic variables were collected. Continuous variables were compared using the Mann–Whitney U test, and categorical variables using the chi-squared test with Yates’ correction. Correction for multiple testing was performed using the Benjamini–Hochberg false discovery rate procedure. Results: Complete flap survival was achieved in 50 patients (89.3%), while partial and total flap loss occurred in 3 patients each (5.4%). No significant associations with flap loss were identified for the type of anesthetic gas, opioid use, induction agents, intraoperative fluid therapy, diuresis, rocuronium dose, or operation time. Lower weight-adjusted doses of midazolam and propofol showed borderline unadjusted associations with flap loss; however, these differences did not reach statistical significance after correction for multiple testing. Patients with flap loss had a higher mean intraoperative body temperature compared to those with successful flap survival (36.65 °C vs. 36.05 °C; p < 0.05). Conclusions: In pediatric head and neck free flap reconstruction, most analyzed perioperative anesthetic factors were not associated with flap outcome. Dose-related findings for midazolam and propofol should be interpreted as exploratory and non-significant after correction for multiple testing, while higher intraoperative body temperature was associated with flap loss. However, these results are exploratory, cannot establish causality, and require confirmation in larger, preferably multicenter studies with adjustment for surgical and patient-related confounders.

BackgroundFluid therapy is central to sepsis management, yet recommendations on fluid type, volume, optimization, and de-escalation remain uncertain. The 2025 ESICM guidelines highlight major evidence gaps in sepsis fluid therapy. Although large language models (LLMs) show promise for guideline interpretation and clinical decision support, their performance in this high-risk domain is unclear.MethodsWe conducted a prospective, cross-sectional observational study using nine guideline-derived sepsis-related clinical questions addressing fluid selection, resuscitation volume, and fluid removal during de-escalation. Questions were queried in both English and Chinese across three consecutive days, generating three independent responses per model from ChatGPT-5, ChatGPT-4o, and DeepSeek-V3.1. Three blinded intensivists evaluated responses for accuracy, completeness, and consistency using 5-point Likert scales. Readability was assessed using Flesch Reading Ease (FRE) and Flesch–Kincaid Grade Level (FKGL) for English responses and a validated Chinese readability framework. Inter-rater agreement was quantified using Kendall’s W coefficient.ResultsIn English responses, ChatGPT-5 achieved the highest accuracy, although inter-model differences were not statistically significant. In Chinese responses, ChatGPT-5 demonstrated significantly higher accuracy than ChatGPT-4o (p < 0.05). DeepSeek-V3.1 produced significantly more complete English responses than ChatGPT-4o (p < 0.05). Consistency was high across all models and languages. FKGL scores differed significantly among models (p < 0.01), with ChatGPT-5 generating more linguistically complex English text. No significant differences were observed between English and Chinese responses across evaluation dimensions.ConclusionsAdvanced LLMs show potential for supporting sepsis fluid therapy guideline interpretation, but consistent overconfident responses in guideline-defined uncertainty domains highlight important safety limitations. Clinical oversight remains essential when deploying LLMs for high-risk decision support.

IntroductionCytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) is a treatment for peritonitis carcinomatosa. These procedures often involve significant blood and fluid loss, leading to hyperdynamic circulation and vasodilation, necessitating intraoperative fluids and vasoconstrictors such as catecholamines. Excessive fluid administration to counteract vasodilation can cause intraoperative fluid overload, which is linked to increased postoperative complications. Vasopressin has emerged as a potential alternative to catecholamines, restoring vascular tone via non-adrenergic pathways and supporting perfusion pressure, potentially reducing the need for compensatory fluids solely administered to compensate for vasodilation. We hypothesise that compared with norepinephrine, vasopressin reduces cumulative intraoperative fluid administration during CRS-HIPEC within a goal-directed fluid therapy (GDFT) protocol, ultimately leading to a lowering of postoperative complications.Methods and analysisHiPress is a two-centre, two-arm randomised clinical trial with blinding of both patients and outcome assessors. A total of 70 adult patients undergoing CRS-HIPEC will be included. Patients will be randomised to receive either continuous low-dose argipressin or continuous low-dose norepinephrine. Both groups will receive standardised GDFT during the procedure. The primary endpoint is cumulative intraoperative fluid administration (mL). Secondary endpoints include direct fluid-related outcomes (eg, cumulative intraoperative fluid (ml/kg/hour), postoperative fluid balance until day five and ultrasound-assessed pulmonary oedema and venous congestion) and indirect fluid-associated outcomes (eg, quality of recovery, surgical and abdominal complications, acute kidney injury (AKI), pulmonary complications, length of ICU and hospital stay and 30-day mortality).Ethics and disseminationThe study is enrolling patients since February 2025. The trial is approved by the Medical Research Ethics Committee (hereinafter: MREC) NedMec, The Netherlands (Ref: D-25-500202). Results of the trial will be published in an international peer-reviewed journal and announced at national and international scientific meetings.Trial registration numberClinical Trials Information System (CTIS): European Union clinical trials register (EUCT) number: 2024–5 13 598-33-00

Clinical analysis of Rhododendron decorum Franch. flower poisoning in Northeast Yunnan