Fluid Therapy Research Articles

Prediction of hematocrit decline and the impact of peri-operative fluid use in lumbar spinal fusion surgery

PurposePeri-operative blood loss unaccounted for and post-operative hematocrit decline could have a significant impact on the outcome of elective spinal surgery patients. The study assesses the accuracy of predictive models of hematocrit decline and blood loss in spinal surgery and determines the impact of peri-operative fluid administration on hematocrit levels of patients undergoing first-time single level lumbar fusion surgery for degenerative spine disease and the trend thereof in the first 24 h post-operatively.MethodsClinical and biochemical parameters were prospectively collected in patients undergoing single level lumbar spinal surgery. Predictive models were applied to assess their accuracy in intra-operative blood loss and post-operative hematocrit decline.ResultsHigh correlation (0.98 Pearson correlation coefficient) occurred between calculated (predicted) and recorded hematocrit from hours 2 to 6 post-operatively. Predictive accuracy declined thereafter yet remained moderate. Patients received an average intra-operative fluid volume of 545.45 ml per hour (47% of estimated total blood volume). A significant hematocrit decline occurred post-induction (43.47–39.78%, p < 0.001) with total fluid volume received being the significant contributing variable (p < 0.001). Hypertensive patients were the only subgroup to drop below the safe hematocrit threshold of 30%.ConclusionIatrogenic hemodilution can accurately be predicted for the first six hours post-operatively, with high risk patients identifiable. Fluid therapy should be goal directed rather than generic, and good communication between the surgeon and anesthesiologist remains the cornerstone to manage physiological changes secondary to blood loss. Although helpful, predictive formulas are not universally applicable to all phenotypes.

Variations in intravenous fluid management for paediatric hypernatraemia in South Africa: A survey of junior and senior South African paediatric doctors

Background. Paediatric hypernatraemia is a severe and life-threatening electrolyte abnormality that is associated with considerable morbidity and mortality. Although intravenous (IV) fluid therapy is a crucial component of management, there are no management guidelines, and varying approaches to IV fluid therapy are commonplace in clinical practice. Objectives. To determine the variance in IV fluid therapy in the management of paediatric hypernatraemia among paediatric registrars and consultants in South Africa. Methods. A self-administered online survey was conducted from November 2020 to February 2021. The survey assessed paediatricians’ management of three typical clinical scenarios of community-acquired hypernatraemia seen in South Africa. Descriptive results were presented as proportions, frequencies and medians with interquartile ranges. Comparisons were done using contingency tables. Results. Responses from 119 participants were analysed. Most respondents worked in the state sector (69.8%), and were based mainly in Gauteng (46.2%) or Western Cape (25.2%) province. Most (60.2%) respondents considered a serum sodium level ≥146 mmol/L indicative of hypernatraemia, and 43.6% (n=51/117) reported seeing &gt;10 cases of paediatric hypernatraemia in 2019. For all three cases, at least eight different types of infusate (of varying sodium concentrations) were chosen as maintenance fluids. Fluid deficits were calculated using either the free water method or based on the perceived degree/percentage of clinical dehydration. Conclusion. There is considerable variability in the management of hypernatraemia among paediatricians in South Africa. There is an urgent need to develop a standardised guideline for the treatment of paediatric hypernatraemia.

Volume replacement in the resuscitation of trauma patients with acute hemorrhage: an umbrella review

BackgroundThe use of intravenous fluid therapy in patients with major trauma in prehospital settings is still controversial. We conducted an umbrella review to evaluate which is the best volume expansion in the resuscitation of a hemorrhagic shock to support the development of major trauma guideline recommendations.MethodsWe searched PubMed, Embase, and CENTRAL up to September 2022 for systematic reviews (SRs) investigating the use of volume expansion fluid on mortality and/or survival. Quality assessment was performed using AMSTAR 2 and the Certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.ResultsWe included 14 SRs investigating the effects on mortality with the comparisons: use of crystalloids, blood components, and whole blood. Most SRs were judged as critically low with slight overlapping of primary studies and high consistency of results. For crystalloids, inconsistent evidence of effectiveness in 28- to 30-day survival (primary endpoint) was found for the hypertonic saline/dextran group compared with isotonic fluid solutions with moderate certainty of evidence. Pre-hospital blood component infusion seems to reduce mortality, however, as the certainty of evidence ranges from very low to moderate, we are unable to provide evidence to support or reject its use. The blood component ratio was in favor of higher ratios among all comparisons considered with moderate to very low certainty of evidence. Results about the effects of whole blood are very uncertain due to limited and heterogeneous interventions in studies included in SRs.ConclusionHypertonic crystalloid use did not result in superior 28- to 30-day survival. Increasing evidence supports the scientific rationale for early use of high-ratio blood components, but their use requires careful consideration. Preliminary evidence is very uncertain about the effects of whole blood and further high-quality studies are required.

Pre-operative management of a patient with tubo-ovarian abscess and diabetic ketoacidosis

Background: Diabetic ketoacidosis (DKA) is a serious consequence of uncontrolled diabetes, especially in patients complicated by certain infections. Patients with DKA often require surgery; however, at the same time are more vulnerable to unintended postoperative complications. Therefore, proper pre-operative management in these patients is prominent. This study aimed to summarize pre-operative management of a patient with DKA and tubo-ovarian abscess. Case Presentation: A 45-year-old female was referred to Dr. Soetomo Hospital Surabaya with a chief complaint of fever, right abdominal pain, and white vaginal discharge. The patient had a history of uncontrolled DM since 2014. Ultrasonography examination revealed the presence of a hyperechoic mass in the uterine fundus (size: 6,39 x 7,36 cm). Initial laboratory examination indicated leukocytosis, hyperglycemia, hyponatremia, proteinuria, and ketoacidosis condition. The patient was diagnosed with DKA, type 2 diabetes mellitus (T2DM), tubo-ovarian abscess. Before undergoing surgery to remove the abscess, the patient received fluid therapy (NaCl 0,9%); insulin therapy (rapid-acting insulin 2x4 IU intravenous (IV), bicarbonate 100 mEq in 400 mL normal saline/24 hours IV, and rapid-acting insulin pump 1 IU/hour); diet therapy, and antibiotic therapy (ampicillin 1 gr every 6 hours IV, gentamycin 240 mg every 24 hours IV, and metronidazole 500 mg every 8 hours IV). Regular examination was performed, which included the evaluation of random blood glucose (RBG) every 3 hours, serum electrolytes every 24 hours, repeat blood gas analysis every 24 hours, blood culture, and vaginal swabs. Conclusion: Euglycemia is the main goal of perioperative treatment in order to enhance postoperative results. Careful blood glucose management should be performed before surgery to decrease patients' morbidity and mortality. It must also be highlighted that regular patient monitoring through clinical and laboratory markers is essential to treat DKA successfully.

Effect of the Duration of Restrictive Fluid Therapy on Acute Kidney Injury in Robot-Assisted Laparoscopic Prostatectomy.

In robot-assisted laparoscopic prostatectomy (RALP), restrictive fluid therapy (RFT) is often utilized until the vesicourethral anastomosis (console period) is completed. RFT can cause acute kidney injury (AKI). Thus, RFT prolongation in surgeries that utilize the Trendelenburg position and pneumoperitoneum may increase the risk of postoperative AKI. We aimed to evaluate the effect of RFT duration on postoperative AKI. Forty-four patients who underwent RALP were included in this prospective observational study. Patients were divided into two groups according to the RFT duration (Group I, RFT duration ≤ 3 h, and Group II, RFT duration >3 h). AKI was diagnosed and staged according to the Kidney Disease Improving Global Outcomes criteria (KDIGO) using patients' serum creatinine levels after the first 24 h postoperatively. Hemodynamic parameters were monitored using the pressure recording analytical method. The AKI incidence was significantly higher in Group II than in Group I (45.5% vs. 9.1%; p = 0.016). In both groups, all patients who developed AKI were KDIGO stage 1 and all recovered on the second postoperative day. At the end of the console period, the heart rate and arterial elastance were significantly higher, whereas the stroke volume index was significantly lower in Group II than in Group I (p = 0.041, p = 0.016, and p < 0.001, respectively). Although the amounts of fluid administered before and after the anastomosis were similar between the groups, the total amount of fluid administered was significantly different (p < 0.001). There was a significant negative correlation between RFT duration and the total amount of fluid administered (r2 = 0.43, p < 0.001). RFT duration of >3 h, total fluid administration of ≤3.3 mL/kg/h, and stroke volume index (SVI) at the end of the console period of ≤32 mL/m2 increased the risk of AKI by 12.0 times (1.7-85.2) (p = 0.013). RFT prolongation in RALP may increase the risk of developing AKI.

Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease.

While intravenous fluid (IVF) therapy in patients with sickle cell disease (SCD) admitted for a vaso-occlusive episode (VOE) can help reduce red blood cell sickling, clinical practice varies across institutions. We examined the relationship between IVF therapy and hospital length of stay (HLOS), as well as adverse events, such as acute chest syndrome (ACS), pediatric intensive care unit (PICU) transfer, and 28-day re-admission. This is a single-center retrospective analysis of SCD VOE hospitalizations between January 2015 and April 2020. Patients with SCD, age 0-30, with consecutive hospitalizations for VOE were included. For the first 3days of each admission, an "IVF ratio" was calculated by dividing actual IVF rate administered by weight-based maintenance IVF (mIVF) rate. A total of 617 hospitalizations for 161 patients were included. Mean HLOS was 5.7days, (SD 3.9), and mean IVF volume over the first 3days of admission was 139.6mL/kg/day (SD 57.8). Multivariate analysis showed that for each additional 0.5 times the mIVF rate, HLOS increased by 0.53day (p<.001; 95% confidence interval [CI]: 0.609-0.989), but there was no significant association between IVF therapy and adverse events. History of chronic pain was associated with increased odds of re-admission (OR 6.4; 95% CI: 3.93-10.52). Despite the theoretical potential for IVF therapy to slow down the sickling process, our findings suggest that increased IVF therapy was associated with prolonged HLOS, which places a burden on patients, families, and the health system.

Determinants of fluid use and the association between volume of fluid used and effect of balanced solutions on mortality in critically ill patients: a secondary analysis of the BaSICS trial.

Fluid use could modulate the effect of balanced solutions (BS) on outcome of intensive care unit (ICU) patients. It is uncertain whether fluid use practices are driven more by patient features or local practices. It is also unclear whether a "dose-response" for the potential benefits of balanced solutions exists. The secondary analysis of the Balanced Solution in Intensive Care Study (BaSICS) compared 0.9% saline versus Plasma-Lyte 148® (BS) for fluid therapy in the ICU. The relative contribution of patient features and enrolling site (the random effect) on the volume of fluid used up to day 3 after admission was assessed using different methods, including a Bayesian regression, a frequentist mixed model, and a random forest, all adjusted for relevant patient confounders. Subsequently, a variety of methods were used to assess whether volume of fluid used modulated the effect of BS on 90-day mortality, including a traditional subgroup analysis for patients that remained alive and in the ICU up to 3 days, a Bayesian network accounting for competing risks, and an analysis based on site practices. 10,505 patients were analyzed. Median fluid use in the BS arm and in the 0.9% saline arm were 2500mL and 2488mL, respectively. The random effect in the Bayesian regression explained 0.32 (95% credible intervals (CrI) 0.24-0.41) of all model variance (0.33, 95% credible intervals from 0.32-0.35). Frequentist and random forest models produced similar results. In the analysis including only patients alive and in the ICU at 3 days, there was a strong suggestion of interaction between fluid use and the effect of BS, driven mostly by a lower mortality with BS compared to 0.9% saline as fluid use increased for patients with sepsis. These results were consistent in the Bayesian network analysis and in an analysis based on site practices, where septic patients enrolled to BS at high fluid use sites had a lower mortality (absolute risk reduction of -0.13 [95% credible interval -0.27 to -0.01]; 0.98 probability of benefit). Baseline patient characteristics collected in the BaSICS trial explain less of the variance of fluid use during the first 3 days than the enrolling site. Volume of fluid used and the effects of BS appear to interact, mostly in the sepsis subgroup where there was a strong association between fluid use after enrollment and the effect of BS on 90-day mortality.

1376. A Retrospective Analysis of Intravenous Fluid Therapy Practice at Hospital Admission for Adults with Dengue

Abstract Background Dengue epidemics in Asia was almost exclusively a childhood disease but recently dengue in adults have become increasingly prevalent. Yet intravenous fluid replacement (IVFR), the main supportive therapy for dengue, was developed for pediatric dengue. Evidence-based guidance for fluid replacement, especially for older adults with concomitant chronic diseases that both increases risk of severe dengue and complicate fluid replacement, is lacking. We retrospectively analyzed the use of IVFR in adult dengue patients at admission to a tertiary hospital. Methods Medical records of patients diagnosed with dengue (confirmed by rapid NS1 kit or laboratory confirmation of RT-PCR, NS1 or IgM) from January 2020 to December 2022 were analyzed. Recovery phase was defined as fever defervescence for &amp;gt;12 hours with rising platelet count. Appropriateness of IVFR was based on disease severity according to the 2009 WHO dengue classification scheme. Results Preliminary analysis of the first 30 patients found an almost equal number of males (47%) and females. The median age was 52.5 years (range 15.0-83.0). 20 patients had at least one comorbidity with hyperlipidemia (33%), hypertension (23%) and ischemic heart disease (10%) being the most common. Average time from onset to presentation was 4.3 days (95% CI: 3.8-4.9). 16 (53%) met the WHO classification scheme as requiring IVFR at admission; 4 hypotension, 5 acute kidney injury (AKI), 2 hypotension with AKI, 4 hemoconcentration, 1 AKI with hemoconcentration. Of these 16, one also had altered mental status and another had hemophagocytic lymphohistiocytosis-like presentation. Despite 47% having uncomplicated dengue, all patients had IVFR at admission. Total fluid volume administered during hospitalization varied across the population and fluctuated daily for each patient, with 8 patients receiving IVFR beyond the recovery phase. One developed fluid overload while another had IV cannula-related thrombophlebitis. There was no mortality. Conclusion Preliminary findings of our on-going study suggest excessive use of IVFR and the lack of standardization possibly contributed to two iatrogenic complications. We call for development of evidence-based protocol on fluid management in older dengue patients. Disclosures All Authors: No reported disclosures

Usage of mineralocorticoids and isotonic crystalloids in subarachnoid hemorrhage patients in the United States

BackgroundThe usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. MethodsWe surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites in 2023, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters from 2010 to 2020 in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20 % of all acute inpatient care in the United States. ResultsAlthough mineralocorticoids are used by 70 % of the NINDS StrokeNet sites, it is used in less than 20 % of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41 and 45 %, respectively. ConclusionsThe use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.

Response to Fluids with Measurement of the Internal Jugular Vein by Ultrasound in Patients with Spontaneous Ventilation

Assessing intravascular volume status (IVS) in critically ill patients, especially those in shock, is crucial for appropriate fluid therapy. While central venous pressure (CVP) serves as a gold standard, limitations in predicting IVS prompt exploration of alternative methods. Ultrasound measures of the inferior vena cava (IVC) have been proposed for fluid responsiveness. However, the role of internal jugular vein (IJV) ultrasound measures in estimating IVS and their correlation with CVP in spontaneously breathing critically ill patients remains understudied. This review aims to evaluate the reliability, validity, and correlation of IJV ultrasound measures as indicators of IVS in this patient cohort.

7 Mitos en Anestesiología.

Medical evidence is updated on a daily basis with the emergence of the results of research carried out. After all, the advent of new knowledge undoubtedly causes changes in how many things should be done of interventions during clinical practice; however. These changes are not always carried out in the most ideal possible, perpetuating on many occasions actions that little by little they are losing quality in terms of evidence and that, in certain scenarios, they can even increase unnecessary risks. In Anesthesiology there are interventions that have already changed compared to how they began. such as preoperative fasting time or replacement o flfluids during procedures: surgical exposure or the replacement of the same fast, there are others that have shown no usefulness, such as preloads to avoid hypotension induced by spinal anesthesia or the use of excess basis to guide fluid therapy, and finally, there are also those that with emerging evidence have changed the how they should be carried out: perioperative extubation or oxygen therapy during transanesthetic.

Dobutamine and Goal-Directed Fluid Therapy for Improving Tissue Oxygenation in Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Surgery: Protocol for a Randomized Controlled Trial.

Breast reconstruction is an integral part of breast cancer care. There are 2 main types of breast reconstruction: alloplastic (using implants) and autologous (using the patient's own tissue). The latter creates a more natural breast mound and avoids the long-term need for surgical revision-more often associated with implant-based surgery. The deep inferior epigastric perforator (DIEP) flap is considered the gold standard approach in autologous breast reconstruction. However, complications do occur with DIEP flap surgery and can stem from poor flap tissue perfusion/oxygenation. Hence, the development of strategies to enhance flap perfusion (eg, goal-directed perioperative fluid therapy) is essential. Current perioperative fluid therapy is traditionally guided by subjective criteria, which leads to wide variations in clinical practice. The main objective of this trial is to determine whether the use of minimally invasive cardiac output (CO) monitoring for guiding intravenous fluid administration, combined with low-dose dobutamine infusion (via a treatment algorithm), will increase tissue oxygenation in patients undergoing DIEP flap surgery. With appropriate institutional ethics board and Health Canada approval, patients undergoing DIEP flap surgery are randomly assigned to receive CO monitoring for the guidance of intraoperative fluid therapy in addition to a low-dose dobutamine infusion (which potentially improves flap oxygenation) versus the current standard of care. The primary outcome is tissue oxygenation measured via near-infrared spectroscopy at the perfusion zone furthest from the perforator vessels 45 minutes after vascular reanastomosis of the DIEP flap. Low dose (2.5 μg/kg/hr) dobutamine infusion continues for up to 4 hours postoperatively, provided there are no associated complications (ie, persistent tachycardia). Flap oxygenation, hemodynamic parameters, and any medication-associated side effects/complications are monitored for up to 48 hours postoperatively. Complications, rehospitalizations, and patient satisfaction are also collected until 30 days postoperatively. Funding and regulatory approvals were obtained in 2019, but the study recruitment was interrupted by the COVID-19 pandemic. As of October 4, 2023, 34 participants have been recruited. Because of the significant delays associated with the pandemic, the expected completion date was extended. We expect the study to be completed and ready for potential news release (as appropriate) and publication by July 2024. No patients have suffered any adverse effects/complications from participating in this study, and none have been lost to follow-up. CO-directed fluid therapy in combination with a low-dose dobutamine infusion via a treatment algorithm has the potential to improve DIEP flap tissue oxygenation and reduce complications following DIEP flap breast reconstruction surgery. However, given that the investigators remain blinded to group randomization, no comment can be made regarding the efficacy of this intervention for improving tissue oxygenation at this time. Nevertheless, no patients have been withdrawn for safety concerns thus far, and compliance remains high. Clinicaltrials.gov NCT04020172; https://clinicaltrials.gov/study/NCT04020172.

The Impact of Fluid Therapy on Glycemic Variation in Non-diabetic Patients Undergoing Laparoscopy.

Background Hyperglycemia is a risk factor for perioperative morbidity and mortality. A surgical procedure triggers a physiological stress response, which culminates in insulin resistance by activating the sympathetic autonomic system. The impact of fluid management in the perioperative period on the glycemic variation of patients has not been thoroughly investigated. Methods This study, which included 42 non-diabetic patients undergoing laparoscopic surgeries, was an observational, prospective cohort study. The sample was split into two groups according to the type of fluid used intraoperatively: polyelectrolyte and 5% glucose polyelectrolyte. Results No significant differences were found between the groups in demographic and baseline data, including age, BMI, and American Society of Anesthesiologists (ASA) physical status. There were no differences in glycemic variation between the two groups. Blood glucose varied over time with statistical significance in the perioperative period but with no difference between the two groups. Conclusion Using 5% glucose polyelectrolyte in laparoscopic surgery for non-diabetic patients with ASA physical status 3 or lower did not significantly affect glycemic variation compared to polyelectrolyte. These results suggest the possibility of optimizing resources and minimizing waste without compromising patient homeostasis in perioperative care.

CANINE PARVOVIRUS INFECTION IN KINTAMANI DOG

Canine Parvovirus disease is caused by the Parvo virus which belongs to the Parvoviridae family. Clinical signs shown by the dog appear weak, no appetite, vomiting and visible diarrhea mixed with blood with a distinctive smell. The aim of this study was to discuss about parvo virus infection in Kintamani dog. An attack was made on a Kintamani dog named Hiro, aged 2 months and 11 days, who had fever, vomiting, brown diarrhea, refused to eat and drink. On auscultatory examination of the abdomen, the sound of increased intestinal peristalsis was heard and when palpation the abdomen felt hot. The parvo test kit showed positive results for dogs infected with Canine Parvovirus. Based on anamnesis, clinical signs and laboratory examination, a case dog named Hiro was diagnosed with CPV. Handling of case animals was carried out by administering electrolyte fluid therapy in the form of Ringer's Lactat, Cefotaxime 25 mg/kg BW, Metoclopramide 0.5 mg/kg BW, Kaolin-pectin (Guanistrep) 0.4 ml orally and giving multivitamins. On the fourth day the case dog's condition got better and on the sixth day the dog was declared cured and was allowed to go home. To prevent parvovirus transmission, it is recommended to carry out complete vaccination and deworming of dogs under 3 months of age.

Effect of carotid corrected flow time combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients: a prospective cohort study.

Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients. The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90mmHg and MAP below 60mmHg within 3min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8ml/kg of balanced crystalloids (lactated Ringer's solution) in 30min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction. The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%). Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.

Physiopathology and treatment of critical bleeding: a literature review

Objectivesto develop the different factors involved in the physiopathology of trauma-induced coagulopathy, through a review of publications on the matter; as well as to assess the evidence available on the treatment of critical bleeding and the recommendations by clinical practice guidelines. Methodsa search has been conducted on the bibliography published about the physiopathology and treatment of critical bleeding in the PUBMED, BestPractice, UpToDate databases and the Cochrane Plus Library. The main key words used for this search were “early trauma induced coagulopathy”, “mechanisms of early trauma-induced coagulopathy”, “blood transfusion guidelines”, “massive transfusion guidelines” and “fibrinogen replacement therapy”. The most clinically relevant articles were selected for this review. Conclusionsthe physiopathology of the trauma-induced coagulopathy is a more complex matter and involves more factors than was initially assumed. The early treatment of the coa-gulopathy is critical for the initial management of the critical bleeding. However, the use of blood derivatives should be rational and based on homogeneous and high-quality scientific evidence.The main cornerstones for the treatment of critical bleeding are: fluid therapy, fibrinogen concentrate, prothrombin complex concentrate, plasma, erythrocyte or platelet concentrates, tranexamic acid, and calcium. Their administration should be assessed depending on the clinical condition of each patient.

Infusion therapy in critical patients (state of problem). Part 1

Infusion therapy is an important component of many diseases treatment – and one of the main methods of intensive care for intensive care patients. Active infusion therapy using different infusion media, large volumes and high rates of intravenous fluid is especially relevant in critical patients, the most severe of which remains patients with septic shock. For more than two centuries of clinical use, infusion therapy has gone through a long evolutionary path and has become more effective and safer. However, like any drug, infusion therapy (in general and specific infusion media) has a number of side effects, especially when used excessively. Therefore, in recent years, the use of infusion therapy is considered as the appointment of any drug, taking into account indications, contraindications, methods of administration, dosing, duration, deescalation. This made it possible to identify the main stages of infusion therapy of critical conditions and shock: intensive infusion therapy (rapid administration of a large fluid volume), optimization of infusion therapy (reduction of the rate and volume of infusion), stabilization of the patient and minimization of infusion, de-resuscitation – removal of excess fluid from the body. With the development of clinical pathophysiology, the basic concepts of maintaining fluid homeostasis of the body in normal and critical conditions were revised, and the negative effects of infusion therapy at all stages of its use were studied. Therefore, in the intensive care of shock, the main clinical questions are: when to start fluid therapy, when to stop active fluid therapy, when to start fluid removal from the body, and when to stop fluid de-resuscitation. Thus, in order to implement the principle of personalized treatment, it is important to determine not only the «tolerance» of infusion therapy, but also the «sensitivity» to the infusion of a particular patient – the ability to maintain hemodynamics without the risk of fluid overload. Evaluation of routine clinical, instrumental and laboratory indicators of the state of macro- and microcirculation does not provide an opportunity to accurately answer these questions. Modern sonographic methods for monitoring central and peripheral cardiohemodynamics, ‘venous excess’ using Doppler and extended focus echocardiography allow us to assess the ‘tolerance of infusion therapy’. The implementation of this new direction will increase the efficiency and safety of infusion therapy and improve the outcomes of the critically ill patients’ treatment.

Pilot randomized controlled trial of restricted versus liberal crystalloid fluid management in pediatric post-operative and trauma patients

BackgroundIntravenous (IV) fluid therapy is essential in the treatment of critically ill pediatric surgery and trauma patients. Recent studies have suggested that aggressive fluids may be detrimental to patients. Prospective studies are needed to compare liberal to restricted fluid management in these patients. The primary objective of this pilot trial is to test study feasibility—recruitment and adherence to the study treatment algorithm.MethodsWe conducted a two-part pilot randomized controlled trial (RCT) comparing liberal to restricted crystalloid fluid management in 50 pediatric post-operative (1–18 years) and trauma (1–15 years) patients admitted to our pediatric intensive care unit (PICU). Patients were randomized to a high (liberal) volume or low (restricted) volume algorithm using unblinded, blocked randomization. A revised treatment algorithm was used after the 29th patient for the second part of the RCT. The goal of the trial was to determine the feasibility of conducting an RCT at a single site for recruitment and retention. We also collected data on the safety of study interventions and clinical outcomes, including pulmonary, infectious, renal, post-operative, and length of stay outcomes.ResultsFifty patients were randomized to either liberal (n = 26) or restricted (n = 24) fluid management strategy. After data was obtained on 29 patients, a first study analysis was performed. The volume of fluid administered and triggers for intervention were adapted to optimize the treatment effect and clarity of outcomes. Updated and refined fluid management algorithms were created. These were used for the second part of the RCT on patients 30–50. During this second study period, 54% (21/39, 95% CI 37–70%) of patients approached were enrolled in the study. Of the patients enrolled, 71% (15/21, 95% CI 48–89%) completed the study. This met our a priori recruitment and retention criteria for success. A data safety monitoring committee concluded that no adverse events were related to study interventions. Although the study was not powered to detect differences in outcomes, after the algorithm was revised, we observed a non-significant trend towards improved pulmonary outcomes in patients on the restricted arm, including decreased need for and time on oxygen support and decreased need for mechanical ventilation.ConclusionWe demonstrated the feasibility and safety of conducting a single-site RCT comparing liberal to restricted crystalloid fluid management in critically ill pediatric post-operative and trauma patients. We observed trends in improved pulmonary outcomes in patients undergoing restricted fluid management. A definitive multicenter RCT comparing fluid management strategies in these patients is warranted.Trial registrationClinicalTrials.gov, NCT04201704. Registered 17 December 2019—retrospectively registered.

Is Dexmedetomidine Effective on Postoperative Shivering in Patients Undergoing General Anesthesia for an Appendectomy? A Double–Blind, Randomized Clinical Trial

Background: Postoperative shivering (PS) is a mechanism to reduce heat loss and is the most frequent complication during the recovery period after general anesthesia. Shivering can lead to discomfort and is even risky in many patients; therefore, prevention is important. Objectives: Our study aims to determine the effect of dexmedetomidine on preventing shivering after general anesthesia in appendectomy patients. Methods: The present double–blind, randomized clinical trial divided 90 appendectomy patients into two groups. Randomization was performed using the www.random.org website from the numbers of sequence generator option. One group received 0.5 µg/kg of dexmedetomidine before induction of general anesthesia, and another group received normal saline as a placebo. Shivering and other outcomes were checked in both groups. To find a 50% reduction of this incidence, based on alpha error of 5% and beta error of 20%, the sample size of 45 people was determined for each group. A P-value ≤ 0.05 was considered statistically significant. Results: In total, 63 (70%) patients were male, and 27 (30%) were female. There were no significant differences between the two groups in terms of age (P = 0.412), weight (P = 0.460), temperature of serum for fluid therapy (P = 0.315), fluid volume (P = 0.736), perioperative body temperature (P = 0.418), preoperative body temperature (P = 0.540), and room temperature (P = 0.310). The severity of shivering was significantly lower in the dexmedetomidine group (60%) than in the placebo group (P &lt; 0.001). There was no significant difference according to gender and severity of shivering between the two groups (P &gt; 0.05). Conclusions: This study suggests that the administration of dexmedetomidine can prevent postoperative shivering.

CLINICAL AND HEMATOLOGICAL PROFILE OF PATIENTS WITH DENGUE FEVER AT A TERTIARY CARE HOSPITAL: AN OBSERVATIONAL STUDY

Objectives: The objective of this study was to analyze the clinical and hematological profile and studying outcome of patients having dengue fever (DF). Methods: This was an observational study conducted in the Department of General Medicine, Basveshwar Teaching and General Hospital, Kalaburagi, India. One hundred patients with DF were included in this study. Demographic details were obtained, detailed history was taken, and clinical examination was done. The cases were classified into dengue without warning signs, dengue with warning signs, and severe dengue as per world health organization classification of dengue. Clinical features, hematological profile, and outcome were assessed in studied cases. SSPE 21 software was used for statistical analysis. P value less than 0.05 was taken as statistically significant. Results: Out of these 100 cases, there were 62 (62.00 %) males and 38 (38 %) females with a M: F ratio of 1: 0.61. The mean age of male and female patients was found to be comparable with no statistically significant difference in the age group (p=0.391). Out of 100 studied cases, non-severe dengue was seen in 56 (56%) patients whereas 31 (31.00%) patients had non-severe dengue with warning signs and remaining 13 (13.00%) patients had severe dengue. The most common presenting complaint was fever which was present in all patients (100%). The other complaints included headache (82%) nausea and vomiting (74%). Positive torniquet test was seen in 7 (7%) patients and hypotension, decreased pulse pressure, and altered sensorium were seen in 5 (5%) patients each. In cases of dengue with warning signs or severe dengue out of 44 patients, 21 (21%) patients required blood component therapy and 5 (5%) patients landed up in shock despite fluid therapy. Two (2%) succumbed to complications of severe dengue. Conclusion: Comprehensive understanding of clinical features, hematological profile, and warning signs in DF is essential for timely diagnosis and effective management. With early diagnosis and proper management, the outcome of patients is usually good.